SUPPLEMENT 
TO THE 
REFERENCE HANDBOOK 
OF THE 
MEDICAL SCIENCES 
VARIOUS WRITERS 
ILLUSTRATED BY CHROMOLITHOGRAPHS AND FINE WOOD-ENGRAVINGS 
Edited by ALBERT H. BUCK, M.D. 
New York City 
VOLUME IX 
NEW YORK 
WILLIAM WOOD & COMPANY 
1893 WILLIAM WOOD & COMPANY 
TROW DIRECTORY 
PRINTING AND BOOKBINDING COMPANY 
NEW YORK LIST OF CONTRIBUTORS TO VOLUME IX. 
ROBERT ABBE, M.D New York, N. Y. 
Attending Surgeon, St. Luke's Hospital; Consulting 
Surgeon, Hospital for Ruptured and Crippled. 
SAMUEL W. ABBOTT, M.D Boston, Mass. 
Secretary of State Board of Health of Massachusetts. 
MAJOR GEORGE W. ADAIR, M.D Fort Robin- 
son, Neb. 
Surgeon, United States Army. 
CHARLES W. ALLEN, M.D New York, N. Y. 
JOHN AULDE, M.D Philadelphia, Pa. 
Editor of the " American Therapist." 
FRANK BAKER, M.D., Ph.D... .Washington, D. C. 
Professor of Anatomy, Georgetown University, Wash- 
ington, D.C. 
CHARLES P. BANCROFT, M.D Concord, N. H. 
Superintendent of the New Hampshire Asylum for the 
Insane. 
WILLIAM BARNES, S.B., M.D Decatur, III. 
A. D. BLACKADER, M.D Montreal, Canada. 
Professor of Pharmacology and Therapeutics, and 
Lecturer on Diseases of Children, McGill University ; 
Physician to the Montreal General Hospital. 
ALBERT N. BLODGETT, M.D Boston, Mass. 
MEADE BOLTON, M.D Baltimore, Md. 
Pathological Laboratory, Johns Hopkins Hospital. 
JOHN W. BRANNAN, M.D New York, N. Y. 
Visiting Physician, Bellevue Hospital. 
GEORGE EMERSON BREWER, M.D...New York, 
N. Y. 
Assistant Demonstrator of Anatomy, College of Phy- 
sicians and Surgeons. 
NORMAN BRIDGE, M.D , .Los Angeles, Cal. 
WILLIAM BROWNING. M.D Brooklyn N. Y. 
Lecturer on Normal Neurology at the Long Island Col- 
lege Hospital; Neurologist to the Long Island Dis- 
pensary. 
JOSEPH D. BRYANT, M.D New York, N. Y. 
Visiting Surgeon, Bellevue and St. Vincent's Hospitals. 
J. WELLINGTON BYERS, M.D.. .Charlotte, N. C. 
HENRY T. BYFORD, M.D Chicago, III. 
Professor of Gynaecology, College of Physicians and 
Surgeons of Chicago, and of the Post-Graduate Med- 
ical School of Chicago ; Gynaecologist to the Wo- 
man's Hospital, to St. Luke's Hospital, and to the 
Chicago Hospital. 
HENRY DMrIGHT CHAPIN, M.D.New York, N. Y. 
Professor of Diseases of Children at the New York 
Post-Graduate Medical School and Hospital. 
T. M. CHEESMAN, M.D New York, N. Y. 
Instructor in Bacteriology, College of Physicians and 
Surgeons, Medical Department of Columbia College. 
FREDERIC COGGESHALL, M.D Boston, Mass. 
Physician to the Boston Dispensary, Department of 
Nervous Diseases ; Pathologist to the Carney'Hos- 
pital. 
WILLIAM B. COLEY, M.D New York, N. Y. 
Attending Surgeon, New York Cancer Hospital. 
JOSEPH COLLINS, M.D New York, N. Y. 
Instructor in Nervous Diseases, New York Post-Grad- 
uate Medical School and Hospital. 
WILLIAM JUDKINS CONKLIN, M.D.. .Dayton, 0. 
EDWARD COWLES, M.D., LL.D Somerville, 
Mass. 
Medical Superintendent of the McLean Hospital, Som- 
erville, Mass. ; formerly Superintendent of the Bos- 
ton City Hospital ; Clinical Instructor in Mental 
Diseases, Harvard Medical School. 
GEORGE A. CRAIG1N, M.D Boston, Mass, 
Physician to Staniford Street Dispensary, Department 
of Women ; Physician to House of the Good Samar- 
itan. 
ANDREW F. CURRIER. M.D New York, N. Y. 
Gynaecologist to Bellevue Hospital, Out - Patient De- 
partment. 
B. FARQUHAR CURTIS, M.D... .New York, N. Y. 
Attending Surgeon, St. Luke's Hospital. 
THOMAS DARLINGTON, JR., M.D New York, 
N. Y. 
Visiting Physician to the New York Foundling Hos- 
pital ; formerly Physician to the Copper Queen 
Consolidated Mining Company. 
N. S. DAVIS, M.D., LL.D ; Chicago, III. 
Emeritus Professor of Principles and Practice of 
Medicine and of Clinical Medicine, Northwestern 
University Medical School; Professor of Medical 
Jurisprudence, Northwestern University Law 
School. 
ROBERT H. M. DAWBARN, M.D New York, 
N. Y. 
Professor of Operative Surgery and Surgical Anatomy 
in the New York Polyclinic. 
EDWARD B. DENCH, M.D New York, N. Y. 
Aural Surgeon, New York Eye and Ear Infirmary. 
L. M. DENNIS, Ph.B., B.S Ithaca, N. Y. 
Assistant Professor of Analytical Chemistry, Cornell 
University. 
HASKET DERBY, M.D Boston, Mass. 
Ophthalmic Surgeon, Massachusetts Charitable Eye 
and Ear Infirmary. 
F. X. DERCUM, M.D Philadelphia, Pa. 
Clinical Professor of Diseases of the Nervous System, 
Jefferson Medical College ; Neurologist to the Phila- 
delphia Hospital. 
CHARLES N. DOWD, M.D New York, N. Y. 
Asssistant Surgeon to the New York Cancer Hospital. 
THEODORE DUNHAM, M.D New York, N. Y. 
ROBERT G. ECCLES, M.D Brooklyn, N. Y. 
Chairman of the Sub-Committee on Active Principles 
of the United States Pharmacopoeia; Government 
Medical Chemist for the Department of the In- 
terior. 
III LIST OF CONTRIBUTORS TO VOLUME IX. 
JOHN SLADE ELY, M.D New York, N. Y. 
Professor of Pathology, Women's Medical College of 
the New York Infirmary; Assistant in Pathology, 
College of Physicians and burgeons ; Pathologist to 
Bellevue Hospital ; Assistant Physician, Roosevelt 
Hospital, Out-Patient Department. 
HAROLD C. ERNST, M.D Boston, Mass. 
Assistant Professor of Bacteriology in Harvard Univer- 
sity ; Physician to Out-Patients at the Massachusetts 
General Hospital. 
PIERRE A. FISH, B.S Ithaca, N. Y. 
Instructor in Physiology, Vertebrate Zoology, and 
Neurology, Cornell University. 
WILLIAM H. FORD, M.D Philadelphia, Pa. 
President of the Board of Health, Philadelphia ; Mem- 
ber of the American Public Health Association. 
GEORGE R. FOWLER, M.D Brooklyn, N. Y. 
Attending Surgeon, St. Mary's and Methodist Episco- 
pal Hospitals. 
JAMES M. FRENCH, M.D Cincinnati, Ohio. 
Lecturer On Morbid Anatomy and Demonstrator of 
Pathology, Medical College of Ohio ; Physician to 
St. Mary's Hospital, Cincinnati. 
J. McF. GASTON, M.D Atlanta, Ga. 
H. GRADLE, M.D Chicago, III. 
Eye and Ear Surgeon to the Michael Reese Hospital. 
DOUGLAS GRAHAM, M.D Boston, Mass. 
JAMES E. GRAHAM, M.D Toronto, Canada. 
Lecturer on Diseases of the Integumentary System, 
Toronto School of Medicine. 
LIEUT.-COL. CHARLES R. GREENLEAF, M.D.... 
Washington, D. C. 
Deputy Surgeon-General, United States Army. 
JOHN B. HAMILTON, M.D Chicago, III. 
Late Surgeon-General, United States Marine Hospital 
Service. 
HORACE T. HANKS, M.D New York, N. Y. 
Attending Surgeon, Woman's Hospital. 
A. H. HARRIMAN, M.D Laconia, N. II. 
ROBERT P. HARRIS, M.D Philadelphia, Pa. 
GEORGE HAVEN, M.D Boston, Mass. 
Gynaecologist to Out-Patients, Boston City Hospital; 
Gynaecologist to the Boston Dispensary ; Physician 
to Out-Patients, Boston Lying-in Hospital. 
CLARENCE L. HERRICK, M.D Granville, O. 
Professor of Biology, Denison University. 
S. S. HERRICK, M.D San Francisco, Cal. 
WILLIAM B. HILLS, M,D Boston, Mass. 
Associate Professor of Chemistry, Harvard Medical 
School. 
WILLIAM H. KINGSTON, M.D., LL.D Mon- 
treal, Canada. 
Professor of Clinical Surgery, Montreal School of Medi- 
cine (Laval University) ; Surgeon to the Hotel-Dieu. 
RICHARD HODGSON, M.A., LL.D.. .Boston, Mass. 
Secretary of the American Branch of the Society for 
Psychical Research. 
WILLIAM H. HOWELL, M.D Baltimore, Md. 
Professor of Physiology, Johns Hopkins University. 
JOHN H. HUDDLESTON, M.D.. ..New York, N. Y. 
Attending Physician, Gouverneur Dispensary. 
JAMES NEVINS HYDE, M.D Chicago, III. 
Professor of Skin and Venereal Diseases, Rush Medi- 
cal College. 
FREDERICK W. JOHNSON, M.D Boston, Mass. 
Surgeon to the Gynaecological Department of St. Eliza- 
beth's Hospital, and of Carney Hospital. 
WILLIAM W. JOHNSTON, M.D Washington, 
D. C. 
Professor of Theory and Practice of Medicine, Medical 
Department of Columbian University, Washington ; 
Consulting Physician to Garfield, Children's, and 
Emergency Hospitals, Washington. 
(SUPPLEMENT.) 
WYATT JOHNSTON, M.D Montreal, Canada. 
Demonstrator of Bacteriology, McGill University. 
WILLIAM W. KEEN, M.D., LL.D.. ..Philadelphia, 
Pa. 
Professor of Principles of Surgery and of Clinical Sur- 
gery, Jefferson Medical College ; Surgeon to the 
Jefferson Medical College Hospital, and the Philadel- 
phia Orthopaedic Hospital and Infirmary for Nervous 
Diseases. 
CHARLES B. KELSEY, M.D New York, 
N. Y. 
RUFUS A. KINGMAN, M.D Boston, Mass. 
Instructor in Gynaecology in the Boston Polyclinic ; 
Gynaecologist to the Boston Dispensary for Diseases 
of Women, to St. Elizabeth's Hospital, and to Car- 
ney Hospital. 
CARL KOLLER, M.D New York, N. Y. 
Lecturer on Diseases of the Eye, New York Polyclinic; 
Surgeon to the Eye Department, Mount Sinai Dis- 
pensary : Member of the Heidelberg er Ophthalmolo- 
gische Gesellschaft. 
S. P. KRAMER, M.D Cincinnati, O. 
Professor of Pathology and Bacteriology, and Lecturer 
on Clinical Surgery, Cincinnati College of Medicine 
and Surgery. 
CHARLES McK. LEOSER, Esq. .. .New York, N. Y. 
FRANKLIN P. MALL, M.D Baltimore, Md. 
Professor of Anatomy, Johns Hopkins University. 
ANDREW J. McCOSH, M.D New York, N. Y. 
Attending Surgeon, Presbyterian Hospital. 
MIDDLETON MICHEL, M.D Charleston, S. C. 
Professor of Medical Jurisprudence and Physiology,. 
. Medical College of the State of South Carolina ; At- 
tending Surgeon, City Hospital, Charleston. 
WILLIAM S. MILLER, M.D Madison, Wis. 
Instructor in Vertebrate Anatomy, University of Wis- 
consin. 
WESLEY MILLS, M.D Montreal, Canada. 
Professor of Physiology, McGill University. 
J. L. MINOR, M.D Memphis, Tenn. 
JOHN H. MUSSER, M.D Philadelphia, Pa. 
Assistant Professor of Clinical Medicine, University of 
Pennsylvania ; Physician to Philadelphia and Pres- 
byterian Hospitals. 
SAMUEL NICKLES, M.D Cincinnati, O. 
Professor of Materia Medica and Therapeutics and 
Clinical Medicine, Medical College of Ohio. 
JOSEPH O'DWYER, M.D New York, N. Y. 
Visiting Physician, New York Foundling Hospital. 
OSCAR OLDBERG, Phar.D Chicago, III. 
Professor of Pharmacy, School of Pharmacy, North- 
western University, Chicago. 
HENRY F. OSBORN, Sc.D New York, N. Y. 
Da Costa Professor of Biology, Columbia College. 
OLIVER T. OSBORNE, M.D.... New Haven, Conn. 
Assistant Professor of Materia Medica and Therapeu- 
tics, Yale University. 
AUSTIN PETERS, B.S., D.V.S., and M.R.C.V.8., 
Boston, Mass. 
FREDERICK PETERSON, M.D New York, 
N. Y. 
Chief of Clinic, Nervous Department, Vanderbilt 
Clinic, College of Physicians and Surgeons. 
GEORGE A. PIERSOL, M.D Philadelphia, Pa. 
Professor of Anatomy in the University of Penn- 
sylvania. 
CAPT. JAMES E. PILCHER, M.D., Fort Ringgold, 
Rio Grande City, Tex. 
Assistant Surgeon, United States Army. 
F. PEYRE PORCHER, M.D., LL.D., Charleston, 
S. C. 
Professor of Materia Medica and Therapeutics, Medi- 
cal College of the State of South Carolina ; Attend- 
ing Physician, City Hospital, Charleston. 
IV LIST OF CONTRIBUTORS TO VOLUME IX. 
J. PICKERING PUTNAM, Esq Boston, Mass. 
MARY PUTNAM-JACOBI, M.D., New York, N. Y. 
Consulting Physician, New York Infirmary for Wo- 
men and Children, 
LEOPOLD PUTZEL, M.D New York, N. Y. 
Visiting Neurologist, Randall's Island Hospitals. 
B. ALEXANDER RANDALL, M.D., Philadelphia, 
Pa. 
Clinical Professor of Ear Diseases, University of Penn- 
sylvania; Professor of Otology, Philadelphia Poly- 
clinic ; Ophthalmic and Aural Surgeon, Children's 
Hospital. 
J. C. REEVE, M.D Dayton, O. 
EDWARD T. REICHERT, M.D., Philadelphia, Pa. 
Professor of Physiology. University of Pennsylvania. 
CHARLES RICE, Ph.D New York, N. Y. 
Chemist of Department of Public Charities and Cor- 
rection, New York City ; Chairman of Committee 
of Revision and Publication of the Pharmacopoeia 
of the United States of America. 
CLARENCE C. RICE, M.D New York, N.Y. 
Professor of Diseases of the Nose and Throat, Post- 
Graduate Medical School and Hospital. 
JOHN RIDLON, M.D Chicago, III. 
Professor of Orthopedic Surgery in the Northwestern 
University Medical School, and the Chicago Post- 
Graduate Medical School ; Orthopedic Surgeon to 
St. Luke's Free Hospital of Chicago. 
A. D. ROCKWELL, M.D New York, N. Y. 
THOMAS H. RUSSELL, M.D... .New Haven, Conn. 
Professor of Clinical Surgery and Surgical Anatomy, 
Yale University. 
WILLIAM T. SEDGWICK, Ph.D Boston, Mass. 
Professor of Biology, Massachusetts Institute of Tech- 
nology ; and Chief Biologist to the State Board of 
Health of Massachusetts. 
GEORGE B. SHATTUCK, M.D Boston, Mass. 
Visiting Physician, Boston City Hospital. 
BEAUMONT SMALL, M.D Ottawa, Canada. 
Examiner in Materia Medica and Pharmacy, College 
of Physicians and Surgeons of Ontario ; Attending 
Physician, General Protestant Hospital, Ottawa. 
COLONEL JOSEPH R. SMITH, M.D., San Fran- 
cisco, Cal. 
Assistant Surgeon-General, United States Army. 
HENRY R. STEDMAN, M.D .Boston, Mass, 
Superintendent of " Woodbourne" (Hospital for Ner- 
vous and Mental Disease). 
(SUPPLEMENT.) 
THOMAS LATHROP STEDMAN, M.D., New York, 
N. Y. 
LOUIS McLANE TIFFANY, M.D., Baltimore, Md. 
Professor of Surgery, University of Maryland. 
CHARLES W. TOWNSEND, M.D.... Boston, Mass. 
Physician to Out-Patients at the Massachusetts Gen- 
eral, Children's, and Lying-in Hospitals. 
ROGER S. TRACY, M.D New York. N. Y. 
Deputy Register of Vital Statistics, Health Depart- 
ment, City of New York. 
F. TUCKERMAN, M.D Berlin, Germany. 
A. VANDER VEER, M.D Albany, N. Y. 
Professor of Didactic, Clinical, and Abdominal Sur- 
gery, Albany Medical College. 
ELY VAN DE WARKER, M.D Syracuse, N. Y. 
Surgeon to the Central New York Hospital for 
Women ; Surgeon to the Syracuse Woman's and 
Children's Hospital ; Consulting Surgeon to St. 
Ann's Maternity Hospital. 
LEONARD WEBER, M.D New York, N. Y. 
Consulting Physician to St. Mark's and St. Joseph's 
Hospitals. 
EDMUND C. WENDT, M.D New York, N. Y. 
MOSES C. WHITE, M.D New Haven, Conn. 
Professor of Pathology, Yale University. 
JAMES T. WHITTAKER, M.D., LL.D Cincin- 
nati, O. 
Professor of Theory and Practice of Medicine, Medical 
College of Ohio : Lecturer on Clinical Medicine, 
Good Samaritan Hospital. 
BURT G. WILDER, M.D Ithaca, N. Y. 
Professor of Comparative Anatomy and Zoology, Cor- 
nell University. 
CHARLES F. W1THINGT0N, M.D... Boston, Mass. 
ALFRED C. WOOD, M.D Philadelphia, Pa. 
Instructor in Clinical Surgery, University of Pennsyl- 
vania ; Assistant Surgeon, University and Gynecean 
Hospitals, Philadelphia. 
MAJOR ALFRED A. WOODHULL, M.D Hot 
Springs, Ark. 
Surgeon, United States Army. 
CAPTAIN CHARLES E. WOODRUFF, M.D.. .Fort 
Assinniboine, Mon. 
Assistant Surgeon, United States Army. 
PHILIP ZENNER, M.D Cincinnati, O. 
Clinical Lecturer on Diseases of the Nervous System, 
Medical College of Ohio. 
V PREFACE. 
The present volume is the outcome of a decision to bring The Reference Handbook 
of the Medical Sciences fully up to date. It was at first contemplated to revise the vol- 
umes of the work and issue a new edition of the whole ; but as this would practically 
make obsolete the great number of sets of the Handbook now in the libraries of phy- 
sicians all over the world, it was considered preferable to publish a supplementary vol- 
ume, which could be added to those already issued, completing, rather than destroying, 
the original edition, and at the same time enabling present possessors of the work to 
obtain the new matter at a comparatively small cost. Although the original work was 
published at short intervals during the period from 1885 to 1889, and consequently is not 
very old in point of years, nevertheless in some of its departments-especially those of 
Pathology, Materia Medica, and Therapeutics-the changes that have taken place in even 
this brief period of time are so great as to be almost startling in their magnitude. 
Much of this newly acquired knowledge still lies scattered throughout periodical medi- 
cal literature, and has not yet been incorporated into the text-books that are used by a 
large proportion of the profession. The present, therefore, seemed a good time in which 
to gather together into a single supplementary volume all this scattered knowledge. 
Soon after the work was inaugurated, it was found-as we then believed-that all of 
the available space would not be required for the adequate presentation of this recently 
acquired knowledge. Accordingly, provision was made for the introduction of a number of 
articles on different topics which had not been discussed at all in the original work. 
Many of these, it was thought, would add materially to the usefulness of the book as 
a work of reference. 
In the progress of the undertaking the Editor has received valuable assistance from 
the following individuals, to all of whom he would now offer his grateful acknowledg- 
ments : Dr. John Green, of St. Louis, Mo. ; Dr. Thomas Lathrop Stedman, of New York ; 
Professor Charles Sedgwick Minot and Dr. William N. Bullard, of Boston, Mass. ; Dr. 
Beaumont Small, of Ottawa, Canada ; Professor Burt G. Wilder and Professor Simon H. 
Gage, of Ithaca, N. Y. ; and Lieutenant-Colonel Charles R. Greenleaf, Major Alfred A. 
Woodhull, and Major John Van R. Hoff, of the Medical Staff of the United States Army. 
He also takes pleasure in acknowledging the generosity manifested by the publishers 
in the present undertaking; for when it became evident that the volume could not be 
kept within the limits (number of pages) set by them beforehand, and so announced in 
their published circulars, unless some articles should be omitted altogether, and others 
very much shortened, they authorized him to publish all this material in its entirety, 
notwithstanding the great increase in cost to which they would thereby be subjected, 
without any addition in the pecuniary returns to tliem. In consequence of this decision 
the volume, as may be noticed, far exceeds any of its predecessors in the number of pages 
which it contains. 
ALBERT H. BUCK. 
VII SUPPLEMENT TO THE 
REFERENCE HANDBOOK 
OF THE 
MEDICAL SCIENCES. 
Aba no. 
Acetanilide. 
ABANO. An Italian watering-place, known to the 
Romans as Aquae Aponi, or Aquae Patavinae. 
Location.-In the province of Venetia, six miles 
from Padua. 
Access.-From Paris, via the Paris, Lyons & Medi- 
terranean Railroad ; then through the Mont Cenis, Turin, 
Milan, Padua ; or hy steamer from New York to Genoa, 
and thence to Padua. 
Indications.-These celebrated hot (200° F.) sulphur 
springs are much used in rheumatism, gout, scrofula, 
and all cutaneous and syphilitic affections. There are 
ten bathing establishments, with modern appliances. 
The waters contain bromine and iodine, but a reliable 
analysis is not at hand. Peat baths are also employed. 
Accommodation.-Hotels and lodging-houses are not 
of the best. The village is interesting, but not clean. 
Edmund C. Wendt. 
ABBAZIA. One of the newer and most popular health- 
resorts of Austria. 
Location.-Abbazia is situated on a pretty bay of the 
Adriatic, in Istria, district of Fiume, and about one 
hour's drive from the city of that name. It is fairly well 
sheltered from the north, east, and west winds. The 
Monte Maggiore acts as a protecting barrier. It is known 
as a resort on the " Austrian Riviera." 
Access.-By the Austrian " Sudbahn,'' one hour from 
the station Matuglie. 
Indications.-Abbazia has become decidedly popular 
recently as a winter station for neurasthenic people ; also 
for subacute and chronic catarrhal affections of the 
respiratory organs. On account of its attractive location 
it is also used by the natives as a summer resort. Sea- 
bathing, promenades in pretty parks, establishments for 
inhalation, massage, mechano-therapy, etc., are among 
its resources. 
Dr. Glax maintains the superiority of the winter climate 
of Abbazia over many other similar stations {Aerztliche 
MittheUungen aus Abbazia, Wien, 1892). He gives elab- 
orate tables of meteorological observations in substantia- 
tion of his views. But the impartial observer will only 
perceive that the climate of this resort somewhat re- 
sembles that of the Riviera generally, but is rather more 
moist than that district. The sanitary arrangements of 
the place are said to be satisfactory, and of its natural 
attractiveness there is no doubt. Nevertheless, Dr. Glax 
must be regarded as a local enthusiast. 
Accommodation.-There is a large hotel, the Grand 
Hotel Abbazia, several minor ones, and a Kuranstalt 
called "Quisisana." Five or six physicians are in at- 
tendance. The winter season lasts from October to May. 
Splendid promenade along the shore. 
Edmund C. Wendt. 
ACETANILIDE (Phenylacetamide, Antifebrin). Of 
the host of new remedies that have been received during 
the past few years, this is one that has received general 
approbation and has sustained the reputation with which 
it was introduced. In Great Britain it has received offi- 
cial recognition by being placed in the Pharmacopoeia of 
1890. Since its introduction in 1886, by Drs. Kahn and 
Hepp, it has been extensively employed, without detract- 
ing from their estimate of its virtues. Further study has 
established its antipyretic and analgesic properties, and 
were it not that in phenazone and phenacetine we have 
drugs with a similar action it would be prized as of in- 
estimable value. The tendency it has to cause profuse 
sweating and a condition of cyanosis has unfortunately 
engendered in many a sense of dread which has restricted 
its use. This toxicity is greatly over-estimated and 
should not be feared if the dose and mode of adminis- 
tering are attended to. It is rather a danger-signal far 
in advance of any serious consequences. 
Kahn and Hepp in their original papers stated that one- 
fourth of a gramme (3.85 grains) was a sufficient dose, and 
subsequent writers have insisted on the efficacy of even 
smaller quantities. 
Instead of the seven or ten grains so frequently given, 
the consensus of opinion now points to three or four 
grains as a more proper initial dose in every case where 
its use is begun, to be increased as the individual suscept- 
ibility is learned. There are also many points to be con- 
sidered in its administration which influence its action. 
As the effect of the dose is continued for two or three 
hours the dose should not be repeated until that interval 
has elapsed. Where the use of the drug is persisted in 
for some time a day of freedom from its use should oc- 
casionally be allowed to intervene, as it undoubtedly pos- 
sesses a sort of cumulative action. Many instances are 
reported where severe toxic symptoms have followed the 
same dose that had been given for some days with only 
beneficial effects. Wheh the patient is anaemic, and in 
the debilitated and aged, the toxic symptoms more readily 
supervene, and in women, during the few days previous 
to menstruation, the condition of the blood is supposed 
to favor the decomposition of the drug and increase its 
action. The time of the dose, in relation to the natural 
rise or decline of temperature, is of importance; when 
given with the increase of fever its action is slower and 
within control, but if its effect coincides with the decline 
the fall will be rapid and probably in excess of what is 
expected. 
Although the toxic symptoms are alarming it is a ques- 
tion as to how far they are dangerous. The cyanosis and 
sense of depression is not of long duration and is rapidly 
overcome. Fatal cases are rare and very large quantities 
of the drug have been taken without causing death. A 
case is reported in which teaspoonful doses were taken at 
short intervals until one ounce was disposed of, and in 
another instance seven and a half drachms were taken 
with suicidal intent. Tn both cases recovery followed. 
Acetanilide possesses many advantages over other anti- 
pyretics. Its action is rapid and certain ; the amount 
required is small and easily taken by the patient; it has 
no irritating effect on the digestive organs, but rather 
promotes digestion and improves the well-being of the 
body ; and, what is of greater importance, it is devoid of 
any depressive action on the heart or circulation. 
The toxic condition arises from an altered state of the 
blood and disordered function of the medulla and spinal 
1 Acetanilide. 
Acromegaly. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
cord. The early symptoms are profuse perspiration and 
a bluing of the finger-nails and lips, accompanied by a 
sense of oppression ; then follow vertigo and giddiness, 
singing in the ears, dilated pupils, cold extremities, sub- 
normal temperature, slow and shallow breathing, feeble 
pulse, nervous twitchings, and convulsions. 
How the drug produces its action is as yet undeter- 
mined. There is a lessening of the oxidizing property of 
the blood and the production of methaemoglobin, the 
arterial blood becomes of a dirty brown color, the serum 
becomes colored and haemoglobinuria supervenes. In 
extreme cases and where the drug is administered for a 
prolonged period, it produces a state of anaemia. The 
disturbances in the medulla are considered to be second- 
ary to the condition of the blood and not due to any 
direct action of the drug on the nerve-centres. 
To counteract the poisoning, stimulating treatment is 
indicated. Warmth to the extremities and surface ; 
alcohol, ether, and camphor by the mouth or hypoder- 
mically ; belladonna is particularly recommended for its 
stimulant action on the centres, four drops of the tincture 
every half hour for four doses, afterward at longer in- 
tervals, having proved of service. Strychnine is also use- 
ful. The inhalation of oxygen is indicated. In extreme 
prostration the transfusion of saline solution has been 
adopted with benefit. 
Acetanilide in fever is used solely as an antipyretic, 
and as such it has been classed as one of the best we pos- 
sess. It is utilized in typhoid fever, pneumonia, phthi- 
sis, erysipelas, acute rheumatism, and in all conditions 
in which hyperpyrexia is present. It was thought by 
some to have specific properties in many of these dis- 
orders, but such views are no longer tenable ; the dura- 
tion of the disease is not affected, complications are not 
prevented, nor does it guard the patient against relapses. 
It reduces the high temperature and relieves the discom- 
fort and distress that are present, and its sedative action 
on the nervous system adds to its calming and refreshing 
effect. Its continuous administration is not advised, but 
only its use when the temperature is such as to require in- 
terference. 
In phthisis it proves particularly soothing, and by judi- 
ciously controlling the pyrexia night-sweats are lessened 
and prevented. In the hyperpyrexia of pneumonia it is 
used with advantage, but in this condition, as well as in 
advanced phthisis, where the respiratory tissue is reduced, 
it must be given with caution. 
In acute rheumatism it relieves the painful and swollen 
joints and reduces the temperature. When the pains are 
severe it requires larger doses than in other febrile affec- 
tions. Its action is generally thought not to be so effi- 
cacious as that of antipyrin or salicylate of soda, but it 
has not their disturbing influence on the digestive organs, 
and may be given where these drugs are not well borne. 
Its analgesic properties have proved almost as decided 
as its power of reducing pyrexia. It is particularly use- 
ful in all pains due to irritation of the sensory nerves or 
pains of a reflex character, such as pains of locomotor 
ataxia, neuralgia, sciatica, lumbago, pains after opera- 
tions, ovarian and menstrual irritation ; also in migraine, 
nervous headaches, the headaches of growing children, 
and all paroxysmal pains it has proved equally success- 
ful. 
It has been recommended and tried in epilepsy and 
chorea but without much advantage. 
In the diseases of infancy it has proved of decided use- 
fulness. Its effects are of longer duration and the toxic 
symptoms are not so liable to follow its use. In scarlet 
fever, measles, pneumonia, etc., its action has been most 
gratifying, reducing fever and restlessness and inducing 
a quiet and refreshing sleep. In whooping-cough it is 
also used with success ; its action promotes expectoration 
and reduces the frequency and duration of the paroxysms. 
Beaumont Small. 
ACIREALE. A much-frequented climatic health-re- 
sort with thermal waters in Sicily, Italy. 
Location.-Acireale is situated in the province of 
Catania, on the southern slope of Mount Etna. It has 
(SUPPLEMENT.) 
an elevation of 560 feet above sea-level, and has an old- 
established reputation, the springs having been known 
to the ancients as Aqua Santa Venere. 
Access.-It is two hours' ride from Messina, on the 
Messina-Catania Railroad. 
Indications.-The native Italians regard Acireale as 
an all the year round resort, but foreigners go there only 
in the winter season. The waters are sulpho-saline, and 
also contain iodides. The springs have a temperature of 
70° F. They are used with advantage in rheumatism, 
gout, scrofula, and metallic poisoning; also in paralysis 
and neuralgia. The climate is said to benefit phthisis, 
emphysema, chronic respiratory troubles, anaemia, chlo- 
rosis, and neurasthenia. 
The winter climate of Acireale is dry and mild. The 
death-rate is stated to be only nineteen per thousand. 
Mean winter temperature, 55° F. The variations are 
never more than ten degrees. The number of rainy 
days in the year range between thirty and fifty, but do 
not exceed the latter. Snow and fogs are unknown. 
Windy days are less in number than on the Riviera, and 
there is a complete absence of dust. The prevailing 
winds are the S.E., S.W., S.S.E., and E.S.E. The air 
is rich in ozone, owing to the vicinity of the sea. The 
luxuriance of the vegetation is almost tropical. 
Accommodation.-The principal hotel is the Grand 
Hotel des Bains, facing due south. The town has 80,000 
inhabitants. There are several medical establishments. 
Edmund C. Wendt. 
ACROMEGALY, or Akromegaly (aspov, extremity ; 
ptyas, great). Synonyms : Acromegalie ; akromegalie ; 
acromegalia ; pachyacrie ; Marie's disease. 
Definition.-Acromegaly is a chronic disease, charac- 
terized by an abnormal increase in the size of the ex- 
tremities of the body, viz., hands, feet, and generally 
head, due to an hypertrophy of the bones and soft parts 
of these regions. 
History.-The first to recognize this disease as a 
separate entity was P. Maric, who wrote upon this sub- 
ject in 1886. This first article of Marie's describes two 
cases which he had discovered while first assistant to 
Professor Charcot. He named this disease " Acrome- 
galic" because he found all the extremities of the body 
enlarged, viz., hands, feet, and cephalic extremity, while 
von Recklinghausen suggests the name of "pachyacrie." 
Since the publication of Marie's first paper in 1886, a 
number of cases, reported in literature under various 
titles, have been discovered, which in all probability 
were cases of acromegaly. A few of the titles under 
which these cases were reported, all of which have un- 
questionably not yet been discovered, are " Exophthalmic 
Goitre," " Myxoedema," " Hypertrophy of the Tongue," 
and, more frequently than all the rest, " Gigantism," or 
giant growth. 
On the other hand, since 1886, a number of cases have 
been reported as acromegaly, which I do not believe to 
be cases of that disease. Thus far, something more than 
one hundred cases have been published, some few of 
which, as just stated, are probably not acromegaly. 
The first cases discovered and reported as acromegaly (in 
1885 Wadsworth reported a case as myxoedema, which 
was undoubtedly acromegaly) in America were those of 
Drs. O'Connor and Adler, both of which were published 
in 1888. In 1890, Marie published an article on a second 
new disease, which was at first confounded with acrome- 
galy, but which clinically and pathologically is a dis- 
tinct and entirely different disease ("De 1'osteoarthro- 
pathie hypertrophiante pneumique," Hevue de med., 
1890). 
Most of the literature on acromegaly will be found at 
the end of this article, but the disease can be readily 
studied, as a whole, in the following publications : " De 
Facromegalie, Maladie de P. Marie," Souza-Leite, Paris, 
1890, gives a complete description, in detail, of all of the 
cases up to that date, thirty-eight in number. A transla- 
tion of Souza-Leite's article in the New Sydenham So- 
ciety, London, 1891, contains the above thirty-eight cases, 
and adds abstracts of ten more. In our own country, 
2 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Acetanilide. 
Acromegaly. 
Dr. Joseph Collins, of New York, in a most carefully 
prepared article, has brought the subject of acromegaly 
up to 1893, giving abstracts of all the cases reported 
since the publication of the above Sydenham Society re- 
port (The Journal of Nervous and Mental Diseases, Decem- 
ber, 1892, and January, 1893). 
Clinical History.-In acromegaly all of the pro- 
jecting portions of the body are generally enlarged, 
hands, feet, chin, lips, nose, tongue, ears, and often the 
genitalia. Of these parts the bones, cartilages, and soft 
tissues are all hypertrophied. There is more or less pro- 
gressive increase in weight, and generally increased ap- 
The cartilages of the nose are enlarged, as are generally 
the cartilages of the ears and eyelids. 
The soft parts of the nose and ears are also generally 
enlarged, and the nose is often massive. The cranial 
bones are rarely affected. The lower lip is more fre- 
quently enlarged than the upper, and always in excess of 
it. The face is oval, the cheeks flattened, the forehead 
retreating and low, the hair of the head strong and thick, 
and exophthalmos may be present. 
The bones of the thorax are always enlarged, notably 
the extremities of the clavicles, the costal cartilages, es- 
pecially at their junction with the ribs and the sternum, 
more especially at the xiphoid appendix. The ribs are 
generally widened, the scapulae may or may not be en- 
larged, and sooner or later the vertebrae and the inter- 
vertebral cartilages become affected, the latter thicken- 
ing and ossifying, causing kyphosis and other deformi- 
ties of the spinal column. On account of the kyphosis 
and the shortening of the neck, the long projecting chin 
often almost rests upon the sternum. 
The bones of the arm are generally not enlarged, except 
the lower part of the radius and ulna, thus causing an 
enlarged wrist. The bones of the hands, the metacarpal 
bones and the phalanges especially, are all widened and 
thickened. The soft parts of the hands are especially 
hypertrophied, giving the immense and often enormous 
acromegalic hands. 
The pelvic bones are generally enlarged, this being 
particularly noticeable at the pubis and the crests of the 
ilia. 
The thigh-bones are generally not affected except at 
the condyles, which are enlarged, and together with the 
almost constantly enlarged patellae produce enlarged 
knee-joints. The tibiae and fibulae may or may not be 
enlarged, though frequently there is some hypertrophy 
of the extremities of these bones. The ankle-joints are 
generally enlarged, and the feet-bones and soft parts are 
affected similarly to the hands, and, like the latter, are 
enormous. 
The heart, lungs, spleen, and liver are normal, although 
the heart may be slightly hypertrophied. The kidneys 
are generally normal, although there is often polyuria, 
but diabetes and albuminuria have sometimes been pres- 
ent. 
Pain in the head is the most frequent subjective symp- 
tom, often severe and even terrific. There may be, and 
frequently are, joint-pains, or pains referred to various 
parts of the body, more or less persistent, but neuralgic 
in character. Frequently there is tingling of the hands, 
feet, or ears, often ■with numbness of the fingers, but 
with no great loss of sensibility. 
There may be muscular hypertrophy, local or general, 
but later there is atrophy of the muscles. 
Taste and smell are rarely affected, hearing is occasion- 
ally disturbed, sight is frequently impaired. The voice 
is loud and deep. The reflexes are generally normal, at 
least not markedly impaired, and electrical reactions are 
normal. 
The intellectual faculties may or may not be impaired, 
but the memory is generally poor. Somnolency is some- 
times present. 
The superficial veins of the body are often enlarged, 
giving rise to hemorrhoids and varicose veins of the legs. 
The skin may be dry and harsh, and is generally great- 
ly thickened on the affected parts. There is often in- 
creased perspiration, local or general. The subcutaneous 
cellular tissue may be hypertrophied or atrophied. There 
is frequently an increased growth of hair on the body, 
especially on the arms and legs. The skin is often of a 
yellow color, especially marked on the face. Frequently 
molluscous growths appear on the face, neck, or body. 
Such are the notable symptoms of this interesting and 
peculiar disease. We will now enter into a more explicit 
description of the several symptoms. 
General Condition.-The acromegalic patient comes to 
the physician complaining of headache, disturbances of 
vision, severe joint-pains or ringing of the ears (one case, 
at least, Osborne); or the case is discovered while the 
patient is under treatment for an entirely different dis- 
Fig. 1.-Author's Case of Acromegaly. General View of Body. 
petite and increased thirst. Menstruation almost invari- 
ably ceases in the female, and the sexual appetite is 
generally diminished in the male. There is generally 
■constipation ; there may or may not be dyspepsia or po- 
lyuria. 
The lower jaw is almost invariably enlarged, and gen- 
erally to such an extent that prognathism is present. 
The superior maxillary bones may or may not be en- 
larged. The malar bones are generally enlarged, ren- 
dering the cheek-bones prominent. The supra-orbital 
ridges are generally projecting, and the forehead retreat- 
ing. 
3 Acromegaly. 
Acromegaly. 
REFERENCE HANDBOOK OF THE MEDICAfi SCIENCES. 
ease. The head appears too large for the body, and 
more careful inspection shows the face to be entirely too 
large for the rest of the head. The hands and feet are 
enormous, and out of all proportion to the arms and legs, 
and, if the case is at all advanced, humpback or kypho- 
sis is present. 
The family history and the previous history of the pa- 
tient himself have, up to the present time, been of no in- 
terest, so far as showing exciting or predisposing causes 
of this disease. There is never increased temperature 
unless due to an intercurrent affection. The pulse has 
been almost invariably normal, although it was stated to 
have increased in rapidity in one of the forty-six cases 
whose histories I have carefully examined (Godlee's 
case). There is rarely dyspnoea, and if present, only on 
exertion. The appetite is generally increased, and may 
be ravenous, although it is often stated to have been only 
normal. Thirst may or may not be increased. Consti- 
pation is frequently present. Polyuria and dyspepsia 
may be. 
Early History.-In women the cessation of the men- 
struation is generally the first symptom of the disease. 
In two cases there was a history, in the early stages, of 
profuse and recurring epistaxis (Osborne's and Barclay- 
Symmer's cases). From the patient or his family proof 
of the continuous growth of the head, hands, feet, and 
body can generally be elicited, and commonly an ap- 
proximate date for the beginning of the disease can be 
estimated. 
The increase in size of the hats, shirts, gloves, or shoes 
can always be ascertained, and are positive evidences of 
growth. 
In women the increase in the size of the fingers, as 
shown by the inability to longer wear the wedding-ring, 
which in many cases has been sawed off, is a positive 
evidence of growth frequently mentioned in the histories 
of the cases ; also in many instances earlier photographs 
of the patient can be obtained and compared with the 
present condition. These signs and facts show a positive 
and continuous growth, and careful examination of the 
parts affected shows that this growth is largely of the> 
bones. 
I could find no definite data as to an increase of 
height, but it probably does invariably somewhat in- 
crease until the period when kyphosis develops, at which 
time some loss of height may take place, even to six 
inches in Paget's case. The weight always, at least for a 
time, increases. 
Now, to examine the conditions more in detail we will 
begin with the head. 
Head.-We find the forehead low and retreating, due 
to the growth forward of the superciliary ridges, which, 
with the elongation and forward projection of the lower 
jaw, gives the oval or elliptical face so characteristic of 
this disease. The hair is thick and strong, and the eye- 
brows are often heavy. (In Boltz's case the hair was 
gray.) We next notice that the face is entirely too large, 
that it is out of all proportion to the cranium proper. 
The skin of the face is thickened, and of a yellowish 
brown color, most marked on the eyelids, with, perhaps, 
here and there a molluscous growth. 
The skin of the forehead is often redundant, and 
thrown into many transverse wrinkles or folds. The 
cheeks are generally flattened, and often appear sunken, 
largely due to the prominence and projection of the 
malar bones. The circumferences of the orbits are prom- 
inent, and the eyelids are large, due to the thickening 
and widening of the tarsal cartilages, with more or less 
hypertrophy of the skin, especially of the lower lid, 
where it may fall in folds, with occasionally the appear- 
ance of oedema. (In llolsti's case the eyelids wrere oede- 
matous.) The eyeballs are large and generally more or 
less prominent, even to the condition of exophthalmos. 
The nose, even for the size of the face, is too large, 
often immense, due to the thickening and enlarging of 
the nasal cartilages and to the great hypertrophy of the 
soft parts. It is wide, thick, and may be pugged. 
The superior maxillary bones may or may not be en- 
larged, but are frequently lengthened from above down- 
(SUPPLEMENT.) 
ward ; nevertheless, they are never enlarged to the same 
extent as is the lower jaw. 
The upper lip is generally thick and projecting, but 
never attains the size of the lower lip. 
The lower lip is almost invariably large, thick, everted, 
and projecting, and is one of the characteristic features. 
The enlargement of the lower jaw is one of the land- 
marks of this disease, although acromegaly can unques- 
tionably occur without the enlargement of this bone. 
The angle of junction between the rami and the body 
becomes obtuse, and, while the rami may grow to con- 
siderable extent, the chief growth is in the body. The 
body of this bone widens and thickens all over, but espe- 
cially on its alveolar border and at the symphysis, where 
the mental process becomes very prominent. " The rami, 
however, may be so enlarged and widened as to force 
outward the lower part of the external ear (Dulles' 
case). The teeth rarely partake of this growth (in the 
congenital case described by Cenas the teeth were all 
enlarged) ; hence the growth of the alveolar process soon 
tends to separate the teeth from each other by continually 
increasing intervals. The teeth may fall out spontane- 
ously (Mosier's case, aged forty-one years). 
Sooner or later prognathism generally occurs, due not 
only to the growth of the body of the lower jaw, but also 
to the widening of the angle and the changes in the 
glenoid fossa (see description under Pathological Anat- 
omy). This prognathism is of all degrees, and reached 
in Gause's case fifteen millimetres. 
The external ear is generally increased in size, some- 
times even appearing immense. 
The cartilages and the soft parts both take part in the 
growth, and the former may become in places as hard as 
bone. (The cartilage of the helix of the left ear in the 
writer's case has apparently developed into bone, while 
the helix of the right ear is very thick and hard.) 
The cartilages which form the outer portion of the ex- 
ternal auditory canal, as well as the bony walls of the 
canal, may take part in this disease, as in the writers 
case, where the canals are lengthened by the growth of 
the cartilages, and the bony canals are narrowed by the 
growth of exostoses from the superior walls. 
The bones of the cranium are generally not enlarged, 
but the ridges and eminences may be abnormally prom- 
inent, especially the occipital protuberance (Adler's, 
Cenas's, and Campbell's cases). In Massalongo's case 
there were spiky, osseous protuberances along the sut- 
ures of the skull, especially the lambdoid. The entire 
cranium is stated to have been enlarged in the cases re- 
ported by Adler and S. Solis-Cohen, while O'Connor's 
case showed some very atypical enlargements, or tumors, 
on the parietal bones. 
The mucous membrane of the nostrils is frequently 
found hypertrophied. The sense of smell is very rarely 
affected. (Much impaired in Godlee's case.) 
The tongue is broad and thick, and frequently of 
double its normal size, almost entirely filling the cavity 
of the mouth, so that the sides show indentations from 
the teeth. The upper surface of the tongue is often 
deeply corrugated, marked by deep lines and fissures, 
and the papillae may be prominent and projecting. 
During speech the massive tongue gives the impression 
of weight and clumsiness. By the large tongue and the 
prognathism the speech is rendered thick, heavy, and 
often slow, while the labial and dental sounds are poorly 
articulated. The tongue is generally clean, but Long 
found it, in his case, always covered with a grayish-yel- 
low coating. 
The soft palate is often thickened, the uvula may be 
wide and long, even as large as a little finger (Boltz's 
case), and the epiglottis has been found considerably 
thickened. The larynx is enlarged, either as a whole, 
or in one or more sets of its cartilages. The ary-epiglot- 
tic ligaments have been found thickened (Gause's case), 
and the vocal cords hypertrophied (Fratrich's case). 
These conditions render the voice loud and harsh, the 
voice in women becoming masculine, and in men of 
much lower pitch. 
The thyroid cartilage is often enlarged, as is also the- 
4 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Acromegaly. 
Acromegaly, 
■cricoid cartilage and frequently the hyoid bone. The 
submaxillary and other glands (lymphatics) of the neck 
may be enlarged (Adler's case). The thyroid gland may 
be normal in size, hypertrophied, cystic (Godlee's case), 
or so atrophied that it cannot be found. 
The neck is short and thick, and the head leans for- 
ward, which with the cervico-dorsal kyphosis causes the 
long projecting chin to almost rest on the sternum. 
Body.-Sooner or later, but almost invariably if the 
case is far enough advanced, the irregular formation and 
laying on of bone in the spinal column causes deformi- 
ties of the spine. This deformity is almost constantly a 
cervico-dorsal kyphosis (Hare's case was dorsal), giving 
a humpback appearance very characteristic of this dis- 
ease. Occasionally scoliosis is also present, and some- 
times a compensatory lumbar, or dorso-lumbar, lordosis. 
The spinous processes of the vertebrae are frequently 
found abnormally prominent, especially the lower cervi- 
cal. 
The circumference of the chest is greatly increased, 
especially at the level of the ensiform cartilage, where it 
is the greatest. Laterally the chest appears flattened, 
while the antero posterior diameter is often enormous. 
The sternum is generally widened and thickened, and 
projects outward, especially the hardened and enlarged 
xiphoid cartilage. 
There are often prominent transverse ridges on the 
sternum, and there may be a hollowing or apparent sink- 
ing-in in the region of the manubrium, due to the irregu- 
lar growth of the sternal segments. There may be tri- 
angular-shaped hollows at the sides of the sternum. A 
dulness on percussion is sometimes found at the upper 
end of the sternum, attributed by Erb and Verstraeten 
to an enlarged or persistent thymus gland, but though 
this gland has occasionally been found enlarged, Arnold 
has shown that the dulness is due to a thickening of 
the bone. 
The clavicles are most enlarged at the sternal extrem- 
ity, but the acromial end is also generally thickened. 
The ribs are wide and very oblique, and at their junc- 
tion with the more or less enlarged and ossified costal 
cartilages are generally found bony nodules, not unlike 
the rachitic rosary. The ribs are rendered oblique, and 
the lower ones are forced outward, by the great growth 
of the costal cartilages. The hardening of the ligaments 
and cartilages of the chest causes a peculiar stiff and 
constrained up-and-down, or out-and-in, motion of the 
lower part of the thorax during respiration, and the ab- 
dominal respiration is increased. In Packard's case the 
chest was very irregular, some of the ribs being very 
large and having numerous nodosities on their surfaces. 
In O'Connor's case there were distinct, circumscribed 
tumors on some of the ribs, and on each clavicle, at the 
sternal junction, was a sharp, inward projecting exos- 
tosis. 
The abdomen is generally flattened and even appears 
retracted from the forward projection of the sternum 
and costal cartilages, though in Massalongo's case the 
abdomen is stated to have been " bulky and pendant." 
The pelvis is generally enlarged in all parts, but the 
most marked hypertrophy occurs in the pubic bones, 
and in those at the symphysis pubis. The ilia seem to 
be wider apart, and the crests are broad and prominent. 
The penis is often enlarged, notably so in Cenas's case. 
The labi® major®, as well as the labite minor® may or 
may not be enlarged, the clitoris may be hypertrophied, 
and the vagina may be lengthened, but the uterus is 
generally small and atrophied. 
Upper Extremity.-The shoulder-joint may be, but 
rarely is, much enlarged ; the arm is small, at least not 
enlarged ; the elbow-joint may be increased in size ; 
the forearm is often enlarged at its lower third, especially 
just above and at the wrist ; the wrist-joint is almost 
always large. The hand, widened, thickened, and often 
lengthened, is massive and enormous, and appears heavy 
and cumbersome for the relatively small arm to carry. 
The ends of the metacarpal bones and phalanges are 
enlarged, giving prominent joints. The skin of the hand 
and the subcutaneous tissues are greatly hypertrophied, 
(SUPPLEMENT.) 
so that the normal lines of the palm are greatly deepened, 
even to the appearance of fissures in the flesh. At the 
upper part of the hand, and over the metacarpal bone of 
the thumb, and on the ulnar border, the hypertrophy of 
the soft parts is excessive. 
The fingers, by the growth of phalanges and soft parts, 
become of the same width and thickness at the tips as 
at the bases, giving the appearance called "sausage- 
shaped," which is a characteristic feature of this disease. 
The above-shaped fingers, with the great thickness of 
the soft parts over the metacarpal bone of the thumb and 
on the ulnar border of the hand, with the exaggerated 
palmar lines, and the abnormal proportion of the hand 
to the size of the forearm, render the acromegalic hand 
a landmark not easily forgotten. 
The fingers may appear somewhat flattened, and, ac- 
cording to Marie, there is often a manifest swelling at 
the articulation of the first and second phalanges. 
Fig. 2.-Author's Case of Acromegaly. View of Enlarged Right Hand. 
The nails are flattened, short, and sometimes widened, 
but always appear too small for the enlarged fingers, 
whose redundant flesh laps over them at the sides. The 
lateral borders of the nails sometimes curve upward 
when the hand is examined with the palm resting on the 
table (Marie). There are strongly marked longitudinal 
striations, sometimes even with ridges, and there may 
be transverse striations on the nails. They are also often 
brittle, breaking off or cracking easily. 
In Cenas's case the nail of one finger fell off sponta- 
neously and a new one developed. 
Lower Extremity.-The thighs are generally not in- 
creased in size, although the condyles of the femurs are 
generally prominent and enlarged, which with the hyper- 
trophy of the patellae causes a marked enlargement of 
the knees. The upper ends of the tibiae and fibulae may 
or may not be enlarged, but the lower ends of the leg- 
5 Acromegaly. 
Acromegaly. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
bones are generally found hypertrophied, causing prom- 
nent malleoli and large ankle-joints. The tendo Achillis 
is frequently prominent and hardened, or " rope-like'' 
(Barclay - Symmer's case). The foot is described as 
" massive," " colossal,'' and " enormous." The bones of 
the feet are all enlarged and especially the os calcis, 
which projects backward, giving a marked prominence 
to the heel. The foot is thick and broad, with a promi- 
nent cushion of thickened skin and subcutaneous tissue 
on the external border, a characteristic feature of the 
foot in acromegaly. The toes are all large, but more 
especially the big toe, which is immense, and crowds the 
other toes together. The skin of the foot is redundant, 
hypertrophied, and thickened, especially on the toes, 
causing them to appear pushed back and turned up, 
throwing the skin into great folds on the upper sur- 
face of the toes. The nails of the toes present appear- 
ances similar to those of the fingers. 
The projecting os calcis, covered with a cushion of hy- 
pertrophied skin and fat, with the pad of hypertrophied 
tissue on the external border of the foot, with the im- 
mense big toe pushing against the other toes, and the re- 
dundant skin, makes the acromegalic foot as prominent 
a landmark as the hand. 
Asymmetry.-Acromegaly is primarily a symmetrical 
(SUPPLEMENT.) 
left hand were enlarged ; while, on the other hand, all 
the toes of the left foot were hypertrophied, and only 
the first, second, and fifth toes of the right foot. Also- 
peculiar in this case was the fact that the fifth toes on 
both feet were larger than the third and fourth toes. 
Litthauer's case showed a slight talipes valgus. 
Muscles.-At first the muscle-growth and muscular 
power are increased, and sometimes the development of 
the ntuscles may be very great, as in Virchow's case of 
the man Westphalen. Sooner or later, however, the' 
muscles become atrophied in greater or less degree, and 
the muscular power is greatly diminished, even to the 
point of compelling the patient to remain in a sitting or 
reclining posture, or even forcing him to remain in bed. 
There may be recurrent attacks of great loss of muscu- 
lar power, so that the patient must be assisted in his 
dressing, to be followed by periods of improved strength. 
The musqles of the arms and legs at this period are- 
flaccid and shrunken, and Virchow suggests that some- 
of the kyphosis and scoliosis may be due to muscular 
debility. Some of the muscles may be found atrophied, 
as Boltz observed in his case the pectoralis major and 
the supra- and infra-spinatus in that condition. On the 
other hand, even while this condition of muscular weak- 
ness is present, there may be hypertrophies of certain 
muscles. 
Mosier found the deltoid, supra-spinatus, rhomboideus, 
and biceps hypertrophied. In the writer's case, the- 
supra-spinatus on the right side is so greatly hyper- 
trophied as to constitute a large muscle-tumor, adding- 
greatly to the kyphotic deformity. 
Skin.-The subcutaneous fat may be increased or di- 
minished, but later is generally found diminished, ex- 
cept, perhaps, on the diseased portions of the body. 
The skin on the affected parts is hypertrophied, and 
generally, especially where exposed, is olive-brown or 
yellowish in color. This yellow color is most marked 
on the face, and here most noticeably on the eyelids. 
The face may, however, be pale, or the nose may be red, 
as in Mosier's case. The skin may be dry and harsh 
from diminished sebaceous secretion. There is fre- 
quently increased perspiration, coming on with slight 
exercise, or even without exercise, either general or local 
on the diseased portion of the body, and especially fre- 
quent on the legs. This perspiration may have a dis- 
agreeable odor. The growth of the hair all over the- 
body is generally increased. That of the head is thick, 
strong, and coarse, while the hair-on the hands and fore- 
arms, and more especially on the legs, is greatly in- 
creased. There may be pigmentations on the skin, as in 
one of Marie's, in Barclay - Symmer's, and in Massa- 
longo's cases. Litthauer speaks of the hands in his case- 
as being of a light bluish color, while in the very inter- 
esting case of Cenas there were various-sized and -shaded 
violet spots on the hands, feet, legs, and body, with also 
a stripe-like line of vitiligo on the inner and back part of 
the thighs and legs. Growths of molluscum fibrosum 
frequently occur on the face, especially on the eyelids, 
and on the chest or back, generally pendulous in charac- 
ter. Multiple fibromata of the skin may occur, of the 
size of a millet-seed, and, according to Mosier, are espe- 
cially apt to occur on the neck and in the hypochondriac 
regions. Fatty nodules may be found beneath the skin, 
and Litthauer reports, in his case, a 10 ctm. long and 
wide lipoma in the right supra-spinatus fossa. 
Blood-vessels.-There are always vaso-motor disturb- 
ances of the affected portions of the body, as shown by 
the tingling, flushing, and local sweating. The flushing 
is often accompanied by a "burning pain." Besides 
these signs, which denote the dilatation of the small 
blood-vessels, there is a marked tendency to a dilated 
and varicose condition of the superficial veins, which is 
frequently found on the legs. Hemorrhoids are often 
present, and Graham's first case had a double varicocele, 
and profuse epistaxis may occur. O'Connor's case had 
enlarged veins of the neck, and Cenas's case had dilated 
veins on the forearm. Hare's case had a hemorrhage 
from the lungs. Mosier says that the arteries, radial 
and temporal, may show signs of beginning atheroma. 
Fig. 3.-Authors Case of Acromegaly. View of Foot with Enlarged 
Toes. 
disease, one part enlarging correspondingly with Its fel- 
low on the other side, but in many cases it is recorded 
that one side of the body was larger than the other, and 
that the right half of the body was more frequently the 
larger. In a number of cases data are given showing 
the growth to have commenced in one foot or one hand, 
or both feet or both hands, before other parts of the body 
were affected. 
In fact, the growth probably generally starts in the 
hands and feet; later, the face and lower jaw are at- 
tacked ; next, the lower ends of the arm and leg bones ; 
next, the crests, tubercles, ridges, and eminences show 
growth, and about this time kyphosis develops, while 
lastly cartilages and tendons all over the body show 
bone-development. Besides the slight asymmetry of the 
two sides of the body, some atypical cases have oc- 
curred. In Kanthack's case the second toe of the left 
foot was enormously enlarged, far beyond the size of the 
other toes. In Canas's case the face, head, hard palate, 
cheeks, lips, and tongue were much larger on the right 
side than on the left. All the fingers of the right hand 
were affected, but only the thumb and first finger of the 
6 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Acromegaly. 
Acromegaly. 
(SUPPLEMENT.) 
The blood has been many times examined, but, though 
the red corpuscles or the haemoglobin may be decreased, 
no marked or constant changes have been found. 
Internal Organs.-The lungs are normal, although 
there may be some dyspnoea, especially on exertion. 
The heart is normal, though often enlarged by simple 
hypertrophy ; the pulse is generally normal, but tachy- 
cardia was present in Massalongo's case. Boltz found a 
soft systolic blowing sound at the apex in his case, prob- 
ably haemic, while in Holsti's case there was mitral dis- 
ease. The liver and spleen are almost constantly normal 
in size. 
The kidneys, as interpreted by the examination of the 
urine, are generally normal, although polyuria is often 
present, and albuminuria may be (writer's case). Sugar 
has been several times present and persistent, and two 
cases, at least, are recorded as having died of diabetes 
(Bury's and Thomson's). Peptone has been found in the 
urine in acromegaly in a few cases (Graham's first case, 
Canas's case), being first discovered by Professor Bou- 
chard. 
Sight.-The eyes may be normal, but are frequently 
affected, in all degrees from occasional flashes of light 
(writer's case), or eye-blurs, to narrowing of the fields of 
vision and atrophy of the optic nerves, even to absolute 
blindness. Exophthalmos is often present, due both to 
actual enlargement of the eyeballs and to bone-growth 
in the orbital cavities. The pupils are generally normal 
in size but may be dilated (Long's and Ruttie's cases), and 
the reaction is generally as usual, though it may be slow 
to light but normal to accommodation. Nystagmus has 
been present in Boltz's case (rotatory nystagmus), in 
Long's case (which was blind) and in Packard's case 
(vertical nystagmus). Litthauer's case showed some 
strabismus divergens from insufficiency of both internal 
recti muscles, and Packard's case showed the same con- 
dition of the right eye. Marie says that we may early 
find, while vision is but slightly impaired, signs of optic 
neuritis caused by pressure. Narrowing of the visual 
fields has been found in all degrees even to bitemporal 
hemianopsia (Ruttie's, Packard's, Dulles's, Mosier's, 
Hare's, Boltz's, Schultze's, Striimpell's, Litthauer's, and 
Denti's cases). Optic atrophy, partial or complete, of 
one or both eyes, has frequently been found (Hadden 
and Ballance's, Ruttie's, Packard's, Hare's, and Boltz's 
cases, and in Long's case with total blindness). The re- 
tinae may show venous congestion, the arteries may be 
small, or they may appear pale (Massalongo's case), or a 
congestion as of a neuro-retinitis may be present (Denti's 
case). 
Hearing.-The hearing is not generally affected, but 
occasionally there has been decided deafness (Flemming's, 
Berkley's, and Osborne's cases). In two cases, at least, 
Barclay - Symmer's and the writer's, continuous and 
never-ceasing tinnitus aurium has been present, and 
Holsti's case complained of "rumbling and swashing" 
sounds in the ears. This ringing, or singing, in the ears 
is, in the writer's case, greatly increased on lying down, 
and often the patient, from this cause alone, cannot sleep 
at night but must remain in a sitting posture. The tin- 
nitus in this case is increased on excitation as well as on 
lying down, and is often of a pulsating character, though 
of a fine, high-pitched tone, when he is at rest. He refers 
the tinnitus to the middle of his head. The drum may be 
hardened and thickened, and so stiffened as to be im- 
movable. 
Smell and Taste.-These are but rarely stated to have 
been affected, though in Godlee's case both were impaired, 
and in Brignini's case taste was slightly affected. 
Nervous Phenomena.-A most constant symptom is pain 
in the head, which may be referred to any region, but is 
generally frontal or vertical, and in the writer's case was 
located in a small circumscribed spot, tender to pressure, 
over the region of the anterior fontanelle. This pain 
may be so mild that it is hardly complained of, or so se- 
vere, violent, and excruciating as to almost render the 
patient insane. Pain is often present in the joints, es- 
pecially the knees, and is often severe in the fingers. 
Pain is frequently complained of in the chest, or abdomen, 
shooting around the body, or confined to one side, or it 
may be lumbar or sacral. Almost every case of acromeg- 
aly has pain, more or less constant and severe, in some 
part of the body, generally without any local cause. The 
pain in the head, however, I believe is often due to the 
enlarging pituitary body, though at other times probably 
to the dilatation of the blood-vessels of the brain ; hence 
the increased headache on lying down, with the feeling of 
pressure, as has been the condition in several cases. 
Crepitations may be found in some of the joints, which, 
of course, would account for the pain there, though there 
is no swelling or signs of acute inflammation. Pain 
sometimes seems to centre at one of the small fibromata 
which occasionally develop in the skin. 
Sometimes a peculiar nervsus sensation is complained 
of, a sensation as of a nervous discharge, or electric 
shower, starting from the top of the head and passing 
quickly over the body to the feet. This is sometimes 
described as giving the sensation of the rolling of shot, 
hence it has been termed the " shot feel." 
There are no marked or constant parsesthesiee in acro- 
megaly, though slight numbness or prickling of the af- 
fected parts is often found, most frequently in the fingers. 
The tactile sense of the fingers maybe impaired, so that 
small objects cannot be readily handled, and sewing, knit- 
ting, or even dressing, becomes difficult. Where this con- 
dition is present it may become much improved, though 
the growth of the body and the advance of the disease 
may continue (Mosier's case). Of course, there is always 
clumsiness in the use of the fingers from the size 
alone. In Mosier's case the fingers would, at times, be- 
come pale and white, accompanied by severe pain, es- 
pecially at night, evidently due to vaso-motor spasm. 
Formication of the affected parts may be complained of, 
and in Adler's case there was hyperaesthesia of all the 
hypertrophied parts, even slight pressure causing the pa- 
tient pain. Ruttie's case had in the early part of the 
disease numbness all over the body. Permanent anaes- 
thesia, analgesia, or impaired perception of heat or cold 
are certainly rare conditions in this disease. 
The electrical responses of the muscles and nerves are 
rarely found abnormal. 
The reflexes, both deep and superficial, are generally 
unimpaired. Occasionally the patellar reflexes are di- 
minished, and sometimes absent on one or both sides 
(Packard's and Strembo's cases). 
The mental faculties in the majority of cases are not 
impaired, but still in a large number of cases it is re- 
corded that there was loss of memory, or apathy, or 
dulness and sluggishness of the mind, with or without a 
depressed state. Marie says that there may be a state of 
great good humor, but, on the contrary, the condition of 
melancholia is more frequent, and even suicidal tenden- 
cies may develop. 
There may be great irritability (Packard's case), while 
there may be delusions, and the patient may be refrac- 
tory and suspicious (Berkley's case). Pick's case showed 
at times decided insanity, and the patient finally com- 
mitted suicide. 
The writer's case, also, five years ago, for a period of 
four weeks, had frequent attacks of mental aberration, 
in which he not only attempted to commit suicide but 
showed homicidal tendencies. 
Another interesting condition which seems to quite 
frequently occur in acromegaly is somnolency. An 
excessive example of this somnolency was Packard's 
case, which had three attacks, the first lasted for 
three weeks, and the second and third lasted even a 
longer time, the last becoming a profound stupor, so that 
for days at a time the patient lay with the eyes open, but 
could not be aroused. This patient, however, came out 
of this condition, and was able to leave the hospital. 
This somnolency is, however, generally only a drowsi- 
ness, with a constant desire to sleep. 
Vertigo may occasionally occur, and be severe enough 
to cause the patient to grasp something for support, and 
also there may be attacks of syncope. 
Ruttie's case, one year after the stoppage of menstrua- 
tion, was seized with a sudden attack of dizziness fol- 
7 Acromegaly. 
Acromegaly. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
lowed by total loss of consciousness, and for three weeks 
it was thought that she could not live. Convalescence 
was slow, interrupted by relapses of agonizing pain and 
vertigo, with loss of consciousness. These attacks be- 
came less and less frequent, but loss of consciousness 
could be produced at any time by a playful slap on the 
shoulder, or by the slamming of a door. 
Pituitary Enlargement.-Exactly how frequently pitui- 
tary enlargement takes place, of course, cannot be stated. 
A number of autopsies have been made in which the 
pituitary body was not enlarged. Clinically, I believe, 
a positive sign of the enlargement of this body to be im- 
pairment of vision. Out of thirty-three cases stating the 
condition of the eyes, eighteen had impairment of vision, 
of a greater or less degree, while in fifteen the vision was 
normal. In these eighteen cases there was pituitary en- 
largement, in all probability, with pressure on the optic 
tract or chiasma, and it is not at all improbable that 
some of the fifteen negative cases may later show loss of 
vision. In the cases in which tinnitus aurium is con- 
stantly present I believe it is often due to the pressure 
of the enlarging pituitary body, laterally, upon the cav- 
ernous sinuses. It also seems probable that the condi- 
tions showing sudden and serious brain trouble, as in 
Packard's, Berkley's, Pick's, Buttle's, and the writer's 
cases, all of which point to cerebral tumor, are due to 
the first sharp pressure which the enlarged pituitary 
body exerts upon the brain, having perhaps suddenly 
burst from its bony moorings. 
That in some cases one eye, in others both, and in still 
others the ears alone are affected, seems to me could be 
explained by the condition of the bony environments of 
the sella Turcica in the individual skull, the enlarging 
pituitary body tending to press in the direction of the 
least resistance. The middle clinoid processes being 
small the earlier will the pressure be exerted on the optic 
commissure, or if one of these processes is smaller than 
the other the pressure will first be exerted on that side, 
and one eye may be affected. 
The following table shows the frequency of some of 
the most important symptoms of acromegaly : it has 
been compiled from thirty-four original articles of true 
cases of acromegaly, plus the abstracts of twelve cases 
for which I am indebted to Dr. Joseph Collins. These 
forty-six cases have been taken at random, and the com- 
pleteness with which each case was reported varies 
greatly, but the statistics here appended may be of some 
value. In no case is a symptom considered as present 
or absent unless positively so stated to be ; consequently 
the frequency with which any symptom is present or 
absent must be compared with the number of cases re- 
porting it, and not with the forty-six cases. 
(SUPPLEMENT.) 
Important symptoms. 
Number 
of cases. 
Symptoms 
present. 
Symptoms 
absent. 
Pelvis enlarged 
7 
4 
3 
Generative organs enlarged... 
7 
4 
3 
Arms enlarged 
19 
4 
15 
Forearms enlarged. .. 
12 
5 
7 
Fingers sausage-shaped .. 
9 
9 
0 
Nails short, and broad 
16 
14 
2 
Wrist enlarged 
10 
9 
1 
Crepitation in joints 
8 
3 
5 
Legs enlarged 
19 
10 
9 
Knees enlarged 
5 
5 
0 
Patellae enlarged 
8 
7 
1 
Ankles enlarged 
5 
5 
0 
Varicose veins of legs 
8 
7 
1 
Albumin in the urine 
19 
2 
17 
Sugar in the urine 
24 
4 
20 
Skin yellow 
8 
7 
1 
Increased growth of hair 
12 
8 
4 
Paraesthesiae 
21 
16 
5 
Muscular atrophy 
12 
11 
1 
Muscular hypertrophy. 
4 
4 
0 
Increased strength 
6 
4 
2 
Diminished strength 
22 
20 
2 
Increased perspiration 
15 
13 
2 
Pain in some part of body 
17 
16 
• 1 
Headache 
27 
23 
4 
Somnolency 
9 
8 
1 
Intellectual faculties impaired.. 
27 
16 
11 
Increased appetite 
20 
10 
10 
Increased thirst 
16 
9 
7 
Polyuria 
10 
6 
4 
Constipation 
9 
8 
1 
Dyspepsia 
6 
2 
4 
Pathological Anatomy. - Eleven autopsies, at 
least, have been made upon cases that have died while 
suffering from acromegaly. Three of these cases were 
not diagnosed until after death, and after the autopsical 
reports had been on record for some time, viz.: Brigidi's, 
Henrot's, and Thomson's. The other cases are those of 
Klebs, Broca, Virchow (Fraentzel), Holsti, Bury, Arnold, 
Sarbo, and Gonzalez Cepeda. 
Seven of these cases showed either a hypertrophied pit- 
uitary body (Brigidi's, Klebs's, Broca's* Gonzalez Cepe- 
da's, Thomson's) or a tumor excavating the sella Turcica 
(Henrot's, Bury's). Brigidi's case furnishes a skeleton 
very typical of this disease. Henrot's case has been 
considered to be a case of myxoedema, but the positive 
bone enlargement certainly proves it to have been a case 
of acromegaly. In this case there was mucoid degenera- 
tion of the pneumogastric and glosso pharyngeal nerves, 
of the brachial plexus, and of the ganglia and cord of the 
great sympathetic, while a tumor was located in the re- 
gion of the pituitary body. 
Thomson gives a very careful description of the skel- 
eton of a case of acromegaly, the autopsy and history ol 
which had been reported by Dr. I). J. Cunningham 
under the title of "A Large Subarachnoid Cyst Involving 
the Greater Part of the Parietal Lobe of the Brain." 
The pituitary body in this case was greatly hyper 
trophied, being four or five times its usual size, and 
though soft and pulpy had caused considerable enlarge 
ment of the sella Turcica. The brain itself was alsc 
enlarged. 
Klebs found not only enlargement of the pituitarj 
body, but also a large thymus gland. The brain in this 
case was also enlarged, and there was thickening of th( 
cranial nerves, especially the oculo-motor and optic. 
Broca made the autopsy and described the skeleton ol 
one of Marie's first cases. He also found an enlarged 
pituitary body. 
Virchow showed and described the skeleton of th< 
case of Fraentzel. In this case the pituitary body was 
normal. 
Holsti found in his case an enlarged brain, and a large 
pulpy pituitary body. He also considered the crania 
nerves to be broader than normal. There was a fattj 
growth in the region of the thymus. 
In Bury's case there was a large tumor at the base ol 
the brain, a glioma, excavating the sella Turcica, pressing 
upon the optic chiasm, and extending to the cerebellum 
There were traces of what may have been a persisten 
thymus. 
Important symptoms. 
Number 
of cases. 
Symptoms 
present. 
Symptoms 
absent. 
Hands enlarged 
46 
46 
0 
Feet enlarged 
45 
45 
0 
Lower jaw enlarged 
37 
36 
1 
Eyes affected 
33 
18 
15 
Kyphosis 
23 
21 
2 
Prognathism 
17 
15 
2 
Lower lip enlarged 
27 
26 
1 
Upper lip enlarged 
18 
15 
3 
Nose enlarged 
29 
29 
0 
Tongue enlarged 
31 
31 
0 
Voice changed 
24 
23 
1 
Taste impaired 
14 
2 
12 
Smell impaired 
11 
1 
10 
Hearing impaired 
20 
4 
16 
Ears enlarged 
23 
13 
10 
Face elliptical 
20 
18 
2 
Forehead low 
10 
9 
1 
Supra-orbital ridges large....... 
16 
13 
3 
Malar bones enlarged 
21 
17 
4 
Superior inaxillte enlarged 
9 
4 
5 
Exophthalmos 
5 
5 
0 
Eyelids enlarged 
10 
6 
4 
Cranium enlarged 
10 
3 
7 
Clavicles enlarged 
21 
18 
3 
Scapulai enlarged 
9 
4 
5 
Sternum enlarged 
12 
10 
2 
Costal cartilages enlarged 
8 
8 
0 
Lordosis 
7 
4 
3 
Scoliosis 
11 
8 
3 
8 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Acromegaly. 
Acromegaly. 
Arnold gave a very exhaustive and careful description 
of the skeleton of Friedreich's case, viz., one of the 
brothers Hagner. Marie does not consider these brothers 
to have had acromegaly at all, and gives several valid 
reasons for his opinion, but I cannot but think with Vir- 
chow, Arnold, Mosier, and Erb that they did suffer from 
acromegaly. They are, however, very atypical cases, 
and there was unquestionable elephantiasis of the legs 
present. The pituitary body was normal in Arnold's 
case. 
Sarbo found in his case, which had had syphilis, evi- 
dence of peri-encephalitis chronica. The pituitary body 
was normal. 
Gonzalez Cepeda found an enlarged pituitary body. 
Such are the special points of interest in these several 
cases. 
The constant pathological findings in acromegaly are 
enlargement of the bones of the hands and feet, and 
almost invariably enlargement of the lower jaw. The 
ends of the long bones are very generally found enlarged. 
The pituitary body, as we have seen, may or may not be 
enlarged, but if we take into consideration the number of 
cases still living that have shown positive signs and 
symptoms of pituitary enlargement, we cannot but agree 
with Marie and Broca that it is a pathological finding of 
great importance. 
On the other hand, an enlarged thymus gland (Klebs 
and Erb) or the possible fragments of a persistent thymus 
have been found so infrequently as to present no patho- 
logical importance in this disease, but is rather a curios- 
ity. As to the thyroid gland, which Marie at first con- 
sidered to be almost always atrophied in this disease, 
though still a factor of great interest and careful examin- 
ation, it has not shown any very constant condition, either 
clinically or pathologically. It may be enlarged and hard 
(Holsti), enlarged and cystic (Bury), normal (Virchow, 
Sarbo), or diminished in size. 
The lungs are not affected (Sarbo found phthisical 
processes in the lungs of his case); the heart may or may 
not be hypertrophied ; the liver and spleen are normal 
(both diseased in Holsti's case, liver enlarged in Bury's 
case). The kidneys may or may not be found diseased. 
The nerves, as stated above, may be affected, and Ma- 
rie thought that there was constant hypertrophy of the 
cord and ganglia of the sympathetic system. The spinal 
cord does not seem to have been carefully examined. 
Syringomyelia was present in Holschewnikoff's case (if 
indeed this was a case of acromegaly) and mucoid de- 
generation in Henrot's case. The cerebrum has been 
found increased in weight, which is due to a general 
growth, and Klebs found that there was an increase of 
the neuroglia cells, but in direct proportion to the gen- 
eral enlargement of the brain-substance. 
There is widening of the blood-vessels and thinning of 
their walls, especially of the veins, as was. first pointed 
out by Klebs and Erb. The valves of the veins have 
been found enlarged. The thinning of the vessel-walls 
weakens them, especially the veins, and, as a result, we 
frequently find a varicose condition of the veins of the 
legs, haemorrhoids, and enlarged veins of the arms, neck, 
or head. The epistaxis noticed in two cases (Osborne's, 
Barclay - Symmer's) may have been due to the same 
cause. Klebs found an increase of the cells in the walls 
of the blood-vessels, which he considered to be the cause 
of the widely distributed new growths of blood-vessels, 
or angiomatosis, and this the cause of the tissue hyper- 
trophy. Von Recklinghausen, however, found no such 
indication of growth of new blood-vessels. The muscles 
at the time of death, unless the patient dies early in the 
disease from some intercurrent affection, are found very 
generally atrophied, although there may be local hyper- 
trophies. Certain muscles, especially the deltoid or su- 
praspinatus, may become markedly hypertrophied, form- 
ing veritable muscle-tumors. One side of the body, most 
frequently the right, may and often is, larger than the 
other, both in the size of the bones and of the soft parts, 
but more especially the latter. Von Recklinghausen, 
with Marie and Mosier, does not agree with Virchow in 
calling an enlarged extremity a " partial acromegaly." 
(SUPPLEMENT.) 
The subcutaneous fat may be increased or decreased 
in thickness, but in the later stages it is probably nearly 
always decreased. The skin is hypertrophied over the 
affected portions of the body, sometimes enormously. 
All the layers of the skin take part in this thickening. 
Elephantiasis has occurred in three cases-the brothers 
Hagner and in Lombroso's case. In the former cases.the 
legs were affected ; in the last case the forearms and 
face. 
Von Recklinghausen says that fibromata and neuro- 
mata of the skin can be present in considerable number 
in acromegaly. Molluscous growths are of frequent oc- 
currence. 
Now turning to a critical survey of the skeleton, we 
find that we are indebted to Broca, Virchow, Arnold, and 
Thomson for the careful study of the condition of the 
bones found in this disease. Broca says that the enlarge- 
ment of the bones is in the extremities, and at the ends 
of the bones. He also says that it is the spongy tissue of 
the short bones and flat bones that is affected, and the 
epiphyses of the long bones. Holsti, however, found 
the compact substance of the bones thicker than normal. 
This growth of bone is an hypertrophy, the bone grow- 
ing from the periosteum, and in the medullary spongy 
tissue at the ends of the long bones. The growth in the 
early part of the disease seems to be more especially con- 
fined to the periosteum ; later, the apophyses and epi- 
physes become affected ; next, the crests, tuberosities, and 
eminences enlarge and grow in the direction of the mus- 
cular action. The tendons are often found in deep 
grooves or bony canals, and the foramina for the nutrient 
arteries are enlarged. 
Osteophytes may be found in the joints, especially over 
the wrist- and ankle-joints, and the cartilages show bone 
developments. 
The spongy ends of the long bones now become more 
compact, the architecture changing, the bone-cells in- 
creasing, and eburnation taking place. The ends of the 
bones in Sarbo's case showed condensing osteitis. As 
Arnold showed, the long bones may apparently lengthen 
by the laying on of bone at the extremities, while the 
shaft is not at all affected ; and von Recklinghausen has 
suggested that the giant appearance of some cases of 
acromegaly could be due to the late union of the epi- 
physis with the shaft, the epiphysis becoming widely 
separated from the shaft by the new bone, thus causing 
a pronounced lengthening. 
Before turning to a more careful survey of the various 
bones, it must not be forgotten that the duration of the 
disease must be considered when examining any par- 
ticular skeleton, as widely different conditions of the 
bones are found at different stages. 
The bones of the cranium are often found thickened 
(Thomson's case had thickening of the cranial bones 
varying from 6 to 12 mm.) and hardened, true bone 
developing in the diploe, as well as the external and in- 
ternal plates becoming hypertrophied. The ridges and 
crests for the attachment of muscles and fasciae are more 
prominent, while the occipital protuberance has been 
found as a spicula-like outgrowth, an exostosis. The 
parietal eminences are sometimes abnormally prominent, 
as are always the superciliary ridges, the latter being 
due not only to the dilatation of the frontal sinuses 
(Bi'oca), but also to the thickening of the plates of the 
frontal bone in this region (Thomson). The sphenoidal 
sinuses have been found dilated (Broca), and also the 
antrum of Highmore. 
The lengthening of the face is largely due to the in- 
crease in the vertical diameters of the superior and in- 
ferior maxillae. The malar bones are almost always 
prominent and projecting, the ridges for muscle at- 
tachment being pronounced. The orbital cavities are 
large, widened transversely, with the borders prominent, 
especially at the external angle. Some of the sutures of 
the bones may be obliterated, as in the articulations of 
the superior maxillae and malar bones in Thomson's case. 
The external auditory canal may be increased in length 
by the growth of the cartilages and the formation of new 
bone. These canals may also be found narrowed by 
9 Acromegaly. 
Acromegaly. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
exostoses. The glenoid cavities are increased in size, 
probably due, as Thomson suggests, to the large size of 
the condyles of the lower jaw. The eminentia articularis 
may disappear, giving an opportunity for the condyle to 
come forward, thus adding to the prognathism caused 
by the growth of the lower jaw. 
The lower jaw is described as massive, the chief 
growth being in the body, which is found lengthened 
and widened, especially at the symphysis, with the men- 
tal process prominent and projecting. The alveolar 
process is widened and thickened, and the rami also may 
partake of this growth, while the angle of junction be- 
tween the body and rami becomes more obtuse. In 
Thomson's case the coronoid processes extended upward 
more than one-third higher than normal. The growth 
of the alveolar process is rarely participated in by the 
teeth (except Cenas's case), they remaining normal in size, 
so that, the alveolar cavities enlarging, we frequently 
have spontaneous falling out of the teeth. 
The projecting lower jaw and lengthening of the chin, 
it must be remembered, are not always found in acro- 
megaly, as undoubted cases have occurred in which 
these conditions were absent. This growth of the lower 
jaw being present, on the other hand, with enlargement 
of the hands and feet, is, I believe, pathognomonic. 
Thomson found the margin of the foramen magnum sur- 
rounded by irregular protuberances of spongy bone. 
Whenever an enlarged pituitary body has been found 
the sella Turcica has been found deepened and enlarged 
in all directions, due to the bone wasting from pressure. 
The hyoid bone may be enlarged and its ridges very 
prominent. 
Changes are always found in the spine, the degree be- 
ing due to the age of the disease. The bodies of the ver- 
tebrae are enlarged, and especially from the laying-on of 
bone on the anterior part. In the cervical and dorsal re- 
gions the increase in bone is often restricted to the upper 
part of the inter-articular cartilages, while in the lumbar 
region the increase of the bone is more general. The spi- 
nous processes are enlarged, and the transverse processes 
may be. The irregular thickening of the inter-vertebral 
cartilages, with the irregular growth of the bodies of the 
vertebrae, sooner or later causes deformities of the spine, 
viz., kyphosis, lordosis, or scoliosis (Virchow-Fraentzel 
case showed alternate right and left scoliosis in the dorsal 
region). Anteriorly the spine may appear as one bone, 
due to the growth of spongy bone in the anterior ligament, 
forming bridges of bone connecting the vertebrae to- 
gether (Virchow-Fraentzel's, Thomson's). 
The sternum is enlarged and thickened, and the ensi- 
form cartilage is ossified, generally projecting outward. 
Often very large transverse ridges are found on the 
sternum, also a hollow or depression may be seen -at 
the upper part, due to to the manubrium not enlarging 
relatively to the body of the sternum. 
The costal cartilages are large, with more or less bone- 
formation, and with prominent cartilaginous or bony 
nodes at the junction with the ribs, simulating the ra- 
chitic rosary. The bone-growth in the costal cartilages 
may give an apparent great widening of the sternum. 
The ribs are wide and thick, and by the faster growth of 
the costal cartilages become abnormally oblique. 
Small bony tumors have been found on some of the 
ribs (O'Connor's case). 
The clavicles are always found enlarged at their ex- 
tremities, but more especially at the sternal end. A 
sharp, inward projecting spicula of bone, exostosis, was 
found in O'Connor's case. 
The scapulae are generally found enlarged, and more 
especially is the spine large and thickened. Thomson 
found the glenoid articular surface enlarged, due to the 
ossification of the glenoid ligaments. 
The articular surfaces of all the long bones may be 
roughened (Broca, Thomson), and there may be exostoses, 
spongy growths, and osteophytes in and around the joints. 
The humerus .may be thus affected, but is infrequently 
enlarged. The radius and ulna, if the case is of long 
standing, are found enlarged at the lower extremities, 
and, perhaps, at the lower third of the shafts. As be- 
(SUPPLEMENT.) 
fore stated, the ridges and protuberances are enlarged on 
all of the long bones, if the disease is at all advanced. 
The enlarged lower extremities of the radius and ulna, 
with the widened and thickened carpal bones, give the- 
large wrist and hand. The metacarpal bones and pha- 
langes are widened and thickened, the former especially 
at the head, and the latter at each extremity, causing the 
prominent joints. The phalanges are generally equally 
affected, but one set may be more affected than the 
other. 
The pelvis is almost always enlarged, especially the 
pubic bones. The symphysis is thick and deep, and the 
crests of the ilia are wide and prominent. Thomson- 
found the ileo-pectineal line on the right side raised into 
a prominent crest, and the acetabula enlarged by partial 
ossification of the cotyloid ligaments. 
The femurs are only enlarged at the lower extremities, 
viz., the condyles, as are also the heads of the tibiae and 
fibulae and the patellae. 
The malleoli are frequently found enlarged. Of the 
tarsus the os calcis is the most affected, growing backward 
into a prominent projection. The metatarsal bones and 
the phalanges are all enlarged similarly to those of the 
hands. Thomson found several of the phalanges of the 
toes ossified together. 
Etiology.-Thus far there has been no positive cause 
found for the occurrence of this disease. Various theo- 
ries have been offered, one of the most interesting of 
which is that by Freund. He suggested the probability 
that acromegaly was a disease of puberty or thereabouts, 
i.e., a disease of development, a possible returning to- 
type, the large hands and feet, projecting jaw, and retreat- 
ing forehead being certainly very suggestive. 
Klebs partially supported this theory, but laid great 
stress on the enlargement of the thymus gland. Virchow, 
however, does not support this theory of Freund at all. 
Professor Freund said that this anomaly of develop- 
ment had some relation to the condition of the develop- 
mental organs, to sexual development, and that the early 
cessation of menstruation or early loss of sexual power 
caused acromegaly. 
This theory is not supported by facts. 
The ages at which forty-six cases were discovered and 
reported are as follows: 
2 cases in second decade of life (10 to 20 years), 
Cenas'scase and Hennig's daughter (Virchow-Fraentzel), 
6 cases in third decade of life (20 to 30 years). 
8 cases in fourth decade of life (30 to 40 years). 
20 cases in fifth decade of life (40 to 50 years). 
8 cases in sixth decade of life (50 to 60 years). 
2 cases in seventh decade of life (60 to 70 years). 
It is here seen that two and one-half times as mahy 
cases first come for treatment, or are discovered, between 
forty and fifty as at any other decade of life. Four- 
teen of the 2Q cases which first came in the fifth decade 
(from forty to fifty), were between forty and forty-five 
years old. 
Of 39 cases giving data of more or less successfully es- 
timated age at which the disease started : 
2 are congenital (Cenas' case and Mennig's daughter). 
4 began in the second decade (10 to 20 years). 
16 began in the third decade (20 to 30 years). 
12 began in the fourth decade (30 to 40 years). 
'5 began in the fifth decade (40 to 50 years). 
This shows nearly three-fourths of these cases to have 
begun between the ages of twenty and forty, and 33 of 
the 39 cases after twenty years of age. 
By the above facts I fail to see how the Freund theory 
is tenable. 
Sex does not seem to bear any special relation to the dis- 
ease. Out of 50 cases, 27 were women and 23 men. 
Of 13 women who were at an age at which menstru- 
ation does not normally cease, 9 had cessation of men- 
struation as a first symptom, while 4 menstruated for 
a time after the beginning of the disease, but soon 
stopped. 
One case, a woman aged fifty-three (Harris's case), had 
had acromegaly for twenty years, but had a child at 
forty-three years of age. 
10 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Acromegaly. 
Acromegaly. 
(SUPPLEMENT.) 
Of 12 cases of men in which it is mentioned, 10 had 
diminished or lost sexual power, while 2 were normal 
in this respect. 
I believe these phenomena are only symptoms, and can- 
not attribute to them, as does Freund, a causative relation 
to this disease. 
While the cessation of menstruation is unquestionably 
an early and a very frequent symptom, it is not constant, 
and is only a symptom. 
The loss of sexual power in the male is a gradual loss, 
diminishing with the progress of the disease. Virchow 
and Verstraeten both find no causative relation between 
the generative organs and acromegaly. 
Klebs and Fritsche found an enlarged thymus gland 
in their case, while Erb found, in three cases, a dulness 
at the upper part of the sternum which he attributed to 
an enlarged thymus. Klebs at first thought that this 
gland, being enlarged or persistent, might have some- 
thing to do with the increased growth of blood-vessels 
and tissue. Later autopsies, however, have proved this 
gland to be generally absent, and Arnold has shown, as 
before mentioned, that the thickening of the sternum in 
the region of the manubrium could give the dull percus- 
sion note sometimes heard. These facts preclude the 
enlarged thymus from the position of an important fac- 
tor in the etiology of this disease. 
Of 19 cases giving data on this point, 15 are recorded 
as having no dulness at the top of the sternum, while in 
4 cases dulness was found. 
The thyroid also has come in for a share in the etio- 
logical interest of this disease, but its condition is found 
to be so varied that it is only of symptomatic importance. 
Out of 32 cases making record of the condition of this 
gland, it was atrophied 14 times, enlarged 8 times, and 
normal 10 times. 
On the other hand, of more than ordinary interest is 
the pituitary body, which has so many times been found 
enlarged in autopsies of this disease, and so frequently 
can be diagnosed as being in that condition in living 
cases. Of 33 cases of acromegaly reporting the con- 
dition of the eyes, 18 had eye-changes, more or less severe, 
and 15 at the time of reporting had no eye-changes, while 
4 had ear-trouble. Headache, sometimes violent, is a 
very frequent and almost constant (23 times out of 27 
cases) symptom. Though acromegaly can surely occur 
without enlargement of the pituitary body, still we must 
acknowledge that it stands very close to some etiological 
factor (angiomatosis, or neurotic origin). 
Nativity does not play any important part in the 
causation of acromegaly, although a number of the cases 
reported in America have been Germans. One case 
(Berkley's) occurred in a negress ; hence the colored race 
is not exempt. 
As to the hereditary history in 46 cases, rheumatism 
was stated as present in the families of 2 of them, 3 had 
tuberculosis in the family, and 2 had a neurotic family 
history. 
The Hagner brothers, atypical cases of acromegaly 
combined with elephantiasis of the legs, were similarly 
affected. 
The daughter of Mennig (Fraentzel's case of acromeg- 
aly, whose skeleton was exhibited by Virchow) had the 
disease ; and Fratrich says that the father of his case had 
large hands like the patient. 
As to the personal history of 46 cases, rheumatism was 
stated to have been present 5 times, 1 had had asth- 
ma, 1 pleurisy, 1 a winter bronchitis, 1 pneumonia, 1 
abscesses of each hip, and 2 had had a severe typhoid 
fever, from which the disease could be dated, while 1 
case (Massalongo's), when twenty-two years old, had 
"loss of consciousness and delirium, which lasted forty 
days, called cerebral fever." 
Klebs is inclined to refer this disease to the vascular 
system, regarding it as an angiomatosis, and Gauthier 
agrees with him. We certainly frequently find varicose 
veins, sometimes hemorrhoids, and occasionally vari- 
cocele and epistaxis, but we do not find blood-vessel 
growths, and von Recklinghausen could not find indica- 
tions of actual growth of new vessels. There is fre- 
quently a burning and flushing of the affected parts, 
showing an increased blood-supply, due to the dilatation 
of the blood-vessels, probably of vaso-motor origin. The 
blood, though many times examined, has shown nothing 
of moment. 
Von Recklinghausen believes that this disease is of 
neurotic origin. He says that acromegaly may be caused 
by vaso-motor disturbances -which may cause neurotic 
hypersemia, going on even to inflammation of the nerves. 
This would explain the condition of a few of the nerves 
found at some of the autopsies. The widening of the 
blood-vessels and the thinning of their walls, especially 
of the veins, can well be the result of such abnormal 
innervation of the vessels. He also thinks that the dis- 
turbance of menstruation can be explained by this general 
angioneurosis. It is also known that disturbed nervous 
conditions can cause hypertrophies of both bones and soft 
parts. 
On the other hand, except the conditions in the brain 
due to direct pressure from an enlarging pituitary body, 
but few signs or symptoms referable to the nervous system 
are found. In forty-six cases some mild paraesthesise 
were stated as present sixteen times, such as numbness, 
prickling or formications, generally in the hands, some- 
times in the feet or ears. The "shot-feel" was twice 
mentioned, once vertigo, and twice fainting attacks. 
Sensibility and electrical conditions were always normal. 
Six times it was stated that the patellar reflexes were 
diminished or absent. Hence, in these forty-six cases 
there was no serious lesion of the nervous system, except 
the trouble caused by the pituitary body. Holschewni- 
koff's case of syringomyelia, with enlargement of the 
bones (acromegaly ?), was probably a mere concidence. 
Although, then, acknowledging that we have not yet dis- 
covered the origin of this disease which affects nerves, 
blood-vessels, glands, bones, cartilages, tendons, muscles, 
skin, and nails, I believe that the spinal cord, especially 
the vaso-motor centre, and the sympathetic system fur- 
nish the most promising field for future research. 
Diagnosis.-This disease must be diagnosed from 
myxoedema, gigantism, erythromelalgia, elephantiasis, 
leontiasis ossea, chronic rheumatism, syringomyelia, 
rachitis, osteitis deformans, arthritis deformans, osteo- 
arthropathie hypertrophiante pneumiqve, local hypertro- 
phies, and adiposis dolorosa. 
More than one case of acromegaly has been described 
under the name of myxadema. Myxoedema is an affec- 
tion associated with an increase of the subcutaneous fat 
and connective tissue, and is characterized by a mucoid 
deposit in the skin and some of the internal organs, 
with marked changes in the thyroid gland and in the 
sympathetic nerves. There is swelling of all parts of 
the face, tongue, throat, and larynx, but generally there 
is no pitting. The hands become large and clumsy, and 
there may be pain in the joints and head. There may 
be loss of hearing, choked disk, and impaired mental 
faculties, even to dementia in the last stages. 
The principal clinical differences between these two- 
diseases are as follows: 
Myxoedema. 
1. About eighty per cent, of all 
cases are women. 
2. Occurs most frequently be- 
tween the ages of forty and fifty. 
3. Bones are never enlarged. 
4. Face has the appearance of a 
"full moon " (Sir William Gull). 
5. The ends of the fingers are 
swollen and clubbed. 
6.' The skin is pale, waxy, puffy, 
boggy, and shiny. 
Acromegaly. 
1. Both sexes are about equally 
affected. 
2. Begins most frequently be- 
tween the ages of twenty and forty. 
3. Bones are always enlarged. 
4. Face is oval or elliptical. 
5. The ends of the fingers are the 
same size as the bases, i.e., " sau- 
sage-shaped." 
6. The skin is yellowish, wrin- 
kled, and hairy. 
Gigantism, or giant growth, is distinguished from 
acromegaly by the fact that in the former there is sym- 
metrical and general growth all over the body ; the cra- 
nium grows as much as the facial bones, and the face 
does not look too large for the head, nor the head too 
large for the body, as is the case in acromegaly. 
11 Acromegaly. 
Acromegaly. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
In gigantism the ends of the bones are not enlarged 
out of proportion to the size of the shaft, and the hands 
and feet are not enlarged out of proportion to the arms 
and legs. The bones increase in length as well as in 
width and thickness, and that symmetrically, and the 
whole growth of the body is in proportion, as in a nor- 
mal individual, all of which is quite the contrary in 
acromegaly. 
In gigantism there is no projection of the lower jaw, 
there are no nervous phenomena, there are no eye and 
•ear symptoms. The nose, ears, lips and tongue are not 
increased in size out of proportion to the size of the head, 
face, and mouth. The foot in giant growth is in normal 
relation to, or even too small for the length of the body, 
according to Virchow. He says, normally, the foot is 
one-sixth the body's length, and in gigantism the height 
is more than six times the length of the foot, while in 
acromegaly the height is always less than six times the 
length of the foot. 
In acromegaly the bone-growth and hypertrophy are 
always at the ends or extremities of the long bones, 
and never is the shaft lengthened, although an apparent 
lengthening may take place due to a laying-on of bone at 
the ends, producing an actual increase in measurement, 
but -without growth of the shaft. 
In erythromelalgia, a vaso-motor neurosis of the ex- 
tremities, there may be some increase in the size of the 
hands or feet. There may be, according to Weir Mitch- 
ell, severe pain of the part, and there is always an im- 
paired blood-flow, giving burning sensations, local red- 
ness, and even cyanosis, often in patches or spots. Cenas's 
case, with its peculiar pigmentation, is the only case of 
acromegaly that has markedly simulated erythromelalgia. 
In the latter disease, however, there is no enlargement of 
the bones or soft parts of the face, no eye symptoms, no 
marked change in the speech, and the hand itself is un- 
like the acromegalic hand, the fingers are not sausage- 
shaped, but smaller at the tip than at the base. 
Elephantiasis arabum is a hypertrophic disease of the 
skin and subcutaneous tissue, located generally in one, 
■occasionally in two extremities of the body. There is 
generally a history of several attacks of local inflamma- 
tion of the part affected, followed by a continuous growth 
and hypertrophy of the skin, until an enormous size is 
reached. The hypertrophied skin falls in great folds, 
fissures form, and the part becomes one immense, homo- 
geneous mass, without form or shape, and sections show 
a fibrous tissue without nerves or blood-vessels. 
How different is this picture from that of acromegaly, 
where all of the extremities are enlarged, or at least 
one after the other, and the parts never lose the normal 
curves, prominences and hollows, and, though large, pre- 
serve their normal contours. 
Again, in elephantiasis the bones are not enlarged, the 
skeleton is not affected, and the nervous, facial, and cere- 
bral phenomena are not present. 
Leontiasis ossea is the name given by Virchow to the 
condition where osteophytes, or bony tumors, are formed 
on the face and cranium. These bony tumors are of 
irregular distribution, and produce great deformity and 
asymmetry. There is no hypertrophy of the limbs. 
Though this disease has been several times mentioned in 
the diagnosis of acromegaly, I fail to so see how it could 
be confounded with the general constitutional disease of 
acromegaly with its manifold signs and symptoms. 
During the first stages of acromegaly one of the fre- 
quent symptoms, and often a prominent one, is joint-pain, 
which at this stage might confuse the diagnosis with 
that of chronic rheumatism. The joints at this time are 
tender to the touch, but are not reddened or swollen. 
The pain is not permanent in any one or two joints, and 
ankylosis does not take place, although later crepitations 
are often present, and some contractures of the fingers 
may be found, as in Canas's case, due to the flexor tendons 
not growing as rapidly as the bones. As soon as the 
hands, feet, or face begin to enlarge, the diagnosis from 
chronic rheumatism becomes plain. 
Syringomyelia is a disease of the nervous system, char- 
acterized by a " gliomatous new formation about the cen- 
(SUPPLEMENT.) 
tral canal of the spinal cord, with cavity formation " 
(Osler). 
This disease generally begins before twenty, or in early 
adult life, and in its slow development and long dura- 
tion simulates acromegaly. After the complete develop- 
ment of either disease, however, " the amyotrophic pa- 
ralysis, with retention of tactile and loss of thermic and 
painful sensation " (Osler), on the part of the syringo-my- 
elia, and the enlarged extremities, the formation of the 
face and chest, to say nothing of the pituitary enlarge- 
ment, on the part of the acromegaly, render the diagnosis 
easy. 
Holschewnikoff has reported a case of syringomyelia, 
with thg formation of gliomata in the spinal cord, to- 
gether with degeneration of some of the peripheral 
nerves, in -which there was decided bone-growth of the 
extremities, in fact an acromegalic condition. 
Rachitis is a disease of childhood, or rather babyhood, 
occurring most frequently in children under three years 
of age. This alone would exclude the possibility of con- 
fusion with acromegaly, except in congenital cases. 
Rickets is pre-eminently a disease of impaired bone-for- 
mation, as instance slow development or entire absence of 
the teeth, and impaired growth or softening of the bones, 
while acromegaly, on the other hand, is pre-eminently a 
disease of increased bone-formation. 
The ends of the bones, especially the epiphyses of the 
wrist, unquestionably are enlarged in rickets, while the 
hands and feet may be flattened and apparently widened, 
but there is no increase in the thickness of the hands or 
feet. The bones of the head show no malformation, ex- 
cept flattening and lengthening of the cranium with pro- 
jection of the occiput, and the softened spots. This 
causes the cranium in rickets to appear too large for the 
face, while in acromegaly the face appears too large for 
the cranium. 
Also in rickets we find deformation of the pelvis, and 
if the child creeps, deformities of the arm-bones, and if 
he walks, bending of the leg-bones. This is quite differ- 
ent from acromegaly, where we have -widening, harden- 
ing, and general growth of the bones. Softening of the 
ribs causes a sinking in just before the junction with the 
cartilages, giving the formation of the rachitic rosary, 
which from another cause we find in acromegaly. 
Kyphosis, when it occurs in rachitis, is in the dorsal 
region, while in acromegaly it is almost invariably in the 
cervico-dorsal region. It is thus seen that it is hardly 
possible to confound the one disease with the other. 
The diagnosis between the osteitis deformans of Paget 
and acromegaly is generally not difficult. 
The following schedule will show some of the marked 
differences : 
Osteitis Deformans. 
1. Rarely occurs before fifty, 
never before forty years of age. 
2. The long boiies are the ones 
primarily affected, rarely are the 
hands or feet affected. 
3. Long bones are often curved, 
giving great deformity. 
4. Often one limb or one bone is 
affected long before another limb or 
bone. 
5. The cranial bones are affected, 
rarely the facial. 
6. Lower part of face is narrow, 
giving a triangular appearance to 
the face. 
Acromegaly. 
1. Very generally begins before 
forty years of age. 
3. Hands and feet are enormous, 
rarely' tire long bones much affect- 
ed. 
3. Long bones are normal in 
shape, possibly thickened at the 
extremities, but are never curved. 
4. Hands, feet, arms, and legs 
generally nearly symmetrical. 
5. The facial bones are affected, 
rarely the cranial. 
6. Lower part of face is broad, 
giving an elliptical appearance to 
the face. 
The above gross, to say nothing of more minute differ- 
ences, will generally readily make the diagnosis of oste- 
itis deformans from acromegaly. 
Arthritis deformans, perhaps, approaches more nearly 
than any other bone disease to the external conditions 
found in acromegaly. In arthritis deformans decided 
changes take place in the articular tissues, accompanied 
by pain, with sooner or later great deformity and anky- 
losis of the joints. Tender nodules may appear in the 
muscles, while the muscles themselves become atrophied. 
12 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Acromegaly, 
Acromegaly, 
The disease is apt to attack the same joints on both sides 
of the body symmetrically, but soon spreads to all of the 
joints. The hands । are thin from the wasting of the fat 
and muscles, but the ends of the phalanges and metacar- 
pal bones may be enlarged and nodular. The fingers are 
more or less flexed and turned toward the ulnar side of 
the arm, while the joints of the hand are all stiff and 
more or less completely ankylosed. How different is this 
condition from the acromegalic hand ! 
Within the joints bony or cartilaginous protuberances 
are found on the outer' surface of the epiphyses in 
arthritis deformans, while in acromegaly we may find 
osteophytes at the ends of the bones, as in the Virchow's 
skeleton, or the bony growths found in the joints of 
Thomson's case. Outside of this similarity in the joints 
between these two diseases there is no agreement of 
symptoms or appearances. The hypertrophy of the soft 
parts of the hands and face, with the enlargement of the 
bones of the face, with the cervico-dorsal kyphosis, 
enlarged tongue, changed voice and eye changes, if pres- 
ent, will all or any of them make the diagnosis from ar- 
thritis deformans. Schulz has reported a case of acrome- 
galy associated with arthritis deformans. 
In January of 1890, in the Revue de Medicine, appeared 
an article by Marie in which he described a new disease, 
and which he named osteo-arthropathie hypertrophiante 
pneumique. This disease, as its name implies, is char- 
acterized by a disease of the lungs with an enlargement 
of the extremities, and therefore simulates acromegaly. 
The affection of the lungs may be an empyema, a 
bronchitis, or neoplastic formations, and, according to 
Mosier, there is present a micro-parasite, the absorption 
of the products of which into the blood and the deposit of 
these in the joints produces a hypertrophic inflammation. 
The hands are enlarged, but principally in the joints and 
the ends of the fingers, the middle of the hand not being 
attacked. The elbow-, shoulder-, and knee-joints are all 
affected, and there is always more or less impaired 
motion. The wrist-joint is large, the hand proper not 
much enlarged, while the fingers are increased in size, 
especially the last phalanx, but the soft parts are not 
hypertrophied. The appearance of the finger-nails is 
also quite characteristic of this disease. They appear too 
large for the fingers, spreading out at the sides, and even 
curving over the ends of the fingers, often giving the 
appearance of the beak of a bird, while the enlarged 
ends of the fingers have caused them to be likened to 
drumsticks. Turning to the acromegalic hand, with 
its immense thickening of the hand proper, hypertrophy 
of the soft parts, equally enlarged phalanges, sausage- 
shaped fingers, small nails, much too small for the fingers, 
one might make the diagnosis by the hand alone. The 
bones in osteo-arthropathie pneumique are enlarged, but 
not the soft parts, while in acromegaly both are enlarged. 
In the former disease dorso-lumbar kyphosis may be pres- 
ent, while in acromegaly the kyphosis is cervico-dorsal. 
In Packard's case of osteo-arthropathie pneumique, how- 
ever, the kyphosis was cervico-dorsal (Am. Jour, of the 
Med. Sciences, June, 1892). 
The feet and toes in this disease are affected similarly 
to the hands. The face presents a different appearance 
from that of acromegaly ; it is more rounded, the lower 
jaw is very rarely enlarged (occurred in Packard's case), 
prognathism does not occur, the face appears small, the 
soft parts are not hypertrophied, and the lips and tongue 
are normal in size. 
Virchow proposes to call the local hypertrophies which 
are occasionally met with, where one hand, or one foot, 
or one finger or toe, or several fingers or toes, are in- 
volved, " partial acromegaly." Marie and Mosier do not 
accept this classification of these local hypertrophies, 
even if the bone of the part is enlarged, and I agree 
with them that these simple hypertrophies should not 
be confounded with the distinct disease of acromegaly. 
Marie says: "Let established names as macrodactylia 
and macropodia and unilateral macrosomia, etc., be pre- 
served, as the names for these peculiar localized hyper- 
trophies." 
These local enlargements of one extremity, or one 
(SUPPLEMENT.) 
finger, or one toe, are generally congenital, though they 
may increase in growth at the time of puberty, and the 
part is generally increased in length. One side of the 
face may be affected, involving bones and soft parts, in- 
cluding the tongue, tonsil, and palate on that side, but 
whatever the enlargement there is no symmetry. 
One more disease remains to be diagnosed from acro- 
megaly, viz., the disease recently described and named by 
Dr. F. X. Dercum, adiposis dolorosa {American Journal of 
the Medical Sciences, November, 1892). In this article he 
reports three cases, all women, where there was an enor- 
mous growth of fat. In the first case it was especially 
marked on the arms and body, where the fat fell in great 
folds. The second case showed an immense development 
of fat all over the body, but unevenly distributed in 
lumps and in folds ; she had headache, great weakness, 
and cardiac dyspnoea, but no mental impairment, and 
sight and voice were not affected. The autopsy of this 
case showed an indurated thyroid gland, with some de- 
posit of calcareous matter, and there was oedema of the 
lungs. 
The third case showed great development of fat on the 
upper arms, and especially on the abdomen, where the 
fat lay in great folds or tumors. She was somewhat deaf, 
apathetic, and had headache. This case also came to 
autopsy. The thyroid gland was larger than normal and 
somewhat calcified, but nothing else of moment was- 
found. Dr. Dercum says that the nodules of soft tissue 
are at first deposited in one location, or, perhaps, in cor- 
responding places on the upper or lower extremities. 
Then other parts are attacked, though some portions of 
the body are left without much fat development, and soon 
pain and other nervous symptoms appear. In the first of 
these cases of adiposis dolorosa the thenar and hypothenar 
groups of muscles showed the reaction of degeneration. 
Electrical changes are never present in acromegaly. 
Also the absence of any marked enlargement of the 
hands, feet, and face, as well as no bone-growth, excludes 
confusion with acromegaly. 
Prognosis.-Marie estimates the duration of this dis- 
ease to be from ten to twenty years. Of twenty-five cases 
giving the estimated duration only three have died, but 
the average duration of the disease in the twenty-two 
living cases is twelve and one-half years. 
Fifteen of the twenty-five cases are over terf years in 
duration, and six over twenty years, while the range is 
from three years to thirty-four years (Bury's, and Gra- 
ham's second case, both dead). 
This disease is one of continuous progression, espe- 
cially in the growth of the bones. Under treatment, or 
without treatment, periods of apparent quiescence, or 
periods of cessation of symptoms occur, and the soft 
parts of the hypertrophied portions of the body not only 
may not enlarge but actually appear diminished in size. 
Yet even in such cases the bones continue to grow. 
These periods, when the patient may say he feels well, 
are, sooner or later, followed by marked exacerbations 
of all the symptoms, often coming on suddenly, even pre- 
cipitately. These symptoms, all of which may be ameli- 
orated by treatment, are severe headache, often dizzi- 
ness, great constipation, troublesome dyspepsia, aggra- 
vated eye or ear symptoms, great temporary loss of 
strength, and melancholia, with more or less pain referred 
to various parts of the body. At this time the soft parts 
on the hypertrophied portions of the body appear larger, 
although oedema cannot be found. 
A more or less complete recovery from these exacer- 
bations, or severe symptoms, generally occurs, but the 
patient is not quite as well in all respects as he was be- 
fore. Thus the disease proceeds, with some symptoms 
more or less constant, until there is hardly a tissue or 
organ of the body that is not affected in greater or less 
degree. 
Finally, little by little, the patient falls into a condition 
of progressive cachexia, with partial or nearly complete 
loss of muscular power, due to atrophy of the muscles, 
so that he may be compelled to remain in bed. This 
condition may last for several years, and then death oc- 
curs unexpectedly, with the appearance of syncope. It 
13 Acromegaly. 
Adiposis Dolorosa. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
is possible that an enlarged pituitary body may cause 
coma and death. Most cases of acromegaly, however, 
die of some intercurrent affection. 
The headache may become so severe as to cause suicidal 
tendencies, and temporary insanity may occur, probably 
caused by pressure from an enlarged pituitary body. 
Treatment.-This disease is incurable, but in any 
given case we can safely expect to ameliorate many of the 
nervous symptoms. Of all treatment rest is the most im- 
portant, under which all the phenomena, except those 
produced by actual lesions, will improve. Pain, the most 
frequent cause of complaint, has been treated by anti- 
pyrine, acetanilide, phenacetin, exalgine, caffeine, and 
codeia. Dulles gave salol and phenacetin for the head- 
ache, while in Ruttie's case it was helped by exalgine in 
three-grain doses every eight hours. Phenacetin, occa- 
sionally, and codeia, in small doses, continued for one or 
two weeks, have given good results in the writer's case. 
The constipation should be treated, while dyspepsia, 
when present, can be best helped by a diet that requires 
but little mastication, as prognathism, which is so fre- 
quently present, is generally the cause of the dyspepsia. 
The bromide of potassium is often of service in relieving 
the headache and the feeling of pressure in the head. 
Positive impairment of sight or hearing cannot be im- 
proved, and if the sight is affected at all the loss of vision 
will probably increase. Tinnitus aurium, if due to this 
■disease, can probably be but little, if at all, helped. 
Arsenic in some form, given for a long time, has done 
good service. Denti used the arseniate of iron. Mosier 
used baths and the faradic current to the back. 
But, as before stated, any tonic or bracing treatment, 
combined with rest, will generally cause a cessation of 
the acute symptoms and a pause in the disease, except in 
the last stages. A theoretically good treatment, owing to 
the condition of the blood-vessels, dilated and with weak- 
ened walls, and of practical value in Mosier's and the 
writer's cases, is ergot. Ergot or ergotine should be 
given continuously for a long period, the exact length of 
time being governed by the results. 
If there is atrophy of the muscles and great loss of 
muscular power strychnia, by the mouth or hypodermi- 
cally, is of value. 
Phosphorus has been used in acromegaly, also the 
Oertel treatment, and the milk diet. 
Where glycosuria has been present the diabetic diet 
has been used. 
(SUPPLEMENT.) 
1888. Tresilian, Fred.: British Med. Journ., Marcli 24. 1888, 642. 
1889. Virchow, Rud.: Berliner klin. Wochnschr., February 4, 1889 : also 
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1889. Gouraud, X.: Paris, 1889. 
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148. 
1889. Schapovnikow ; Med. Rundschau, 1889 (Russ.). 
1889. Klebs: Die krankhaften Storungen. etc., 1889. 
1889. Schaposchnikoff, B. M.: Mosk., 1889. 
1889. Sacchi, E.: Venezia. 1889. 
1890. Pechadre : Revue de Med., Paris. 1890. 
1890. Holschewnikoif : Virchow's Archiv., Bd. 119, 1890. 
1890. Von Recklinghausen : Virchow's Archiv., Bd. 119. 1890. 
1890. Waldo, H.: Brit. Med. Journ., i., 1890. 
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475-492. 
1890. de Souza-Leite. J. D.: De 1'acromegalie, Paris, 1890. 
1890. Gauthier, G.: Le ProgrSs Medical. Paris, 1890, No. 21. 
1890. Renner: Vereinsblatt der pfoelzischen Aerzte, Frankenthal, Au- 
gust. 1890. 
1890. Graham. J. E.: Tr. Ass. Am. Physicians, Philadelphia, 1890, Ivii., 
390-395; also Med. News, Philadelphia, October 18, 1890. 
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1890. Pick, A.: Prag. med. Wochnschr., 1890, xv.. 521-523. 
1890. Campbell, E. K.: Tr. Clin. Soc. London, 1890, xx.ii., 257-260. 
1890. Flemming, P.; Tr. Clin. Soc., London, 1890, xxiii., 253-250. 
1890. Silcock, A. I.: Tr. Clin. Soc.. London, 1890. xxiii., 256-257. 
1890. Cdnas : Loire Med.. St.-Etienne, 1890, ix., 313-332. 
1890. Claus: Ann. Soc. de med. de Gaud., 1890, Ixix., 281-288. 
1890. Gerhardt, C. : Berliner klin. Wochnschr., 1890, xxvii., 1183-1185. 
1890. Bettencourt, Rodrigues J.: Soc. d. sc. med. de Lisb., 1890, liv. 
366. 
1890. Holsti, H. : Festski. f. Path. Anat. Inst., Helsingfou, 1890, 103- 
126. 
1890. de Souza-Leite, J. D. : Rev. scient., Paris, 1890, xlvi., 801-807. 
1890. Hutchinson, J. : Arch. Surg., London, 1890-1891. ii., 296-298. 
1891. Cheron, P.: Union med., Paris. 1891, 3 s., Ii., 25-33. 
1891. Leizet, C. : Arch. gen. de med.. Paris. 1891. i., 194-212. 
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April, 1891, 144-152. 
1891. Du Cazal : La semaine Medicale, Paris, October 21, 1891. 
1891. Arnold, J. : Beitr. z. path. anat. u, z. allg. Path., Jena, 1891, x., 
1-80. 
1891. Pinel-Maisouneuve, L.: Bull, et m£m. Soc. med. d. hop. de Paris, 
1891, 3 s , viii., 137-139 ; and also Arch, d'opht., Paris, 1891, 
xi, 309-313. 
1891. Mosier, C. F. : Festschrift Rudolph Virchow, Bd. ii., 103. 
1891. Ruttie. R. : Brit. Med. Journ.. London. 1891, i., 697 ; also Med. 
Press and Circ., London, 1891, n. s., ii,, 397. 
1891. Debierre : Rev. gen. d'opht., Paris, 1891, x., 12-14. 
1891. Bury : Lancet. London, 1891, 1., 1383. 
1891. Kanthack, A. A. : Brit. Med. Journ., London. 1891, ii., 188; also, 
Tr. Path. Soc., London. 1890-1891, xliii., 251. 
1891. Marie et Marinesco: Arch, de med. exper. et d'anat. path., Paris, 
1891, iii., 539-565. 
1891. Berkley. H. J.: Bull. Johns Hopkins Hosp., Baltimore, 1891, ii., 
134-136. 
1891. Somers, G. B. : Occidental Med. Times, Sacramento, 1891, v., 
537-543. 
1891. Foy, G.: Med. Press and Circ., London, 1891. n. s., liii., 491. 
1891. Gorjatcheff, I. A.: Chir. Laitop., Moscow, 1891. i.. 155-160. 
1891. Spillman et Haushalter : Rev. de med., Paris, 1891, xi., 775-780. 
1891. Litthauer, Max : Deutsch Med. Wochnschr., November 19, 1891. 
1891. Bignani: Bui. d. Soci Lancisiana d'osp. d. Roma. 1891, x., 238. 
1891. Strembo : Med. Wochenschrift. 1891, Nos. 45 and 46. 
1891. Bradford : Brit. Med. Journ., December 26, 1891, 1354. 
1891. Redmond, J.: Tr. Rov. Acad. M. Ireland. Dublin, 1890-1891, ix., 
64-66. 
1892. Packard, F. A.: Am. Journ. Med. Sciences. Philadelphia, June, 
1892, 657. 
1892. Osborne, O. T.: Am. Journ. Med. Sciences, Philadelphia, June 
1892, 617-625. 
1892. Duchesnau, G.: Contribution a 1'etude anatonnque et Clinique de 
1'acrom^galie et en particulier d'une forme amyotrophique de 
cette maladie, 4to, Lyon, 1892. 
1892. Appleyard : Lancet, London, 1892, i., 316. 
1892. : Lancet. London, 1892, i., 746-748. 
1892. Balzer, F.: Bull, et m6m. Soc. med. d. hop. de Paris, 1892, 3 s., 
ix., 237-239. 
1892. Bard : Lyon med., 1892, Ixix., 547. 
1892. Barrs, A. G.: Lancet, London. 1S92, i.. 683. 
1892. Gonzalez. Cepeda J.: Rev. balear de cien. med., Palma de Mallor- 
ca, 1892. viii., 7-10. 
1892. Hare. H. A.: Med. News, Philadelphia, 1892, lx.. 237-239. 
1892. Hutchinson, J.: Arch. Surg., London, 1891-1892, iii., 343-347. 
1772-1801. Sancerotte communicated a case to the Academie de Chir- 
urgie, 1772. Published in Melanges de Chirurgie, 1801, 
part i., 407. 
1822. Alibert : Precis theorique et pratique des maladies de la peau. 
Paris, 1822, t. iii., 317, 
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Institute di Scienze e Lettere, Adttnanza del 28 Aprile, 1864. 
1868. Friedreich : Virchow's Archiv., Bd. xlvii., 1868, 83. 
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translated by Fraenkel, Virchow's Archiv., Bd. xlvi, 1869, 253. 
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1877. Brigidi communicated a case to the Societa medico-phisica fio- 
rentina. August 26. 1877. 
1879. Taruffl, Ces.: Annali Universal! di Medicina, T. ccxlvii. et ccxlix., 
1879. 
1882. Henrot, H.: Notes de Clinique Medicale, Reims, 1877 ; and Notes 
de Clinique Medicale, Reims, 1882. 
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tersuchungen. Leipzig, 1884. 
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1885: als > Clinical Society's Transact., vol. xxi., 1888. 
1885. Wadsworth : Boston Med. and Surg. Journ., January 1, 1885. 
1886. Marie, P.: Revue de Medicine, Paris, 1886, vi., 297-333. 
1887. Minkowski, O.: Berliner klinische Wochnschr., 1887. No. 21. 
1888. Bier, Aug.: Mittheilungen aus der chiruigischen klinik zu Kiel, 
iv., 1888. 
1888. Godlee, R. J.: British Med. Journal. 1888. 
1888. O'Connor, J. T.: N. Am. J. Homeop., N Y., 1888, 3 s., iii.. 345-358. 
1888. Fraentzel, O.: Deutsche Med. Wochnschr., August 9, 1888. 
1888. Adler, I.: Boston Med. and Surg. Journ., 1888, cxix., 507 
1888. Wilks : Clinical Society of London, April 13, 1888. 
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Paris. 1888, i., 175-182. 
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Literature. 
14 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Acromegaly. 
Adiposis Dolorosa. 
1892. Solis-Cohen, S.: Med. News, Philadelphia, November 5. 1892. 
1892. Harris, H. F.: Med. News. Philadelphia, November 5. 1892. 
1S92. Dulles, C.: Med. News, Philadelphia, Novembers, 1892. 
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1892. Denti : Atti. d'Ass. med. Lombardi, Milano, 1891-92. 41. 
1892. Sarbo, A.: Orvosi hetil. Budapest. 185)2, xxxvi.; also transl. Pest 
med.-chir. Presse, Budapest. 1892, xxviii., 575. 
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1892. Boltz. R.: Deutsche med. Wchnschr., Leipzig, u. Berlin, 1892, 
xviii., 635. 
1892. Fratrich : Allg. Wien. med. Ztg., 1892, xxxvii.. 405-418. 
1892. Holsti. H.; Ztschr. f. klin. Med., Berlin, 1892, xx., 298-310. 
1892. Massalongo, B.; Riforma med., Napoli, 1892, viii., pt. 3, 74-87. 
1892. Buzer, C.: Aerztl. Rundschau, Munchen, 1892, ii. 509-511. 
1892. Mosier : Wien. med. Bl., 1892, xv., 56, 70, 87, 105, 121, 136. 
Oliver T. Osborne. 
(SUPPLEMENT.) 
she was transferred to the nervous wards of the hospital 
and came under the care of the writer. 
Her appearance at this time was striking. She was a 
tall, large-framed woman who looked as though she had 
at one time presented a fine physical development, but 
she seemed unnaturally broad across the back and 
shoulders. On removing the clothing an enormous en- 
largement of these parts was disclosed. The enlarge- 
ment affected both shoulders, the arms, the back and 
the sides of the chest. It was most marked in the upper 
arms and back, forming here huge and somewhat pen- 
dulous masses. It was elastic and yet comparatively 
firm to the touch, and it was impossible to produce pit- 
ting. In some situations it felt as though finely lobulated, 
and in others, especially on the insides of the arms, as 
though the flesh were filled with bundles of worms. 
ADIPOSIS DOLOROSA. At a meeting of the Ameri- 
can Neurological Association, held in New York in 
June, 1892, the writer presented the histories and 
photographs of three cases of an affection which 
up to that time had not been recognized. The 
first of these cases had been under the writer's 
care since 1887, and is still living. The second 
and third were discovered in the wards of the 
Philadelphia Hospital in 1891, and both cases 
dying, autopsies were held in each instance. 
The histories of these cases are briefly as fol- 
lows : 
Case I.-M. G , aged fifty-one, female, 
widow, a native of Ireland, and a domestic. Her 
father had died at forty-five of erysipelas. Her 
mother, who had had eighteen children, died at 
forty of some affection incident to the meno- 
pause. Of her brothers and sisters, seven died 
in childhood, one in adult life of pleurisy, one 
sister in childbirth, a brother and two sisters of 
phthisis, while the remaining five are living and 
apparently in good health. None of the patient's 
relatives have ever suffered, as far as she knew, 
from symptoms similar to her own, nor had any 
of them ever had any nervous or mental affec- 
tion. 
As a child she had had measles, whooping-cough, and 
scarlet fever. Menstruation began normally at fifteen. 
At eighteen she married. Some years later she had an 
attack of pneumonia but made a good recovery. She 
had in all seven children and one miscarriage. Five 
children died in early childhood, one from cholera in- 
fantum, two from measles, one from "congestion of the 
brain," and the fifth from spasms. The menopause set 
in abruptly at thirty-five. From this time up to within 
two or three years her health had continued good. She 
had undergone some increase in weight, but beyond this 
nothing worthy of mention could be elicited. Syphilis 
was denied, as was also alcoholic excess. However, the 
condition of the patient on several occasions upon her 
return to the hospital after furlough was such as to 
throw more than doubt upon her denial of alcoholic 
abuse. 
When forty-eight or forty-nine years of age she noticed 
that her arms were becoming very large. The upper 
arms and shoulders appeared swollen. The swelling con- 
tinued steadily to increase and was for about a year un- 
attended by any other symptom. 
In November, 1886, she was admitted to the surgical 
wards of the Philadelphia Hospital for the rupture of a 
varicose vein of the leg. In the following February she 
was transferred to the medical wards for a severe attack 
of bronchitis. Later she had an attack of severe pain and 
swelling in the right knee, attended by chill and fever. 
She was treated for rheumatism and promptly relieved. 
Two weeks after this she complained of a sharp darting 
pain in the right arm. It begun on the outer aspect above 
the elbow and gradually increased in severity and ex- 
tent, spreading upward to the shoulder and neck, and 
downward to the forearm and hand. It was shooting 
and burning in character. She felt at times as though 
hot water were being poured upon the arm, and again as 
though the hands and fingers were being torn apart. No 
rise in temperature was noted. The pain was often par- 
oxysmal, but it was never absent. On June 4, 1887, 
Fig. 4.-Author's First Case, Showing Large Masses of Fat on Back and Upper Arm. 
The skin was not thickened ; it did not take part in the 
swelling, and it was not adherent to the subjacent tissues. 
In addition the swelling was very painful to pressure. 
Pronounced pressure appeared to be absolutely unbear- 
able. The nerve-trunks also were exquisitely sensitive, 
but this painful condition was not by any means limited 
to them, but permeated the swollen tissue as a whole. 
The muscles were not involved in the swelling. The 
affected parts were, however, quite weak. Examined 
electrically the muscles of the shouldersand arms yielded 
a negative result, partly because of the great resistance 
caused by the intervening tissue. Slight qualitative and 
quantitative changes were noted in the muscles of the 
forearms, while in the hands distinct reaction of degen- 
eration was noted in the thenar and hypothenar groups, 
more evident on the right side. 
Cutaneous sensibility was much diminished. On the 
right arm various areas existed in which no response 
whatever was given to the aesthesiometer. They were 
large and irregular in shape, and very sharply defined, 
and were present on both the inner and outer aspects. 
In the finger-tips the points could not be at all separated. 
In the left arm, some impairment of sensation was de- 
tected on the outer aspect of the forearm, and in the 
finger-tips sensation was decidedly below normal. Sen- 
sibility to heat and cold appeared also to have been les- 
sened. 
On examining the legs it was found that cutaneous 
sensibility was distinctly lessened on the right, while 
showing little or no impairment on the left. 
No enlargement was noted at this time in any part of 
the body save in the arms and shoulders. The face was 
pale, as were also the mucous membranes. There was, 
however, a little color in the cheeks, more noticeable at 
times. Her features were well formed and intelligent. 
Her hair was dark and fine. Her mind was unimpaired, 
except that at times she was much abstracted. Sometimes 
she gave conflicting answers to questions, so that the lat- 
ter had often to be repeated. 
15 Adiposis Dolorosa. 
Adiposis Dolorosa. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Ten days after her admission to the nervous wards she 
had a chill, followed by fever and a painful herpetic 
eruption over the upper portion of the left arm, and an- 
terior portion of the left side of the chest. Some five 
or six- days later another crop of vesicles made its ap- 
pearance on the back and on the front of the chest. 
Nothing further worthy of note occurred until Octo- 
of the scapula, perpendicularly down the back to very 
nearly the lumbar region. Upon another occasion swell- 
ing again made its appearance in the right popliteal 
space, as well as on the inner aspect of the knee. In the 
latter locality the swelling became permanent, and the 
tissues presented the same peculiarities as noted else- 
where. Pain also occasionally appeared in the left arm. 
Prolonged attacks of cardiac dyspnoea occurred 
every week or two, and apparently independ- 
ently of bronchitis. 
An examination of the eyes by Dr. de Schwei- 
nitz revealed contraction of the fields of vision 
for form and colors, most marked in the left 
eye. The other special senses, hearing, taste, 
and smell, appeared to be somewhat obliterated. 
An analysis of the urine yielded a negative re- 
sult. A blood-count failed to reveal an increase 
of white blood-corpuscles. 
Upon a number of occasions the patient dur- 
ing paroxysms of pain vomited blood ; upon sev- 
eral occasions this was observed by the writer 
himself. The quantity could not be accurately 
estimated, but while it was never large at a 
single emesis it was constantly brought up in 
repeated vomiting during an entire night or day. 
Measurements were made of this patient at 
various times, and these have shown a steady increase 
in the bulk of the enlarged parts. 
Of late the patient has not suffered as intense pain 
as formerly. Cardiac dyspnoea, however, is a frequent 
and distressing symptom. The face is still flushed. 
Recently, shooting pains have appeared in the abdominal 
region, and examination discloses in this region an ex- 
tensive deposit of tissue to which the pain is referred. 
A large longitudinal wheal, especially sensitive, is found 
in the left lumbar region. 
Swelling has also made its appearance over the left 
hip, and to some extent over the right. The thighs and 
Fig. 5.-Another View of Author's First Case. 
her 13th, when the patient had another severe attack of 
bronchitis, which was accompanied by much dyspnoea. 
In the latter part of the following December it was 
noted that during one of her paroxysms of pain the 
swelling of the right arm became more decidedly lobu- 
lated. The arm became more sensitive than ever, and 
on examination hard, cake-like masses were felt, resem- 
bling, as the resident physician expressed it, the caking 
of milk in a breast. This caking or increased lobulated 
feel was subsequently repeatedly noticed during parox- 
ysms of pain. At this time also she suffered from an 
attack of pain in the right knee, and in the popliteal 
space a diffused swelling was felt which ex- 
hibited the same nodulated feel as did the 
swelling elsewhere. It was also very pain- 
ful. 
At various times subsequently paroxysms 
recurred, during one of which swelling was 
noticed in the posterior triangles of the neck. 
The latter seemed later to be permanently 
fuller than normal. Bronchitis also recurred, 
accompanied by dyspnoea, and at one time 
with free expectoration of bloody mucus. 
In the following April she experienced an 
attack of pain of unusual severity. The lat- 
ter, which involved the right arm and shoul- 
der, right side of trunk and back of neck, 
now for the first time spread to the face and 
head. The right side of the face became dis- 
tinctly swollen, and presented to the touch 
the same nodulated feel so characteristic of 
the swelling in other portions. At the same 
time the tongue and pharyngeal tissues ap- 
peared to become swollen. Her tongue, she 
said, felt much too large for her mouth. In 
addition her voice was very hoarse, and she 
spoke with great difficulty. This condition 
persisted for upward of a week, and then 
slowly subsided. For some time, subsequent- 
ly, she spat blood, the source of which was 
not determined, though it appeared to come 
from the throat. The reddish color in the 
cheeks also became more pronounced, until 
it covered the entire forehead like an intense blush. 
This blush was afterward observed to occur with other 
paroxysms of pain. 
During the summer of 1888 the patient's condition un- 
derwent some change. The paroxysms became less fre- 
quent and less severe. Hand in hand with this improve- 
ment, sweating became much more marked. However, 
paroxysms occurred from time to time, and upon one 
occasion a thick welt-like swelling, exquisitely painful, 
was observed extending from the upper and inner angle 
Fig. 6.-Microscopic Drawing from Portion Excised from Lett Arm. Middle Third, 
Showing Embryonal Connective-tissue Cells (Carmine). (Drawn by Allen J. Smith.) 
buttocks do not seem enlarged in proportion, but soft 
masses are now found on the inner sides of both knees, 
the right larger than the left, the former more painful 
to pressure. A small nodule to the right of the scro- 
biculus is especially painful. 
At various times, by means of a Duchenne trocar, 
fragments for microscopic examination were removed 
from either arm. They revealed connective tissue and 
fat-cells present in varying degree. It was observed 
that the former was decidedly embryohal in type, the 
16 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Adiposis Dolorosa. 
Adiposis Dolorosa. 
cells being large and fusiform, and their nuclei cor- 
respondingly large and prominent. The fat-cells for 
the most part were associated with these connective 
tissue-cells, and occasionally individual fat-cells were 
seen in which the fatty metamorphosis had not been 
complete. These appearances are well illustrated by 
Figs. 6 and 7. 
In one of the fragments removed the writer was 
fortunate enough to find nerve-elements. These had 
Her present malady began about fifteen years ago, 
when she was forty nine years old. At that time she 
was living in California. The first thing noticed was a 
constant feeling of coldness about the knees, followed by 
swelling, which gradually increased. At first she thought 
that the swelling was due to her growing fat, but later 
was astonished to see that there was a localized mass on 
the inner aspect of each knee. At the time there was 
dull aching pain in the affected parts. Later, the right 
arm became involved, a mass making its appearance on 
the outer aspect. Her body she now noticed also became 
larger, as her stays were too small for her. During this 
time, while still in California, inability to perspire freely, 
except at the Turkish bath, was marked, and was part of 
her reason for coming East. Since she has been in Phila- 
delphia the lack of perspiration has not been as marked 
as before. Various plans of treatment were tried, but 
did not influence the progress of the disease, i.e., the 
growth of the swelling. Five or six years ago, injections 
of chloroform were made into the swellings on the inner 
sides of the knees, but no good was accomplished. Pain- 
ful ulcerations were the result, and scars of considerable 
size mark their location. 
About five years ago a slight swelling appeared in the 
epigastrium. * This gradually increased in size until it re- 
sembled the breasts in shape, and afterward spread so as 
to involve nearly the whole abdomen. 
From the knees the process extended to the thighs, and 
gave rise to large masses on their outer side and about the 
hips. 
At various times she had suffered with pains apparently 
situated in the enlarged tissues, or running down the 
limbs. Sometimes these attacks were fairly well localized 
in one limb, in one side, or about a joint. 
Five years ago her attention was called to a peculiar 
condition of the right hand. The last phalanx of the 
second finger began to be fixed in a flexed position, while 
the end of the finger appeared to be growing somewhat 
smaller. Later the remaining fingers of this hand be- 
came involved, and all the phalanges deformed. The 
deformity, as seen now, is flexion of the first phalanx, 
marked over-extension of the second, and half-flexion of 
Fig. 7.-Another Portion of the same Specimen. Showing Fat Cells and 
Oil Drops. (Drawn by Allen J. Smith.) 
probably been included in the grasp of the trocar by the 
latter grazing a blood-vessel, as the fibres were non- 
medullated. The latter revealed decided changes, their 
connective tissue was denser than normal, and they pre- 
sented an unusual number of nuclei, which here and 
there were aggregated in clusters (see Fig. 8). The most 
interesting finding, however, was a more or less complete 
ganglion of relatively large size (see Fig. 6). The capsule 
of the ganglion was evidently sclerosed. Certainly it ap- 
peared very dense and excessively thick. 
Case II.-E. W . female, aged sixty-four, married, 
a native of England. Her father had died of alcoholism 
at middle life ; her mother of oedema of the brain (veri- 
fied post mortem). Has living an elder brother and 
sister, and one younger brother. The younger 
brother, when a child, was peculiar, he would 
run to people in a fright and say that he was 
drowning, and the like. He is now in average 
health, but drinks heavily. He has a contract- 
ure of the ring finger. Has nine children, all of 
whom appear to be well. The older brother suf- 
fers periodically from violent headache ; also, 
since a young man, he has suffered from constantly 
cold feet, this so severe as to disturb sleep, and 
cause great distress. He has had five sons and 
two daughters. One son died of tetanus (trau- 
matic), the others are well. One daughter has a 
contracted middle finger of the right hand ; has 
never suffered pain in the finger. Patient's sis- 
ter is living, sixty-five years old ; no children. 
The patient herself does not remember having 
had the ordinary diseases of childhood. In early 
infancy she had convulsions, which recurred with 
great frequency for a time. On her being re- 
lieved of lumbricoid worms, however, the con- 
vulsions ceased. 
At seventeen she was married. She had two 
sons, the older of whom is now forty, and who 
has seven healthy children. The younger son 
died at two years of age, of hemorrhagic diar- 
rhoea. The patient had no miscarriages and no 
still-births. Left her husband because of vene- 
real disease, contracted by the latter. She was 
told by a doctor that she had escaped infec- 
tion. A year later, however, she had sore throat, with 
white patches. For many years she was an immoderate 
drinker. For weeks at a time she was intoxicated every 
night. 
Menstruation began at eleven and ceased abruptly at 
thirty-five. She lost habitually an unusual quantity of 
blood, but never suffered any discomfort. 
Fig. 8.-Microscopic Drawing from Portion Excised from Left Arm, Lower Third, 
Showing Inflammation of Non-medullated Nerves (Carmine). (Drawn by Allen 
J. Smith.) 
the third. The thumb is also stiff, but all of its 
joints are flexed. For some time she has noticed the 
thumb of the left hand becoming like that of the 
right. 
A year ago the patient had a quasi-rheuinatic attack 
affecting the deformed hand and the arm. The pains 
seemed to run up and down in the arm rather than about 
17 Adiposis Dolorosa, 
Adiposis Dolorosa, 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
the joints. Some months ago she had pneumonia of the 
right lung, and made a good recovery. 
For several months past she has had slight uterine 
hemorrhages at times, associated with which were dull, 
remarkable degree the swollen tissues of Case I. It gave 
the same nodular feel, and could not be made to pit on 
pressure. At the time of the examination no tenderness 
existed in the swellings, but shooting pains were referred 
to them in various situations. This was particularly the 
case in the mass over the right hypochondrium. In ad- 
dition, she complained of scalding sensations on the 
inside of the right cheek and the right side of the tongue. 
Nothing abnormal could be discovered in the mucous 
membrane of these parts. No tenderness could be dis- 
covered in any of the nerve-trunks at the time of the 
examination. The patient was excessively weak, and 
could move about her bed or sit up only with great diffi- 
culty. Her grip was almost nil. No tendon-jerks could 
be elicited, probably because of purely mechanical diffi- 
culties. For the same reason an electrical examination 
could not be made. 
Slight diminution of tactile sensibility and of the tem- 
perature sense and also some analgesia were present. 
An area of absolute anaesthesia existed on the back of 
the left arm, extending thence over the posterior aspect 
of the left shoulder. A marked increase in the swelling 
had taken place during the last year, measurements 
showing, for instance, that the left forearm had increased 
one inch and seven-eighths, and the right forearm one 
inch and three-eighths ; the left arm one and a half, and 
the right arm two inches. This increase appeared to be 
maintained throughout. 
Fig. 9.-Another View from the Same Portion of Tissue Removed from 
the Left Arm. (Drawn by Allen J. Smith.) 
aching pains, resembling those formerly felt before men- 
struation. 
In addition, she stated that the swelling had spread up 
from the knees over the thighs unequally ; that the left 
thigh and buttock had been earlier and more conspicu- 
ously enlarged than the corresponding parts on the right 
side. Gradually, however, the latter became enlarged to 
an almost equal degree. Later, swelling appeared over 
the left arm, and later still on the back and sides of the 
trunk, and wherever appearing, it gradually became dif- 
fused, and finally reached very great proportions. The 
patient further volunteered the statement that she had 
formerly been very slight in build. 
To ordinary observation she merely presented the ap- 
Fig. 11.-RearView of Author's Second Case. 
Subjectively the patient complained much of head- 
ache. Her face was very much flushed, and she suffered 
greatly from cardiac dyspnoea. It was a persistent and 
distressing symptom. Examination of the eyes proved 
negative, as did also that of the urine. Perspiration, 
according to the patient's statement, was scant. Face 
not involved in the enlargement; no subnormal tempera- 
ture ; hair thin, but not excessively so; no difficulty in 
speech ; no mental impairment. 
The patient remained very much in the same condition 
for some two weeks following her admission to the 
nervous wards, when her dyspnoea greatly increased. 
Her pulse, already soft and compressible, became ir- 
regular and intermittent. This condition, though re- 
lieved from time to time, persisted until hands and feet 
became puffy, the face cyanotic, and the lungs oedematous 
and congested. Death occurred on December 22, 1891. 
Autopsy, December 23(Z.-Body that of a very large 
woman. Weight estimated at about three hundred 
pounds. Face dark from venous congestion. Some dis- 
coloration on under surface of body and thighs. A 
number of large white scars on either side over the knees. 
Legs and feet cedematous. Body distorted and flattened, 
as though by its own weight. 
Scalp and calvarium revealed nothing abnormal. Veins 
of dura and longitudinal sinus full. Venous congestion 
of the pia. Cortex a little darker than normal. Puncta 
vasculosa prominent. Brain otherwise normal. Spinal 
cord appeared normal. Skin of thorax appears normal. 
The subcutaneous tissue is fatty and moist. 
Fig. 10.-Author's Second Case. 
pearance of an excessively obese person. However, ex- 
amination soon revealed that the enlarged tissue was 
very unevenly distributed. In the region of the knees, 
where it had first made its appearance, it was excessively 
irregular and lumpy. To the fingers it resembled in a 
18 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Adiposis Dolorosa. 
Adiposis Dolorosa. 
Thyroid gland small, indurated, and infiltrated by 
calcareous matter in both lobes. 
Right lung oedematous and tightly adherent to chest- 
wall. Left lung oedematous, with hypostatic congestion 
posteriorly. Both pleural cavities contain a large excess 
■of fluid. 
Pericardium contained some six or eight ounces of 
fluid, in which was suspended some flocculent lymph. 
Weight of heart twenty-seven ounces; the right side 
dilated, the moderator band much thickened. Walls of 
left side also much thickened, marked hypertrophy of the 
columnse carneae and papillary muscles. Some fatty 
change, especially in the walls of the right ventricle. 
Over the abdomen the subcutaneous fatty tissue was 
three inches thick. About a pint of ascitic fluid in ab- 
domen. Stomach much dilated. Intestines normal. 
Liver showed some fatty infiltration ; otherwise normal. 
Spleen apparently normal, though somewhat dark. 
Kidneys both reveal, excepting slight adhesion of the 
capsules, nothing specially abnormal. 
In the pelvis an ovarian cyst, containing some six 
•ounces, and a hydrosalpinx were found on the left side. 
Uterus seemed a trifle larger than normal. Bladder 
normal. 
Brain, cord, some of the nerve-trunks, pieces of skin 
and subcutaneous tissue, pieces of the liver, kidneys, 
spleen, a fragment of muscle, and the whole of the 
thyroid gland, were removed for microscopic examina- 
tion. The specimens were left in the care of Dr. H. W. 
Cattell, assistant to the pathologist of the hospital. Un- 
fortunately, Dr. Cattell fell ill with scarlet fever, and 
during his absence the specimens, together with those of 
Case III., were thrown away by an attendant. 
Case UI.- M. M , aged sixty years, widow, a tailor- 
ess by occupation, and a native of Germany, but a resident 
of America for twenty-six years, was admitted to the 
nervous wards of the Philadelphia Hospital, October 7, 
1891. Memory very poor. History obtained in part 
from relatives. 
Her father and mother healthy, though her mother 
died of heart disease. She had seven brothers and sisters, 
all apparently well. She had no children ; had never 
been pregnant. 
Many years ago a lump appeared at the back of the 
neck, for which she consulted Dr. Gross at the Jefferson 
Medical College, but for some reason no operation wTas 
performed. At various times thereafter swellings made 
their appearance in various situations. Further, she lost 
more blood at her menstrual periods than normal. Oc- 
casionally she suffered from haematemesis and epistaxis. 
(SUPPLEMENT.) 
swellings in various situations. Thus, a large, soft mass 
was found over either biceps, and others, somewhat 
smaller, over the outer and posterior aspect of either 
upper arm. Two large masses were found over the belly, 
separated above the umbilicus by a deep, transverse crease. 
Another gave excessive prominence to the mens Veneris. 
From the back of the neck, at its lower part, sprang a 
big mass like a hump, while a diffuse swelling gave a 
Fig. 13.-Rear View of Author's Third Case. 
cushion-like coating to either half of the back, and ex- 
tensive deposits gave unnatural prominence to either hip. 
In marked contrast, the deposit was absent from the 
forearms and hands, from the face, from the thighs and 
legs, and from the buttocks. The gluteal regions, in 
fact, seemed flattened and sloping. 
The deposit over the back seemed tolerably firm and 
resistant ; over other portions it was quite soft, though 
elastic, and exhibited the same nodular feel noted in the 
previous cases. Further, it was discovered at once that 
these masses were painful to the touch, the patient com- 
plaining very much when only moderate pressure was 
exercised. This was especially true of the deposits over 
the arms and back of the neck. In addition, the patient 
complained of stabbing pains in the deposits, more marked 
in the regions just mentioned. There was no tenderness 
over the nerve-trunks. She complained also of headache. 
In making the examination it was also further noted 
that the left radius was rough and nodular for about two 
and a half inches in its middle third ; also, that there was 
a large discolored area on the outer aspect of the left fore- 
arm resembling a syphilitic scar. Both tibiae were some- 
what nodular, though no scars were discovered on the 
legs. A few white scars were seen on the forehead. 
Finally, quite a number of purpuric spots were observed 
on the forearms, thighs, legs, and back. 
The skin of the forearms and hands, and that 
of the legs and feet to a less extent, was dry, 
dark, and much roughened. 
Cutaneous sensibility was found generally 
diminished, while a few patches of anaesthesia 
were noted. One of these was an area diffused 
over the right side of the trunk and the right 
shoulder. They appeared to be constant, and 
were confirmed at various examinations. 
Owing to the extreme weakness of the patient, 
the study of the eyes could not be made satis- 
factorily, but, as far as it went, was negative. 
The urine contained albumin, though no casts 
were found. 
In answer to questions the patient said that she 
had not been sweating freely for years, but ow- 
ing to her mental condition no importance was 
given to this statement. She at no time pre- 
sented any change in temperature. Iler hair 
was well preserved. 
The patient seemed to fail slowly and steadily, although 
liberal diet and stimulants were freely used. Her de- 
mentia gradually deepened, and for some days before 
death she voided urine and faeces involuntarily. She 
finally died in a comatose state on November 5, 1891. 
Autopsy, November Qth.-Body that of a large woman 
with irregularly distributed fat-like masses. Some dis- 
colorations on the back. Small bed-sores beginning on 
the buttocks. 
Fig. 12.-Author's Third Case. 
The climacteric occurred at forty-six. No history of 
any intercurrent affections. Mental impairment had been 
noticed for about two years. 
On examination the patient was found to be excessively 
feeble. For some two weeks she had been unable to 
walk. She lay, for the most part, in a quiet, apathetic 
state, though when aroused she answered questions 
slowly, but intelligently. She was also somewhat deaf. 
Examination further revealed, soft, fat-like masses or 
19 Adiposis Dolorosa. 
jEtiology. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Scalp and calvarium normal. Dura normal. Pia very 
oedematous. Brain very soft and (edematous. Cord re- 
vealed nothing abnormal. 
On incising the skin of the chest and abdomen it was 
found to be normal in appearance, but the subcutaneous 
tissue, which looked like very white fat, was excessively 
thick, attaining below the umbilicus a depth of seven 
inches. 
The thyroid gland was larger than normal, harder to 
the feel, and much calcified, especially the right lobe. 
The heart weighed eight and a half ounces. Both aortic 
and mitral valves were slightly thickened. Heart sub- 
stance evidently fatty. Lungs emphysematous. 
The mucous membrane of the stomach revealed a 
chronic gastritis. The liver weighed forty-four ounces, 
and, beyond some fatty infiltration, was practically nor- 
mal. Spleen normal. The kidneys, however, showed 
decided shrinking and loss of cortical substance, with 
somewhat adherent capsules. Nothing noteworthy was 
seen in the pelvic organs. 
As in Case IL, brain, cord, nerve-trunks, skin and sub- 
cutaneous tissue, thyroid gland, and portions of other 
viscera were removed for microscopic examination, but, 
as already mentioned, the specimens were subsequently 
lost. 
It was not without some hesitation that these cases 
were presented together. The writer was well aware 
that without a microscopic examination to supplement 
the autopsies their study was incomplete, and yet the 
cases are in themselves so interesting, and appear to be so 
unusual, that their publication in a group, with such data 
as are at hand, was more than warranted. Case I. had 
originally been published in the University Medical Mag- 
azine for December, 1888, under the title, "A Subcuta- 
neous Connective Tissue Dystrophy of the Arms and 
Back, Associated with Symptoms Resembling Myxoede- 
ma." Case II. had been discovered in the medical wards 
of the Philadelphia Hospital by Dr. Frederick P. Henry, 
in 1890, and was published by him in the Journal of Ner- 
vous and Mental Diseases for March, 1891, as a " Case of 
Myxcedematoid Dystrophy." Dr. Henry fully recog- 
nized the relation existing between this case and that pre- 
viously described by the writer, and he adopted the term 
dystrophy in order to bring the cases " into the same cate- 
gory." In November, 1891, this case (Case II.) having 
been transferred to the nervous wards of the Philadel- 
phia Hospital, came under the care of the writer, and 
was studied again. The account here given is abstracted 
partly from the notes of Dr. Henry, and partly from 
those of the writer. 
Case III. was discovered in the nervous wards in Oc- 
tober, 1891. 
Certainly these cases differ radically from ordinary 
cases of lipomatosis, and certainly the nervous symptoms 
present must have a special significance. To begin, the 
enlarged tissue makes its appearance in a very irregular 
way. Nodules of soft tissue are, at first, deposited in 
some one situation, or perhaps in corresponding places in 
both arms or in both legs. For a time the deposit is lim- 
ited to these original areas, but subsequently it makes its 
appearance elsewhere, and may become very extensive. 
Regions, however, may exist which remain permanently 
uninvaded. In Case I. the enlargement was first noticed 
in both upper arms, and later in the back. Subsequently 
a swelling made its appearance on the inner aspect of 
the right knee, to be followed months after by a similar 
swelling in a corresponding position over the left knee. 
Later still, swellings made their appearance in various 
other situations. However, the legs, with the exception 
of the knees, have remained free from involvement, while 
the thighs and buttocks have only recently shown a doubt- 
ful change. In Case II. the enlargement began on the 
inner aspect of either knee, and then gradually spread 
unequally over the thighs and buttocks. Later, the left 
arm became involved ; next the sides and back, and, 
finally, the entire trunk. In Case III. the enlargement 
began in the back of the neck, and then at various times 
appeared in other situations. It remained absent from 
the face, the forearms, the legs, the thighs, and the but- 
tocks. It is a peculiarity of this case, also, that the en- 
largement tended to produce distinct segregated masses. 
Not only is the development of the enlargement ir- 
regular and even capricious in these cases, but there is,, 
in addition, another important fact to be remembered, 
and that is : that at some time or other the enlargement 
is accompanied by pain or other nervous symptom. Thus 
in Case II. pain, shooting in character, and a sensation of 
coldness preceded the appearance of the nodules on the- 
insides of the knees. In Case I. shooting and burning 
pains made their appearance about a year after the swell- 
ing had appeared in the arms, while similar pains, very 
great in intensity, preceded the appearance of the swelling 
on the inner aspect of right knee and in other situations. 
Case I., it should be remembered, was observed by the 
writer for a number of years, and was therefore studied 
in great detail, and pain was noted as a marked feature- 
of the case, especially in the early course of the disease. 
Occasionally it was observed in old areas of enlargement, 
and again in regions free from the swelling, but in which 
the latter subsequently appeared. In Case III. stabbing 
pains were complained of and were referred to the de- 
posits, and the latter were very painful to examination. 
We may say, therefore, that pains, shooting, burning, 
or stabbing in character, were present in all cases at vari- 
ous times in their history. 
Some of the paroxysms observed in Case I. w ere partic- 
ularly suggestive. Sometimes a welt-like swelling sud- 
denly made its appearance, evidently following the course- 
of a cutaneous nerve-trunk and at the same time being 
exquisitely painful. After a time the swelling would 
become slightly less, but would never wholly disappear. 
Several such "welts" are still demonstrable in Case I. 
If the paroxysm of pain made its appearance in an area 
of old enlargement, that is, reappeared or recurred, a de- 
cided and sudden increase would take part in the swell- 
ing, and it would become for the time being firmer and 
more resistant and occasionally more nodulated than be- 
fore, and generally a permanent increase in the swelling- 
could be demonstrated. Further, it should be remem- 
bered that at one time some of the nerve-trunks of the- 
right arm were very sensitive to pressure, that some of 
the muscles, those of the thenar and hypothenar groups- 
of either hand, revealed reaction of degeneration, and 
finally that the patient suffered on two occasions from 
herpes zoster. 
In Cases II. and III. tenderness over the nerve-trunks 
was not present at the time of the examination. In Case 
I., however, this symptom is also no longer present, its- 
absence having been noted for some time past. This 
and other circumstances justify the assumption that 
Cases II. and III. were further advanced than Case I., 
and that the latter was really observed during a develop- 
mental period and while more active changes were going 
on. 
Among the nervous symptoms must also be placed the 
diminished cutaneous sensibility and the patches of anaes- 
thesia as well as perhaps the excessive weakness. It is 
probable also that the absence and the diminution of 
sweating belong to this category. It will be remembered 
that this symptom was undoubtedly present in Cases I. 
and II. and doubtfully in Case III. Lastly, headache 
was noted in all the cases. 
Among other symptoms present in these cases should 
be noted haematemesis in Case I., haematemesis and epis- 
taxis in Case III., and a recurrence of uterine flow many 
years after the cessation of menstruation in Case II. In 
Cases I. and II. the menopause occurred unusually early, 
namely, at thirty-five, and in Case II. menstruation was 
unusually free. In Case III. the menopause occurred at 
forty-six, and menstruation was likewise said to have 
been excessive. Finally Case III. presented a well- 
marked purpura. What significance these symptoms- 
may have, it is impossible to say. It may not, however, 
be out of place to recall the not infrequent occurrence of 
uterine hemorrhages in women who subsequently suffer 
from myxoedema. 
Bronchitis is a most frequent and persistent symptom 
in Case I., while both Case I. and Case II. suffered mark- 
20 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Adiposis Dolorosa. 
Etiology. 
■edly from cardiac dyspnoea. But these symptoms were 
absent in Case III. 
As already stated, fragments of the enlarged tissue 
were removed from Case I. by the Duchenne trocar, as 
also from Case II. In both instances fat-cells and con- 
nective tissue were found in varying proportions. At 
times the connective tissue appeared decidedly embry- 
onal in type (see Fig. 4). This was especially so in 
Case I., in the fragments removed from the upper third 
of the right arm. It would seem further that in the 
more recent formations the fat-cells are less perfectly de- 
veloped, while in the older areas a fully formed adult 
fatty tissue is present. It is especially to be regretted 
that the loss of the specimens from the autopsies of 
Cases II. and III. prevented a confirmation of these 
results. 
The fact that in both cases the thyroid gland was found 
indurated and much infiltrated by calcareous deposit is 
not only very interesting but exceedingly suggestive. 
Without microscopic studies, however, and without a 
more extended series of cases it is impossible to draw 
a conclusion. The part, if any, played by the thyroid 
in this curious affection can only be determined by fut- 
ure autopsies. It goes without saying, also, that the 
thyroid should be studied in every case of obesity, 
whether typical or otherwise, that reaches the post-mor- 
tem table. 
With the above data before us, it is impossible to 
■classify these cases under any well-established disease. 
Evidently the affection is not simple obesity. If so, how 
are we to dispose of the nervous elements present ? It 
is equally certain that we have not myxoedema to deal 
with. All of these cases lack the peculiar physiognomy, 
the spade-like hands, the infiltrated skin, the peculiar 
slowing of speech, and the hostof other symptoms found 
in myxoedema. It would seem, then, that we have here 
to deal with a connective-tissue dystrophy, a fatty met- 
amorphosis of various stages of completeness, occurring 
in separate regions, or at best unevenly distributed and 
associated with symptoms suggestive of an irregular and 
fugitive irritation of the nerve-trunks-possibly a neu- 
ritis. This, however, does not embrace the whole truth, 
and it remains for future research to determine to what 
this neuritis is due, whether it is a cause of the fatty 
metamorphosis or only concomitant, and whether the 
thyroid gland does not play some mysterious part in its 
causation. 
Inasmuch as fatty swelling and pain are the two most 
prominent features of the disease, the writer has pro- 
posed for it the name Adiposis* Dolorosa. 
F. X. Dercum. 
/ETIOLOGY (now often less authoritatively written 
Etiology ; from Lat., mtiologia ; Gr., atria, cause, Adyos, dis- 
course) is the general science of causation. In a nar- 
rower sense it forms one of the grand divisions of Biology 
-the science of living things-the others being Mor- 
phology, Physiology, and Distribution. ^Etiology deals 
with the causes and the explanations of the phenomena 
■of biology, and with the whole subject of origins. Dar- 
win's classical work, the " Origin of Species," is a good 
example of a monograph in aetiology. Examples in 
medical literature will occur to everyone. Professor 
Huxley has defined aetiology in biology as that science 
which has for its object " the explanation of biological 
phenomena by showing that they constitute particular 
cases of general physical laws." ■ • 
If we keep this definition in mind we shall immediately 
discover the place of aetiology among the medical sci- 
ences. The phenomena of disease are quite as truly bio- 
logical phenomena as are those of health, for pathology 
is simply the morphology, physiology, and aetiology of 
the morbid organism. In this case, therefore, aetiology 
has for its special province the explanation of the phe- 
(SUPPLEMENT.) 
nomena of disease by showing that they constitute particu- 
lar cases of general physical laws. The importance of a 
science which seeks to do this can be appreciated only 
by those familiar with the history of medicine from the 
time of its gradual emancipation from priestcraft and dae- 
monism, through the humoral pathology, methodism, 
pneumatism, and the like, to the dawn of the cellular 
pathology in the middle of the present century. It 
means nothing less than the search of modern science for 
the causes of disease. 
The word aetiology is used in the medical sciences in 
two distinct senses, which may be described as the prox- 
imate and the ultimate, or the practical and the theoreti- 
cal. The term is known most widely in connection with 
the proximate causation of diseases, and to observe the 
difference in its application it is only necessary to take 
an example from any well-known disease, for instance, 
typhoid fever. By the aetiology of this disease is usually 
meant the mechanism of infection ; how the specific germ 
(if this be now allowed to exist) is distributed in a com- 
munity, how it finally arrives in the alimentary canal 
and by what vehicles, namely, polluted milk, water, or 
other food materials, secondary infection, climatic or 
" pythogenic " influences, broken drains, miasmata, the 
level of the local ground-water, etc. This aspect of the 
subject may be called the proximate, immediate, or prac- 
tical side of aetiology. But after the specific materies 
morbi of typhoid fever has arrived in the body it has still 
to do its work. It must somehow derange the normal 
structure or function, or both, of some part or parts, 
or of the whole body. It must unduly disturb the living 
stuff. It is the doing of this act which constitutes true 
aetiology ; this is the real causation of typhoid fever. 
The aetiology of the disease is the ultimate action upon 
the normal organism, the reaction to which is seen in 
the chain of phenomena called the disease. Obviously, 
practical aetiology becomes the foundation-stone of sani- 
tary science and preventive medicine ; while theoretical 
aetiology is the goal of pathology. 
We may conceive of the living organism as a living 
machine, having, in health, certain normal structure and 
functions. Disease will then be manifested by abnormal 
structure or function. This might be due, conceivably, 
to inherent defects in the constitution or construction of 
the machine,-as when a watch breaks down or keeps 
time badly owing to poor construction or poor constitu- 
ent materials ; or to some interference with the machine 
by something proceeding from without,-as when dirt or 
injury interferes with the running of the watch. Dis- 
eases due to defective structure or poor materials of the 
machine may be called intrinsic, diseases coming from 
the environment may be called extrinsic. The former 
are strictly constitutional, the latter strictly environ- 
mental in their origin. But organisms can never be free 
from the influence of their environment to which they 
must constantly be adjusting and readjusting them- 
selves. So fundamental is this phenomenon that Mr. 
Herbert Spencer has seized upon it as the main phe- 
nomenon of life itself, which he defines as " the continu- 
ous adjustment of internal to external relations or, in 
other words, adjustment of a changing organism to its 
changing environment. There can be no question that 
for the student of aetiology this is the most important 
feature of normal life, and that it furnishes a sound basis 
for his definition of disease. From this point of view 
life is a long series of departures from the normal, each 
followed by a return or readjustment. Adopting the 
definition and applying it to disease (abnormal life) we 
may define the latter as partial failure in the adjustment 
of internal to external relations-a total failure being 
death, either local or general. 
Physiology teaches that the function of functions is 
metabolism, and the continuous adjustment just referred 
to is based upon the hypothesis of a flexible metabolism, 
itself in constant change and also capable of responding 
to changes in the environment. In the language of 
physiology, metabolism is here co-ordinated with irrita- 
bility. In less technical language the living machine dif- 
fers from an ordinary lifeless machine in the remarkable 
* Adiposis, as is well known, would be etymologically more correct if 
it were written adipositas, but adiposis has been so long in use that it 
must be regarded as established. Adiposis Dolorosa has also perhaps a 
less formidable sound than has its Greek equivalent "Lipomatosis 
Algera." 
21 JEtiolojjy. 
Aix-la-Chapelle* 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
extent of its power of repairing itself and adapting itself 
to the varying demands made upon it. But we must 
immediately qualify this statement. It is only the well- 
built living machine that can do this, and even the best 
of such machines can do it only to a limited extent. Here, 
then, lies the true conception of disease. Given a poorly 
made machine, or one of poor materials, and in time, no 
matter how favorable the environment, break down (or 
disease) is certain to occur. Or, on the other hand, given 
a good machine, but an environment to which it is un- 
able fully to adjust itself, and again disease and disaster 
ensue. 
Disease, then, like ordinary life, is a condition ; if the 
organism is well-made and capable, and adjusts itself 
without undue strain to its environment, health, or at 
least freedom from constitutional disease, is assured to it. 
But if it be poorly built, or of poor materials, it will ul- 
timately fail to do its work well and disease will appear ; 
or, it will fail utterly and death will supervene. Again, 
given a good living machine, its environment may change 
beyond its power of adaptation to it, as when a strong 
man is poisoned or falls into molten metal. In physio- 
logical language disease is to be conceived of as either 
imperfect metabolism or excessive (irreparable) interfer- 
ence with metabolism. 
That nosology is the simplest, and also the most scien- 
tific, which regards diseases as either intrinsic or extrin- 
sic, constitutional or environmental, and places diseased 
life in the same general category with normal life. If we 
accept this view and hold that disease is disturbance or 
abnormality, due either to defects in the living machine 
itself, or to environmental conditions or influences with 
which the machine cannot deal without exceeding its or- 
dinary powers of adjustment and suffering thereby, we 
shall arrive at the fundamental conception of aetiology. 
We shall see that the causes of disease may be many, but 
that all causes, in the last analysis, must be either consti- 
tutional or environmental, or both. 
At the present time there is remarkable activity in the 
domain of aetiology. The proximate causes of disease, 
the mechanism of infection, the distribution of specific 
germs, the sanitary effect of particular occupations or 
trades, such as stone-cutting and match-making, the in- 
fluence of climate, diet, urban and suburban life, and the 
like, are being eagerly studied. Preventive medicine, 
working with the invaluable clews supplied to it by the 
germ theory of disease, is making progress that may fairly 
be described as immense, and is enriching almost daily our 
knowledge of proximate and practical aetiology. But it 
is in the field of ultimate or theoretical aetiology that the 
most remarkable achievements are now being made. In 
the course of the hot pursuit of immunity, which is one 
of the features of the day, much has come to light con- 
cerning the facts of cellular irritation, defence, and dis- 
ease. It appears that in acute infectious disease-and 
at present our knowledge is largely restricted to the en- 
vironmental diseases-there is first an invasion of the 
organism by something proceeding from without, it may 
be lifeless substances (poisons) or living organisms (germs, 
parasites, etc.). These act upon some or all of the living 
cells of the body, which in turn, by the exercise of their 
ordinary functions of adjustment, react upon the foreign 
matters. The extent of their reaction will depend upon 
the emergency and upon their own powers. The nature 
of the reaction will depend upon the particular irritation 
applied. The success of the reaction will depend upon 
its victory or failure. The reaction itself may make its 
appearance as functional disease or disturbance, such as 
fever, or as lesion, discoverable by structural changes in 
tissues or organs. 
^Etiology here becomes the history of a battle in which 
the living machine struggles with an unfavorable envi- 
ronment. If it struggles easily, naturally, and success- 
fully, the phenomenon is called ordinary life. If vio- 
lently, and with fever, delirium, and slow convalescence, 
we must think of disease, but not necessarily of perma- 
nent lesion. If with obvious injury, and sequela1 such as 
indicate lesion, we must suppose that the machine has 
suffered beyond complete repair, though it may still con- 
(SUPPLEMENT.) 
tinue to work. If death ends the struggle, it means that, 
however heroic may have been the effort, the mechanism 
proved inadequate to cope with its environment-unable 
to adjust its internal to its external relations. 
Turning to the intrinsic or constitutional diseases we 
find ourselves dealing with a much more difficult phase 
of the subject. The special structure of the vital appa- 
ratus depends chiefly upon heredity, though its powers 
are influenced by environmental conditions, such as 
food, temperature, electricity, and moisture. What it 
is, precisely, that distinguishes the protoplasm of A 
from that of B we cannot say ; why the one forms biliary 
or urinary calculi, while the other does not, though liv- 
ing under apparently similar conditions, we do not know. 
The microscope fails to reveal the important differences 
of molecular structure which must exist. Yet there can 
be no doubt that, if these could be seen, differences might 
be detected as great as those between any two machines 
intended to serve precisely the same purpose-for exam- 
ple, two clocks of different manufacture. 
Enough has now been said to show that while we are 
yet very much in the dark concerning the aetiology of 
disease, we are certainly making headway in " the expla- 
nation of biological phenomena by showing that they con- 
stitute particular [and usually extreme] cases of general 
physical laws.'' The " general physical laws " prevailing 
in disease are the general laws of biology ; the "particu- 
lar cases " which diseases constitute are those of poorly 
built organisms struggling with ordinary environments, 
or, perhaps, as often, well-made organisms struggling 
with unfavorable environments ; i.e., normal organisms 
with abnormal conditions, or else abnormal organisms 
with good conditions. For a recent and suggestive treat- 
ment of the aetiology of disease see the Lumleian Lectures 
by P. H. Pye-Smith, delivered at the Royal College of 
Physicians, London, in The Lancet, 1892, Vol. L, p. 847 
et seq. The debate now going on concerning Immunity 
(which see) should also be carefully followed. 
William T. Sedgwick. 
AGARICIN, AGARIC ACID.-The active principle of 
Boletus Laricis, Linn., White or Purging Agaric. 
It occurs in white crystalline needles, soluble in alco- 
hol, ether, and chloroform ; boiling with water forms a 
gelatinous solution. 
The use of this drug has been revived as a remedy for 
profuse sweating, especially the colliquative sweats of 
phthisis. Its effect is produced by its action on the 
glands themselves and not by any action on the nerve-cen- 
tres. It is superior to white agaric on account of a more 
prompt and certain action and by not producing as much 
irritation of the digestive organs. 
The dose is from -jL to | gr., increased to 1 gr. ; it 
should be administered five or six hours before the ex- 
pected sweating. It is given in pill or powder, com- 
bined with small doses of Dover's powder to counteract 
any tendency to diarrhoea. It may be administered by 
hypodermic injection. The following solution is recom- 
mended : Agaricin, J gr. ; alcohol, absolute, 807T[. ; 
glycerine, 1 drachm. Beaumont Small. 
AIX-LA-CHAPELLE (Ger., Aachen). Although the 
beneficial action of the thermal waters of Aix-la-Chapelle 
on a great variety of morbid processes has already been 
set forth (see art. Aachen, Vol. I. of this Handbook), 
the chief eclat of this resort is undoubtedly due to the- 
successful treatment there of syphilis. Many physicians 
have questioned whether the waters of Aix-la-Chapelle 
were possessed of curative properties unassisted by or- 
dinary antisyphilitic treatment. Be this as it may, there 
is no doubt that better results are obtained at this spa, in 
all syphilitic diseases, than at any other watering-place in 
Europe. 
It seems worth while to examine somewhat more 
closely the management of syphilis at Aix-la-Chapelle, 
for there is no theoretical reason why similarly good re- 
sults should not be attainable at some of our own hot. 
sulphur springs. 
22 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
^Etiology. 
Aix-la-Chapelle. 
At Aix-la-Chapelle, mercury, properly given, is recog- 
nized as the true antidote to the poison of syphilis. And 
in agreement with the dictum of Sigmund, not only is 
the manifestation of mercurial poisoning held to be not 
needed, but syphilis is thought to be the more certainly 
cured in proportion as the body is protected from the 
toxic effects of mercury. 
The Aix method of treating syphilis consists in the an- 
cient practice of inunction, assisted by thermal baths 
and the drinking of mineral water. 
The writer has closely followed the reasoning and 
rules given by Dr. Brandis, one of the most experienced 
physicians of the spa, as laid down in a series of articles 
published in the Medical Press. For more detailed infor- 
mation the reader is referred to " Aachen als Kurort," 
edited by Du. Beissel, in association with the leading 
practitioners of the town, and published at Aix in 1889. 
Dr. Brandis insists on three points : 
1. The body must always be adequately prepared for 
the absorption of the mercury, and the gray ointment 
must always be used carefully and in sufficient quantity. 
The patients are directed to take a warm bath of half 
an hour's duration, and at a temperature of 95° F., so as 
to be prepared for the subsequent inunction. From this 
rule it may be necessary to deviate for various reasons. 
A very frequent cause which compels us to allow another 
treatment to precede the specific treatment is mercurial- 
ism, the result of previous incautiously applied mercu- 
rial treatment. If we are to undertake the inunction 
cure it is necessary to pay- attention to the state of the 
skin. The Aix baths possess in a high degree the prop- 
erty of making the skin soft and absorbent. After the 
bath the patient must be most carefully dried, and im- 
mediately, in the bath-room, rubbed with gray oint- 
ment. 
During the entire treatment it is advisable to allow the 
patients to drink the warm waters ; two or three glasses 
should be drunk in the morning, and now and then in 
the evening also. In winter and cold weather they 
should be taken in bed ; during the summer and on 
warm days, while walking about. Nevertheless, we 
must carefully notice if the internal employment of the 
waters disturbs the digestion, if it take away the appetite 
and thus interfere with the fulfilment of a very weighty 
indication, namely, the good nourishment of the body. 
For removing the debility of the patients Dr. Brandis 
relies not on the use of the waters, but on the abundant 
drinking of warm milk, a measure the merits of which 
are not sufficiently appreciated. 
Vapor-baths, followed by copious sweating, are indi- 
cated where the mercury no longer exercises its action 
on the healing process, and later on, in spite of continu- 
ous employment of co-operating remedies, appears not 
merely to remain inactive, but to give place to a new 
outbreak of the disease. As a rule, therefore, patients 
are directed, possibly after the twentieth inunction, to 
take a vapor-bath on three consecutive days, and after 
that to take the baths after each tenth inunction. Dur- 
ing these days the rubbings must be discontinued. 
As to the method of performing the inunctions, Sig- 
mund's instructions are observed. But it is essential that 
competent rubbers do the work. 
The ointment must be rubbed in with the entire sur- 
face of the hand, and with both hands conjointly, so 
that when, for example, the legs are subjected to the 
rubbing, the surfaces of the hands glide up and down si- 
multaneously. 
The use of gloves and pads is prohibited, as absorbing 
too much of the ointment. Mercurial poisoning in the 
rubbers is not observed. Every rubbing is to last fully 
twenty minutes, ten minutes for each half of the dose. 
The instructions of Sigmund are as follows : 
On the first day rub both legs ; on the second, both 
thighs ; on the third, abdomen and breast; on the fourth, 
the back ; and on the fifth, both arms. 
Many patients, however, cannot endure the rubbing of 
the breast and abdomen ; in such cases the sides of the 
body and the nates are employed. The daily dose varies 
with the body-weight and the susceptibility of the pa- 
(SUPPLEMENT.) 
tients-between four and five grammes for adults, and 
from one to two grammes for children. 
2. During a course of treatment the body must be 
maintained in good condition ; exercise in the open air, 
spacious bedrooms, personal hygiene, good food in plenty 
are all to be thought of in this connection. 
The treatment of the mucous membrane of the mouth 
is of great importance, for through its local treatment we 
must strive against the commencement of mercurial sto- 
matitis. 
Dr. Brandis employs a preparation made according to 
the following recipe : 
B- Pulveris aluminis, 
Plumbi acetatis... aa 30.0 
Aquae destillatae 300.0 
Misce et Ultra. 
This solution may be used diluted with pure water, or 
some aromatic water, about two dessertspoonfuls in a 
glass of water. The mouth must be regularly rinsed out, 
from the beginning of treatment, ten or twelve times a 
day, or even oftener ; even when taking walks the pa- 
tients must carry a small bottle of the liquid; and in 
urgent cases they must even use it repeatedly at night. 
After each meal the teeth must be brushed with a mixt- 
ure of prepared chalk and camphor. 
The author states that by most carefully carrying out 
these measures, we generally succeed in averting saliva- 
tion ; but occasionally it may happen that we may be 
obliged to suspend the inunction for a time. One thing 
more is to be observed-namely, we may accustom even 
highly sensitive patients to tolerate mercury. If we know 
beforehand that we have to deal with such, we begin with 
small doses of the mercurial ointment, and gradually in- 
crease to larger. Or if we have the misfortune to induce 
stomatitis, and are obliged to suspend the remedy, we 
postpone resuming it until all these symptoms have dis- 
appeared ; we then begin again with small doses, and 
gradually rise to larger. A practical suggestion relates to 
ulcerative processes, so frequently observed in the course 
of syphilis. It is not always quite simple to distin- 
guish mercurial from syphilitic ulcerations ; they both 
occur in the most different parts of the mucous membrane 
of the mouth, and may look very like one another. Be- 
fore all, this holds good of those mercurial ulcerations 
which occasionally appear on the tonsils and on the soft 
palate. Here frequently only long-continued observa- 
tion can decide the matter ; if, however, we are still in 
doubt, the inunctions must be suspended ; the mercurial 
ulcers will then heal, whereas the syphilitic ulcers will 
be aggravated. They also behave differently when cau- 
terized with nitrate of silver. The mercurial sore stands 
an energetic cauterization very well; in fact, its healing 
is furthered by it; whereas the opposite is generally the 
case with the venereal ulcers. Increased secretion of sa- 
liva may also occasion doubt, for at times syphilitic dis- 
orders which affect the cavity of the mouth directly pro- 
duce salivation. Another disagreeable result of the in- 
unction treatment is mercurial diarrhoea. This symptom 
sets in suddenly, the evacuations follow one another 
rapidly, there is pain and tenesmus, the stools are scanty 
and show mucus and blood. Treatment by opiates is 
indicated, but theinunctions must beat once interrupted. 
Healthy persons lose in weight if subjected to mercu- 
rialization. In contradistinction to this, syphilitic patients 
gain in body-weight as soon as they enter the stage of 
convalescence. This applies to recent cases, as well as 
to those of old standing. 
The inunctions must be employed for a sufficiently 
long time. As our task consists in healing the symptoms 
of the disease, and, as much as possible, in averting re- 
lapses, the earlier the syphilitically infected person is 
brought under mercurial treatment, the milder is the 
course of the illness. 
3. Above all things, Brandis insists that we must not too 
soon dismiss the patient from treatment; indeed, never, 
until all symptoms have disappeared, up to the last ves- 
tige ; and also, that even the slightest attacks must be 
23 Aix-la-Cliapelle. 
Akinesia Algera. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
energetically treated from the outset. If experience 
shows us on the one hand that an inadequate treatment 
either fails to remove completely the existing symptoms, 
or, where complete recovery is achieved for the time, can- 
not avert later relapses, on the other hand we find that 
the desired result will be obtained in both directions, in 
those difficult and obstinate cases in which a long and 
energetic mercurial treatment must perforce be carried 
through. 
In all ordinary cases the inunctions are prolonged 
eight or ten days beyond the time of healing of visible 
lesions, and the thermal baths need not be given for a 
longer period. 
It is probable that Dr. Brandis goes a little too far when 
he claims that there are absolutely no contra-indications to 
anti-syphilitic treatment, as practised at Aix-la-Chapelle. 
The writer has visited Aix on several occasions, and he 
is convinced of the great efficacy of its waters, when 
(SUPPLEMENT.) 
and contains over fifty douche-rooms-general and local 
vapor-baths, swimming baths, and a large number of 
other baths, as well as the throat, eye, and ear douches, 
inhalation- and spray-rooms. Two thousand douches and 
one thousand baths can be, and often are, given daily. 
The principal application of the Aix waters is by what 
is now called the " douche massage" (Forestier). The 
patient is taken into one of the large douche-rooms,where 
he is met by two of the attendants, male or female as the 
case may be. They seat the patient on a wooden stool, 
and, one taking the lower extremities and the other the 
back, they shampoo, knead, or rub according to the di- 
rections previously given by the patient's medical ad- 
viser. This is the " massage,'' in which all the attend- 
ants are skilled at Aix, it having been handed down to 
them from father to son, and from mother to daughter 
for many years past. The masseurs each have a hose 
under their arms from which they direct the water over 
Fig. 14.-Method of Conveying Patients to and from the Thermal Establishment at Aix-les-Bains. (The Patients are Wrapped in Blankets only.) 
used in conjunction with other remedies. But the very 
aged and extremely debilitated, as also the very young, 
should be judiciously treated at home, rather than incur 
the risks of a long and tedious journey to the ancient 
spa of Aix-la-Chapelle. Although it is an " all the year 
round '' watering-place, the warm season should be given 
the preference. In the fall and winter months, the town 
is cold, dreary, and depressing, a circumstance worth 
remembering in sending patients there. 
Edmund C. Wendt. 
AIX-LES-BAINS. In addition to the information al- 
ready published (see Vol. I. of Handbook) concerning 
Aix, it may be well to give a supplementary description 
of certain features of this popular spa. It is not to be 
forgotten that no other resort in France is so largely fre- 
quented in the summer months by English and Ameri- 
cans as Aix-les-Bains. Dr. Linn (The Climatologist, June 
15, 1892) has given a resume of Aix in its modern de- 
velopment as a fashionable resort, from which the fol- 
lowing account is taken: 
The thermal establishment is one of the finest in France, 
the bather. It is this massage under the hot sulphur 
water that constitutes the principal treatment at Aix. 
The temperature of the water is varied by the physician's 
orders. As a rule, ten to fifteen minutes is the duration 
of this operation, when the patient is rubbed dry and en- 
veloped in a blanket, put into a bath-chair and carried 
home by porters, who not only take him to his hotel, but 
also to his room, and place him in bed. This specialty 
of Aix is most important, as a rheumatic person seems to 
obtain more barm than good by having to dress after a 
douche or bath, and walk home afterward. 
The waters of Aix-les-Bains are so abundant that they 
are allowed to flow away from an ugly public fountain. 
They act energetically by a stimulation of the cutaneous 
surface. It is, as it were, a purgation of the skin, mak- 
ing it eliminate whatever excrementitious matters may 
have been retained in the system, and relieving conges- 
tions of the deeper parts or organs, while giving a stimu- 
lus to the circulation in general. To this may be added 
the effects of the mineral elements in the waters taken 
into the system and blood both by drinking them and in- 
haling them during the douche and baths. 
24 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Aix-la-Chapelle. 
Akinesia Altera. 
Dr. Linn accepts the usual indications for treatment, 
such as gout,rheumatism, skin diseases, syphilis, catarrhal 
affections of the respiratory passages, etc. But he has 
this to say as to contra-indications: 
" It is easy to understand that all acute diseases would be 
better without the stimulation of the Aix treatment, and 
that its province is in chronic troubles only. Degeneration 
■of the muscular fibre of the heart is a contra-indication, 
but valvular affections coming.from a rheumatic cause im- 
prove at Aix,unless there be a tendency to syncope. Under 
this heading we think that patients should be warned 
against taking these powerful massage douches without 
medical advice, as they are apt to do great harm by an in- 
judicious use of them. Many people insist on the masseurs 
giving them a vigorous treatment, when they have no 
proper power of reaction, and simply exhaust themselves, 
producing a state of feverish debility and weakness. 
Others, again, when the baths are crowded, get up at a 
very early hour to secure a douche or to have their morn- 
ing free. We are of opinion that in many cases it will be 
found best to have a light breakfast and take the douche, 
as we do a sea-bath, at nine or ten in the morning or even 
later, and npt attempt to turn out delicate people at five 
•or six o'clock on a cool or wet day. As to the best 
time of the year to take this treatment, as a rule it 
should be during the summer months, June io the end of 
September, when the external warmth and greater equa- 
bility of temperature, less risk of chill and its conse- 
quences, will allow patients who have rheumatic trouble, 
•especially, to get the best results. It is remarked that 
July and August are the crowded months at the hydro- 
pathic stations, and many volumes have been written to 
try and persuade the good public that they would do bet- 
ter to come at other times; but the great mass are right, 
for very delicate people the hot months are the best for 
.bath treatment. 
" The establishment is, however, open all the year 
round, and those who like bracing air and want more 
reasonable rates can come at any time. The duration of 
the treatment has been rather arbitrarily fixed at three 
weeks or twenty-one days, but this depends on the case, 
as almost every patient demands a careful study by a 
physician, who alone can fix the time. It may be said, 
though, that many people get saturated with strong min- 
eral waters in about three to four weeks." 
Aix now has two casinos, the " Cercle " and the " Villa 
des Fleurs." Good music and operas, reading-rooms, a 
race-course, pigeon-shooting, tennis, and other " distrac- 
tions" are always provided at Aix. There are excellent 
•opportunities for pleasant walks and excursions. The 
hotel and boarding-house accommodations are ample and 
.highly satisfactory. 
Concerning Marlioz, which is almost now a part 
of Aix, the same author gives the following informa- 
tion : 
" Marlioz, an important sulpho-sodiac and bromo- 
iodurated water, is in the suburbs of Aix, and now forms 
part of it. It is a pleasant walk down the Avenue de 
Marlioz of about fifteen minutes, and the omnibus or 
tram runs there in less time. There are three springs, 
which are compared to the sulphur waters of the Py- 
renees, like Eaux Bonnes. These springs are much 
richer in mineral elements than the hot waters of Aix 
itself. Patients live in Aix, but some rooms can be had 
close to the pretty little establishment in Marlioz. The 
specialty here is throat troubles. Its pulverizing or 
spray arrangements and inhaling-rooms are excellent and 
complete in every particular ; there is also a good bath- 
ing department. The waters are highly efficacious in all 
chronic affections of the respiratory passages, chronic 
catarrhs, etc. ; and form with the Chalies water, which 
is also given in Aix, drawn from fountains in the chem- 
ists' or druggists' places like soda-water, a valuable ad- 
junct to the other courses of treatment given in Aix-les- 
Bains." 
Altogether the spa of Aix-les-Bains deserves the popu- 
larity which has been so liberally bestowed upon it by 
the exacting Anglo-American public. 
Edmund C. Wendt. 
AKINESIA ALGERA. Moebius' has given this name 
to an array of symptoms, among which the most char- 
acteristic is loss of power of movement as the result of 
accompanying pain, while no sufficient cause for the lat- 
ter symptom has yet been found. 
The cases which he reports -were persons of neurotic 
inheritance, so-called desequilibres, in whom the disease 
manifested itself after mental over-exertion. In the one 
case neurasthenia, in the other hysteria, was present. In 
both cases the disease was quite protracted. The first 
case reported by him occurred in a man, a teacher in the 
gymnasium, thirty-three years old. The father suffered 
from paranoia. The patient during his youth was very 
excitable and extremely ambitious. No history of sexual 
perversion. In 1887 he suffered from headache and in- 
somnia. In the spring of 1888 he was unable to carry on 
his work, and was sent to an institute. Subsequent to 
this there occurred a loss of memory for three or four 
weeks. After every movement the patient experienced a 
heaviness of the limbs and pains in the muscles. Im- 
provement took place under prolonged rest, or the Weir 
Alitchell treatment. Following this a relapse occurred, 
during which the patient abstained from all movement 
of the limbs. The skin- and tendon-reflexes were present; 
the patellar reflex was quite marked. On the right side 
the ankle reflex was weak ; on the left it was marked. 
There was found hypenesthesi^ in the hands and forearms; 
no points of pain, however, were discovered. Organs of 
special sense normal. Every voluntary movement of 
the limbs and trunk was accompanied by severe pain, 
lasting for hours. These pains were most marked in the 
forearms. The head was free from pain, and there was 
no difficulty in moving it. There was a very slight 
muscular atrophy of the left hand, which was possibly 
caused by the pressure of pasteboard splints. 
In the way of treatment, bromide of potassium, given 
in the evening in doses of from three to four grains, pro- 
duced rest. Hypnotic suggestion was without result. 
Improvement followed after several months' rest. The 
tendon reflexes became weaker and finally normal, there 
remaining a weak ankle clonus on the left side. Subse- 
quent to this, and following a considerable excitement, a 
relapse occurred, with subsequent improvement. The 
hands, however, remained quite painful. 
The second case occurred in a woman, forty-three 
years of age, by occupation a teacher of music. A neuro- 
tic family history was given. From her twentieth year 
onward the patient had suffered from tremors, with semi- 
unconsciousness. The hands were painful, and were 
held in a flexed position. She also suffered from in- 
somnia, and was incapable of mental work. The feet 
were painful, and walking was impossible. After suffer- 
ing in this way for ten years, improvement set in, and the 
patient was comparatively well for a subsequent period 
of ten years. In the summer of 1889, probably as the 
result of over-work and excitement, a relapse occurred, 
from which she had not recovered up to the time of the 
report. There were found, extreme irritability, a forced 
position of the hands, and pain in the legs. The latter 
could be moved, but they soon became tired, and suffered 
from quite severe after-pains. Auditory and visual func- 
tions were normal. Hypnotic treatment without result. 
The patient twice attempted suicide, and finally gave evi- 
dence of mental trouble, with hallucinations of persecu- 
tion. She subsequently died in an insane asylum. 
In a subsequent publication2 Moebius reports another 
case in which, in addition to the absence of motion re- 
sulting from pain, and really superseding it in impor- 
tance, there was present an extreme degree of photopho- 
bia. We have here a condition very similar to that which 
has occurred in regard to motion, a condition in which 
the patient will not see because of the attending pain. 
Moebius seeks to widen the term by calling it " Apraxia 
algera," or abeyance of the function of any or all or- 
gans because of the pain attending their functional ac- 
tivity. 
In the last case this was very w'ell illustrated by the 
very severe pain in the head attending any mental effort 
'whatever. The case has a further interest in that the 
25 Akinesia Altera. 
Alexander-A dams. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
report is taken from the " Autonosography " of the dis- 
tinguished psycho-physicist, Gustav Theodor Fechner. 
Longard3 reports a case occurring in a young lady, 
aged twenty-nine. Her mother had suffered from ar- 
thritis deformans ; her father, in 1874, became, afflicted 
with paranoia. The patient had for years previously 
suffered from pelvic troubles (pelvic inflammation, uter- 
ine fibroids, metritis, etc.). The symptoms observed in 
this case were mental excitement and peculiar pains over 
the entire body, which later became so severe as to com- 
pel the patient to abstain from all motion. The psychical 
excitement also increased. During the later period of 
observation, retention of urine, marked constipation, and 
very obstinate insomnia showed themselves. Objective- 
ly, an increase of the tendon reflexes was found. The 
course of the disease was not materially altered during 
six months' treatment in the hospital, improvement oc- 
curred later as the result of improved surroundings. 
Longard calls attention to the fact that these cases 
of akinesia algera give the same clinical picture as 
was formerly described under the name of spinal irrita- 
tion. 
According to Moebius the affection is a functional or 
psychic one, and is not due to organic disease. The 
pains he regards as hysterical, or pain-hallucinations. 
The disease itself is not, however, a pure hysteria, but 
may be regarded as an analogue of the general anaesthesia 
described by Krukenberg, Heyne, and von Ziemssen. 
The cases reported by W. Neftell in 1883, and called by 
that author Atremia, are regarded by Moebius as similar 
to his cases. 
The prognosis is not very favorable. In the matter of 
treatment the best thing to do is to accede to the wishes 
of the patient for rest. 
S. P. Kramer. 
1 Dent. Zeit. fur Nervenheilkunde, 1891, vol. i. 
2 Ibid., vol. li., 431. 
3 Ibid., vol. ii., 455. 
ALASSIO. A winter health-resort on the Italian 
Riviera, which is lately claiming an increased share of 
attention. It is prettily situated, but owing to its com- 
parative newness the accommodations for invalids are far 
from perfect. The only reliable meteorological data avail- 
able are those of Dr. Schneer (" Alassio and its Climate," 
Turin, 1878) and a synopsis published by Dr. M. G. 
Foster {British Medical Journal, November 7, 1891). Dr. 
Foster, who is now practising at San Remo, informed 
the writer that the authorities of Alassio appeared to 
lack energy in effecting reforms, more particularly from 
a sanitary point of view. Dr. Foster spent two winters 
at Alassio, and did not observe any typhoid fever there ; 
but it is said to occur there every summer. There is no 
system of drainage, the excreta being collected in cess- 
pools. The drinking-water is hard, but as to organic 
impurities reliable (lata are not at hand to justify its 
condemnation or acceptance. Sparks (" The Riviera," 
London, 1879), claims that the water is good and potable. 
Alassio is on the north shore of the Mediterranean, 
about equidistant from Nice and Genoa. It lies at the 
head of a curving bay, which is some five miles wide. 
The town has about 6,500 inhabitants. Its latitude is 
about the same as that of San Remo. Dr. Foster's de- 
scription is here reproduced, as it is accurate and devoid 
of local bias: 
" Without the gates of the city proper at either end 
stretches a suburb composed of dwellings of the Italian 
population mingled with a few villas. Each of these 
suburbs contains a hotel situated facing the sea, while a 
third is placed about a hundred yards behind the main 
street of the town. The villas of the English residents 
are dotted over the lowermost spurs of the encircling 
hills. The hills form an unbroken semicircle round the 
town. Their greatest elevation is on the north (1,963 
feet). Numerous valleys run up among the lower spurs 
of these hills, but none pierce them. 
" Alassio thus secures good protection from the north, 
■west, and southwest. The seashore is generally windy, 
but in the valleys running up among the hills the wind' 
is rarely severely felt, and on most days the air in these- 
situations is almost entirely still." 
The records of temperature (as given by Foster) are as 
follows: 
" October has a mean temperature of 61.9 Fahr. 
November " " 54.3° " 
December " " 49.7° " 
January " " 47.3° " 
February " " 48.2° " 
March " " 52.3° " 
April " " 56.4° " 
May " " 64.3° " 
" The mean temperature of the three winter months is 
therefore 48.4° F." 
Turning now to the rainfall observations, the records 
give the following results : 
"October showsan average of 7 days on which rain 
fell, an average rainfall of 93.1 millimetres, and a mean 
relative humidity of 55.2. 
"November shows an average of 8.6 clays on which 
rain fell, an average rainfall of 163.7 millimetres, and a 
mean relative humidity of 58. 
" December shows an average of 5.6 days on which 
rain fell, an average rainfall of 43.3 millimetres, and a 
mean relative humidity of 55.4. 
" January shows an average of 4.3 days on which rain 
fell, an average rainfall of 60 millimetres, and a mean 
relative humidity of 52.9. 
" February shows an average number of 4.8 days on. 
which rain fell, an average rainfall of 70.9 millimetres, 
and a mean relative humidity of 55.7. 
" March shows an average of 6.6 days on which rain 
fell, an average rainfall of 50.7 millimetres, and a mean 
relative humidity of 57.9. 
"April shows an average of 10.8 days on which rain 
fell, an average rainfall of 111.9 millimetres, and a mean 
relative humidity of 62.8. 
" May shows an average of 5 days on which rain fell, 
an average rainfall of 46.4 millimetres, and a mean rela- 
tive humidity of 63.1. 
" Fog has been recorded on 14 days in the six win- 
ters. " 
In his summary of what class of cases are likely to- 
derive benefit from a winter residence at Alassio, Dr. 
Foster expresses the following opinions : 
"The climate of Alassio possesses those advantages- 
which a tolerably high and fairly equable temperature, 
abundance of sunshine, and freedom from fog can give. 
Cases of gout and chronic rheumatism do well there. 
Cases of heart disease certainly appear to do well ; they 
eat and sleep better, and, with ordinary precautions, at- 
tacks of secondary bronchitis can be prevented. Cases 
of bronchitis and emphysema, with care, keep very free 
from winter cough. Cases of phthisis require very care- 
ful selection. Early cases, with limited consolidation 
and only slight fever, generally do well. Later cases 
with cavities seem to show improvement, the cough and 
expectoration diminish, and, since the patients can gener- 
ally pass a fair amount of time in the open air, the appe- 
tite and sleep are both improved. Cases characterized 
by frequent hemorrhage, with only slight physical signs, 
seem generally to do well. Owing to the proximity of 
the principal hotels to the sea, the effect of the climate 
varies in different cases ; some patients sleep badly by 
the sea, and thus lose much of the benefits ; others again 
sleep better there than elsewhere. Weakly and strumous 
children certainly show great improvement, as they can 
pass a large amount of time on the seashore. Finally, 
with regard to that numerous class of cases which are 
sent to the Riviera under the generic title of nervous 
breakdown, some cases seem to show great improvement 
and regain their lost health, while in other cases all the 
symptoms appear to become aggravated." 
Alassio is a somewhat cheaper place to live in than 
many of the other Riviera stations. 
Edmund C. Wendt. 
26 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Akinesia Altera. 
Alexander-Adams. 
ALEXANDER-ADAMS OPERATION. The operation 
of shortening the round ligaments for the cure of pro- 
lapsus uteri was proposed by Alquie, as applicable to the 
cure of retroflexion. Aran, according to Tillaux, sug- 
gested this operation. The same thought occurring to 
Freund he performed the operation on the cadaver. It 
was first performed on the living subject by Alexander, 
of Liverpool, in 1881. Adams, of Glasgow, performed 
it in 1882, without a knowledge of Alexander's opera- 
tion. During the past ten years the operation has been 
done hundreds of times, and principally in America. 
This operation has been severely criticised by many, both 
here and abroad, but on carefully looking up these criti- 
cisms it was found that they were wholly based on theo- 
retical grounds, or had been brought forward by those 
who had not done the operation sufficiently often to be 
familiar with it or its results. Those who have done the 
operation the most times and have seen the excellent re- 
sults that follow in properly chosen cases, are its most 
enthusiastic advocates. Hysterorrhaphy is advocated by 
some, especially by operators on the Continent, in prefer- 
ence to the Alexander-Adams operation. I have had 
considerable experience with hysterorrhaphy for the re- 
lief of retroversions and flexions, both with and without 
adhesions, attended both with and without prolapsed and 
adherent ovaries. My results have been excellent, there 
having been but one failure and one death in quite a con- 
siderable number of cases. 
As far as I can ascertain we have no data relative to the 
effect of pregnancy on the adhesions produced between 
the parietal peritoneum and the peritoneum covering the 
uterus. With the other operations inside the abdominal 
cavity that secure the forward position of the fundus 
uteri I have had no experience. But opening the ab- 
dominal cavity is not wholly without danger, conse- 
quently the Alexander-Adams operation is preferable, 
especially as it will accomplish, in just as satisfactory a 
manner, everything that an intra-abdominal operation will 
do, and it is practically free from danger. 
Indications for the Operation.-1. For the cure of 
uncomplicated retroversions and retroflexions where the 
patient is desirous of getting rid of wearing a pessary 
which necessitates her consulting a physician at stated 
intervalsand makes her feel that she is still on the invalid 
list. Patients often choose this operation to avoid wear- 
ing a pessary. 
2. For the cure of retroversions and retroflexions where 
a prolapsed ovary or ovaries prevents the wearing of a 
pessary, either by mechanically diminishing the trans- 
verse pelvic space, thus causing a pessary to ride ob- 
liquely instead of horizontally, or where, through sensi- 
tiveness of one or both ovaries, a pessary cannot be tol- 
erated. 
3. For the cure of retroversions and retroflexions with 
prolapse in the second degree, and for all cases of pro- 
cidentia ; it being understood that whatever plastic ope- 
ration on the vaginal walls or perineum is called for, 
shall be done at the same sitting. As this operation 
diminishes a rectocele, but increases a cystocele, I advise 
doing the Alexander-Adams operation before operating 
on the vaginal walls. All operations on the vaginal walls 
can be done without bringing any strain on the round 
ligaments, just fastened in their new relations. If a tra- 
chelorrhaphy is called for it should be done at the same 
sitting with the Alexander-Adams, but prior to it, as all 
dragging down on the round ligaments should be avoided. 
4. For the relief of lateral displacements, retroversions, 
and retroflexions with adhesions. Often, after packing 
faithfully for weeks, sometimes for months, in the Sims 
position, we are unable to relieve this class of cases, the 
more or less fixed position of the uterus and our inability 
to keep it forward in anteversion being due to adhesions 
between ovary and tube, or ovaries and tubes, and peri- 
toneum covering uterus, broad ligaments, rectum, or in- 
testine. In my experience these cases give a history of 
septic peritonitis following labor, abortion, or salpingitis. 
In opening the abdominal cavity in cases where there has 
been for months or years retroposition with adhesions- 
often cases of pyosalpinx with a history of repeated at- 
(SUPPLEMENT.) 
tacks of peritonitis-I have over and over again been sur- 
prised at the ease with which the uterus could be ante- 
verted by the intra-abdominal fingers, and in a good 
proportion of the cases the fundus would stay forward 
without being supported. This led me in 1889 to make 
attempts, under ether, through the rectum, to replace 
uteri retroverted or retroflexed and adherent, after the 
packing bad been thoroughly tried. The index linger of 
the left hand is passed up the rectum, the patient being 
thoroughly etherized, flat on the back on an even hard 
surface, with the knees -well separated and the thighs 
drawn forward to an angle of forty-five degrees with the 
table. The index finger is passed up until, with the aid 
of counter-pressure by the right-hand fingers through the 
abdomen, it feels the whole of the posterior surface of 
the uterus, the posterior surface of the broad ligaments, 
the fundus, the ovaries, and the tubes. In this way all the 
pelvic structures can be actually examined and their re- 
lations to each other, changes in size, etc., can be more 
accurately determined. Then gently, but slowly, the 
uterus is ante verted. At times the adhesions are over- 
come with difficulty. Dr. Conant and myself worked 
over one hour in breaking up the adhesions in one case, 
and half an hour is no unusual time to be consumed in 
replacing the uterus. Then, while the uterus is held in 
position by a Kingman's or Emmet's uterine repositor, 
the cervix being pushed well back into the post cul-de- 
sac, an Alexander-Adams operation is done. The uterus 
is thus held upward, non-flexed, and forward while the 
raw surfaces of the peritoneum are becoming adherent to- 
each other. 
In some cases it is impossible to correct the retrodis- 
placement, owing to the quantity, quality, or location of 
the adhesions, without using more force than would be 
safe. In such cases, if the condition of the patient de- 
mands interference,-or if she is sterile and willing to run 
the risk, coeliotomy should be done, all adhesions broken 
up, and the uterus fastened in anteversion by hysteror- 
rhaphy. This combination has worked admirably in cases 
where it was impossible to satisfactorily replace the uterus 
through the vagina or rectum. 
When, the patient being under ether,-and a diagnosis 
not made when the patient is thoroughly anaesthetized 
should not be accepted as final,-the tubes are found to 
contain fluid or are much enlarged, I think it advisable 
not to interfere with adhesions, for fear of rupturing the 
tube or tearing away the fimbriated extremity, thus allow- 
ing septic material to escape into the peritoneal cavity. 
5. While witnessing Dr. Conant make several dissec- 
tions for the round ligaments, I was surprised to see how 
securely and evenly the internal abdominal rings were 
closed when the round ligaments were drawn out, and 
it occurred to me that the Alexander-Adams operation 
might be done for the radical cure of hernia. 
Dr. Conant wrote me the following, under date of 
August 24, 1892 : " I have had one case for radical cure 
of hernia by the Alexander operation. The case was one- 
of double inguinal hernia in a young girl of nineteen. I 
practically did the regular Alexander, except that I was 
somewhat puzzled to find the round ligament on the 
right side, owing to the size of the sac. The result of the 
operation was very gratifying. Previous to the operation, 
which was done last spring, she was unable to work, but 
since the operation she has been at work for the last 
three months. She is in good health, although she has 
some pain at times in her left side. I have examined the 
case within a week and found a firm cicatrix about the 
pillars of the rings on both sides. She never wore a 
truss." In October, 1892, I did an Alexander-Adams 
operation for procidentia of six months' standing, and 
left inguinal hernia. At the present time (January, 1893)' 
the uterus is in perfect position, there is complete relief 
of all symptoms, and there has been no symptom of a 
return of the hernia. 
6. In two cases I have done the Alexander-Adams oper- 
ation to prevent incarceration of a fibroid which threat- 
ened to take place at any time, the growth of the tumor 
being very rapid. In both cases severe symptoms from 
pressure were present. In both cases the fibroid, which 
27 Alexander-Adama 
Operation. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
was interstitial, in the posterior uterine wall, was got out 
of the hollow of the sacrum with great difficulty. In both 
cases, one a woman who had borne five children, the 
other not married, the ligaments were as large as a 
No. 2 Faber lead-pencil. The first case was operated 
on in March, 1891 (reported in list of cases). Examina- 
tion one year later revealed the uterus to be in perfect 
position, with a marked diminution in the size of the 
fibroid. (Treatment with the idea of arresting the 
growth of the fibroid had been continued throughout the 
year.) The second case was operated on in June, 1892. 
At present (October, 1892) the uterus with its large fibroid 
is up out of the pelvis, and there is relief from all former 
distressing symptoms. 
Those opposed to this operation bring forward the fol- 
lowing objections : 
1st. That the ligaments are often absent. 
2d. That there is great difficulty in finding the liga- 
ments. 
3d. That it is a dangerous operation. 
4th. That it prevents the usual course of pregnancy, 
causing it to terminate in abortion. 
5th. That after pregnancy the uterus returns to its 
former malposition. 
6th. That it may give rise to serious secondary symp- 
toms or conditions. 
7th. That it is limited in its application. 
8th. That it will soon become obsolete. 
1. In my experience with over one hundred and twen- 
ty-live cases, I have never failed to find the ligaments 
except in one case. This was among the very first 
operated on. No doubt the ligaments were present and of 
good size, but I failed to find them. Since then I have 
operated successfully on a case where the operation had 
been attempted, but abandoned on account of the inabil- 
ity of the operator to find the ligaments. The patient was 
told that she had no round ligaments. I agree with Dr. 
W. M. Conant in his statement, that " The ligaments are 
never wanting provided there is a uterus." They may 
be very small, but they are there and are of a good size 
nine times out of ten after they are drawn out. 
2. The difficulty in finding the ligaments depends en- 
tirely on the experience of the operator. The descrip- 
tion of the operation given in many text-books is mis- 
leading. The beginner is led to think that he is about 
to do an operation the success of which depends on his 
ability to recognize each layer of tissue and every vessel 
and nerve from the skin down until he has reached the 
aponeurosis of the external oblique muscle. Now this 
is at times difficult to do with thin abdominal walls, and 
often so in a fat patient, and it is no wonder that the be- 
ginner gets wound up with a round turn just at the time 
when it would mean success for him to have some fixed 
and easily recognized landmarks. Many descriptions of 
the modus operand! of the Alexander-Adams operation 
remind me of the old way in which an abdominal sec- 
tion was described-where layer by layer the tissues were 
cut through on a grooved director with a dull knife 
down to the peritoneum, more time being used up in 
getting inside the peritoneum than is now often con- 
sumed in getting in, doing what is necessary, and getting 
out. If the operator will mark, read, learn, and in- 
wardly digest Alexander's excellent article, fully describ- 
ing the operation, in the " Transactions of the Interna- 
tional Medical Congress," 1887, vol. xi., p. 742, and 
Mundi's admirable article in the American Journal of 
Obstetrics, 1888, he will have no difficulty in finding the 
ligaments. 
3. Alexander has operated eighty-four times and has 
never had a death, and in the article above referred to he 
says, " I no more expect a death from it than I expect a 
death from an amputation of the finger." 
Munde has operated thirty-seven times and has never 
had a death nor any unpleasant results. 
Reid has operated thirteen times with no death. 
Edebohls has operated twenty-nine times with no un- 
pleasant results. 
Newman, in 1888, read a paper on this subject, and 
estimated there had been up to that time three hun- 
dred cases operated on. Of this number he knew of 
three deaths. 
W. M. Conant has operated over thirty times with no 
death. 
F. B. Harrington has operated twenty-five times with 
no death. 
Kingman has operated over twelve times with no death. 
Burrage has operated over sixteen times with no death. 
J. G. Blake has operated twenty-five times with no 
death. 
J. B. Swift has operated thirteen times with no death. 
I have operated over one hundred and twenty-five 
times with two deaths. The first was due to acute sep- 
sis. The abdominal cavity was opened while drawing 
out one of the ligaments. This was among my first 
operations and before the rigid asepsis now employed was 
used. The second was due to pneumonia and occurred 
six days after the operation. The wounds had healed 
by first intention throughout. The various journals for 
the past few years have contained abundant testimony 
like the above. 
In over two hundred and forty-six cases operated on 
in Boston, most of the cases having been operated on since 
1888, I have been able to learn of only three deaths, two 
mentioned above and a third, due to sepsis, the bladder 
having been opened on the left side, either by the knife 
or a deep stitch. On this followed infiltration of urine 
with pelvic abscess, to which the death was to be directly 
attributed. In nearly a thousand cases collected by Dr. 
W. M. Conant he found a record of only seven deaths. 
4 and 5. These can best be answered in one. That 
it does not prevent the usual course of pregnancy can, 
as Dr. Conant has shown, be best determined by a ref- 
erence to the cases reported. He collected twenty 
cases ; seven by Alexander, five by Munde, two by Co- 
nant, two by Johnson, and four unknown. Alexander 
claims that pregnancy is favored by this operation and 
that there is little danger of the return of the former 
malposition. Dr. Munde wrote Dr. Conant as follows: 
" In four the uterus remained in its normal position after 
confinement. One, done for prolapse, became pregnant 
soon after the operation and after the confinement the 
prolapse returned. This is the only case where the dis- 
placement, retroversion or prolapse, returned after the 
operation, so far as I know." 
Dr. Conant's first case was the first one he operated 
on ; about a year after the operation she was married and 
was unwell only twice, when she became pregnant. She 
has been delivered at term. My two I will report here 
at some length. 
Case I.-Diagnosis under ether : Ruptured perineum ; 
retroflexion ; bilateral laceration of the cervix ; left ovary 
prolapsed and adherent at a point close to the uterus at 
the base of the left ligament. By packing, the uterus 
was got into normal position, but a pessary could not be 
worn on account of the prolapsed and adherent ovary. 
She was advised to have the lacerated cervix operated on 
and to have an Alexander-Adams operation to relieve the 
sagging and dragging down. She had aborted four times 
since her last confinement live years ago. The operations 
were done in February, 1890, and perfect results were 
obtained. In a few months she became pregnant and 
was delivered at term. The family attendant answered 
the following questions. 
Length of labor? "About one and three-quarters 
hours." 
Sex and weight of child? "Boy; nine and one half 
pounds." 
Character of labor ? " She had good pains, better 
than ever before." 
Puerperium ? "She remained in bed fourteen days. 
She flowed a good deal-not post-partum hemorrhage,- 
but during her stay in bed she lost considerable blood, 
although there was good and permanent contraction of 
uterus. She was weak on getting up, but nothing of 
interest occurred. She nursed the baby." One year 
after pregnancy took place she was examined at my 
office. The symptoms for which the operations had 
been done had never returned. The uterus was in per- 
28 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Alexander-A dams 
Operation. 
feet position. Cavity measured two and one-half inches. 
No discharge from vagina or cervix. 
Case II.-Sterility. Diagnosis under ether : Retrover- 
sion with adhesions ; left ovary prolapsed and adherent; 
chronic endometritis. 
She had been married five years. Never pregnant. 
Sought relief for the sterility and for back-ache and pain 
in the left ovarian region. January, 1891, the uterus 
was forcibly restored to its normal position and the round 
ligaments wrere shortened. Both sides suppurated, but 
the result was perfect, except that the uterus was drawn 
over toward the right side. She became pregnant two 
months after the operation and was delivered at term. 
Examined at my office one year after confinement. Ute- 
rus was in the same position that it was directly after 
the operation. Left ovary could not be found. Since 
the operation there has been complete relief of all back- 
ache and pain in left ovarian region. 
6. I have had four cases in which pneumonia followed 
this operation, but I could see no connection between the 
operation and the lung trouble. All four occurred in 
hospital practice, during the winter, and at a time when 
the grippe was very prevalent. One case, noted above, 
died. I have had several cases in which pneumonia 
followed coeliotomy and in no way, so far as I could 
see, was it connected with the operation. 
Cases of cystitis have been reported, but I have seen 
but one such case, and I attributed it to washing out the 
bladder. For the relief of frequent and painful micturi- 
tion the nurse in my absence was ordered to wash out 
the bladder, and a violent cystitis followed, lasting two 
weeks. In quite a large proportion of the cases operated 
on by myself there has been bladder-trouble, showing 
itself in frequent and painful micturition with scalding 
referred to the meatus and urethra, and suprapubic 
distress or dull pain. In some cases there has been 
tenesmus with the forcing out of a few drops of blood at 
the end of micturition. In these cases the urine has 
been of a high color, high specific gravity, and loaded 
with mucus and urates. 
Unfortunately, in almost every case after this operation 
there is inability to empty the bladder for the first 
twenty-four hours, and sometimes it is three or four days 
before the catheter can be dispensed with. But in some 
of my cases the above symptoms occurred when no 
catheter was used, and whenever the catheter was em- 
ployed the greatest vigilance was exerted to secure clean- 
liness. In the cases where no catheter was used, the symp- 
toms were usually less severe, lasted a short time, and 
were more amenable to treatment. Still, the severest cases 
got well after a time. One class of these cases is peculiar, 
and points to the fact that the operation is directly the 
cause of the bladder trouble. In this class there had been 
no previous bladder trouble, no retention, and no cath- 
eter had been used. The bladder symptoms appeared, 
but not for eight or ten days, and in one case they did not 
appear for three weeks after the operation. I have gone 
thus extensively into the bladder trouble following this 
operation, as it is a strong point with the opponents of 
the Alexander-Adams operation. For twelve years I have 
seen a great deal of gynecological surgery, both hos- 
pital and private, and at the hands of the very best men, 
and have known the above-mentioned bladder symptoms 
to be present, even severe attacks of cystitis, over and 
over again, after perineorrhaphy where the catheter was 
used, after trachelorrhaphy and operations on the vaginal 
walls where no catheter was used, and after coeliotomy 
both where the catheter was and where it was not used. 
I have known of one case of double phlegmasia alba do- 
lens. It followed an attempt to do an Alexander-Adams 
operation, but the ligaments were not found. Drainage 
was used and was probably the cause of the trouble. In 
almost all of my cases where the nerve was broken or in- 
jured in drawingout the ligaments there was more or less 
neuralgic pain in the neighborhood of the incision. At 
times the pain would extend upward as high as the 
floating ribs, at times it would reach over the thigh and 
down the sciatic nerve and its branches. These pains 
were complained of usually after the patients were up 
(SUPPLEMENT.) 
and about, or after they had got home. In these cases an 
attack was pretty sure to come on at menstrual periods. 
These attacks of pain come on every day or two, lasting 
from a few minutes up to an hour or two, but in the se- 
verest cases give no trouble after a few weeks. A burn- 
ing feeling in the incision, with numbness in the mons 
veneris lasting from a few days up to a week or ten days, 
was not uncommon. It occurred in at least ten cases. 
Haematuria occurred in three cases. They were cases of 
retrodisplacement with extensive adhesions, and the for- 
cible breaking up of these adhesions, as pointed out by 
Dr. Conant, may have injured the ureters. The hem- 
orrhage was small and occurred only during the first 
twelve hours after the operation. 
The liability to hernia has been brought forward as an 
objection to the operation. If the operation is properly 
and successfully done no hernia can occur, as the internal 
abdominal rings are completely and securely covered 
over by the anterior surface of the broad ligaments. 
Unfortunately, sloughing of the wound is not uncom- 
mon in the experience of all. Whether the fault is in 
the ligament, its vitality being poor, whether the fault 
lies in the poorly vitalized aponeurosis to which we fasten 
the ligaments, or whether the damage is due to the bruis- 
ing and stretching of the ligaments during extraction, has 
not yet been settled. That this suppuration is not due to 
the operator or to the variety of suture material used, has 
been proved. After looking over the cases it was found 
that suppuration occurred in thin as often as in fat ab- 
dominal walls. In the first twenty-five cases done by 
Alexander, nearly one-third sloughed on one or both 
sides ; in the remaining fifty-nine cases only two sloughed. 
Sloughing of the wound delays convalescence, and often 
sinuses remain until the sutures put in to hold the liga- 
ments are discharged or removed. Sloughing of the 
wound does not interfere with a perfect result as far as 
the position of the uterus is concerned. Sloughing of 
the w ound is not dangerous if the pus is let out as soon 
as formed. I have never known an instance where peri- 
tonitis or any intra-abdominal symptoms followed slough- 
ing of the wound. 
7. Enough has been said above to show that it is not 
limited in its application. 
8. It certainly will be a long time here in Boston before 
this operation becomes obsolete. Those who see much of 
gynecological practice are doing the operation more and 
more. In proportion to its size I doubt if there is a city 
in this country where more men are doing this operation 
than in Boston. 
A success surgically and a success therapeutically are 
two very different things. Those who are most pleased 
wuth the operation are those who know enough about 
gynecology to operate on proper cases. 
Anatomy.- "The round ligaments are two fibro- 
muscular cords that arise from the upper end of the 
uterus anteriorly and run through the superior portion 
of the broad ligament to the internal ring and pass 
through the inguinal canal, and terminate in fibrous ex- 
pansions over the symphysis, becoming lost in the mons. 
They can, therefore, be divided into three parts-the 
portion external to the canal, the portion in the canal, 
and the portion within the pelvic cavity. The pelvic 
portion is attached to the upper angle of the uterus, in 
front of and just belowr the origin of the Fallopian 
tubes. It runs in the anterior fold of the broad liga- 
ment, and comes upward, outward, then forward and 
inward to the internal ring. After it leaves the broad 
ligament it is covered with peritoneum and lies in the 
lateral wall of the pelvis, crossing the external iliac ar- 
tery. At the ring the epigastric artery is to the inner 
side, and at the operation can be easily felt pulsating. 
At first the ligament is large, but in leaving the broad 
ligament it is smaller and rounded. In the canal it ta- 
pers gradually, and has the same relations as the sper- 
matic cord. As it leaves the external ring, the ligament 
runs near the outer side of the pubic spine and then 
each breaks up over the symphysis into thin sets of 
fibres. A branch of the genito-crural nerve lies to the 
outer side of the ligament as it emerges from the ring. 
29 Alexander-Adams 
Operation. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
The length of the ligament is about four inches. Be- 
sides areolar tissue and vessels, the ligaments contain, 
•chiefly in their inner third, plain muscular fibres which 
are prolonged into them from the outer muscular layer 
of the uterine wall. Each ligament receives a covering 
from the peritoneum which projects into the internal 
Ting as the canal of Nuck. When traction is made on 
the round ligaments the uterus is pulled forward and up- 
ward; the broad ligament resumesits normal position, 
and a prolapsed tube and ovary are lifted out of the pos- 
terior cul-de-sac. There seems also to be puckering up 
•of the broad ligament." (W. 31. Conant.) 
Preparation of the Patient, Operator, Instruments, Liga- 
tures, Sponges, etc.-Thirty-six hours before the operation 
■one ounce of castor-oil is administered. After this noth- 
ing but gruel is allowed for nourishment, and the patient 
is kept in bed. The evening before the operation the 
patient takes a tub-bath, and the abdomen below the' 
umbilicus and the pubes are thoroughly washed with 
soapsuds and all the hair shaved off; then the parts are 
washed with ether, then with a 1 to 1,000 solution of cor- 
rosive sublimate, and a corrosive sublimate pad (1 to 
3,000) is fastened over the whole lower abdomen and 
pubes. This pad is not disturbed until the patient is 
■on the table ready for the operation. Every six hours, 
beginning thirty-six hours before the operation, the 
vulva is washed with a 1 to 1,000 solution of corro- 
sive sublimate and vaginal douches of the same strength 
are given. Two hours before the operation two ounces 
■of whiskey are given by the rectum, and one hour 
before administering ether one one-hundredth grain of 
atropia is given by the mouth. In several years' ex- 
perience with atropia, it has been found that when it 
is administered as above, seven-tenths of the patients 
•do not vomit on coming out of the ether, and in part, 
or wholly, it prevents the filling up of the mouth and 
fauces with mucus. While the patient is being ether- 
ized, the instruments, ligatures, sponges, and towels are 
placed in an Arnold steam sterilizer. The room, table, 
and clothing has been prepared as if a coeliotomy was to 
be done. The operator and assistant remove their outside 
garments, substituting freshly washed cotton trousers, 
frock, and canvas shoes. The hands and forearms are 
scrubbed in soapsuds with constant rinsing for ten minutes 
by the watch, great care being taken to clean the finger- 
nails ; then they are washed in a saturated solution of per- 
manganate of potassium until of a dark mahogany color ; 
then, finally, the permanganate stain is removed by per- 
oxide of hydrogen or oxalic acid. If at any time after 
this the fingers touch anything or any part of the patient 
that is not aseptic, the hands are washed in running water 
with brush and soap. When the patient is etherized, the 
bladder is emptied and the vagina and vulva are vigor- 
ously washed with soap and water. Dr. W. L. Burrage's 
method of cleaning the vagina is a good one. He takes 
a piece of moderately soft soap as large as a French prune, 
introduces it with a little water into the vagina, and with 
the index and middle fingers of the right hand he thor- 
oughly lathers the whole vaginal mucous membrane. 
After washing out the vagina and cleansing the vulva 
with a hot 1 to 1,000 solution of corrosive sublimate the 
uterus is put in extreme anteversion. If adhesions are 
present they are overcome as mentioned above. As it has 
been my experience, backed up by that of the pathologist, 
to find chronic hyperplastic endometritis in every case 
where an Alexander-Adams operation was called for, I 
dilate the cervix, thoroughly curette the endometrium 
with the sharp curette, and pack the uterine cavity with 
sterilized gauze, on which iodoform or dermatol, as rec- 
ommended by Burrage, has been freely dusted. The 
gauze is allowed to stay in the uterus from a week to ten 
days. By using Burrage's uterine speculum no trouble 
is experienced in introducing the gauze. 
All being ready for the Alexander-Adams, the corrosive 
sublimate pad is removed, a Kelley pad is put under the 
patient, and clean rubber sheets are put above and below 
to protect the patient and conduct the water into the pad. 
Between the thighs a Ferguson speculum is placed to 
conduct all wash water into the pad. The abdomen 
(SUPPLEMENT.) 
is thoroughly scrubbed with soapsuds and then washed 
off with hot water that has been boiled and filtered. 
From the time the first incision is made until the wound 
is closed the field of operation is very frequently flooded 
with hot water that has been boiled and filtered. The 
sterilizer is now brought into the operating-room, and hot 
steaming towels are placed around the field of operation. 
The instruments are taken out on trays, which are put in 
pans filled with hot water that has been boiled and fil- 
tered. The sponges, made of folded gauze, are taken 
from the sterilizer and put in covered pails containing 
hot water that has been boiled and filtered. 
Operation.-Two, and only two, landmarks need be 
kept in mind. One only is really necessary, but as some 
operators get into the peritoneal cavity without apparently 
knowing the fact until they are there, the second land- 
mark, the observance of which will surely keep them 
out, is given. First of all, locate the pubic spine. This 
is usually done with ease, and it is only exceptionally 
that the spine is not pointed enough to be readily rec- 
ognized. When, either through fat in the abdominftl 
walls or lack of development, the spine cannot be 
located with entire satisfaction, make an incision an inch 
long through the skin and subjacent tissues over where 
you think the spine should be, and the definite location 
of it will then be settled by the finger. I am thus parti- 
cular about this because I have never seen anybody fail 
to find the ligaments when they kept the finger and their 
mind's eye on the pubic spine. The pubic spine located, 
cut down at once to the aponeurosis of the external 
oblique muscle (see that the lower end of the incision 
stops just over the pubic spine). This white glistening 
tissue cannot be missed. This is the second landmark, 
and if the operator keeps above this he will never unin- 
tentionally enter the abdominal cavity. Stop all bleeding 
as you go along, so that the aponeurosis may be kept 
white and clean. Use as few pressure-forceps as pos- 
sible, as union by first intention is desirable. Clean up 
the aponeurosis for an inch and a half from the pubic 
spine, and then with the index finger on the spine the 
ligament will be found without any difficulty. Some- 
times the external ring can be seen, usually it can be 
felt ; now and then the intercolumnar fascia is so 
strong that no ring can be seen or felt. In this latter case 
if the fascia is cut through just in front of the pubic 
spine, a mass of fat will protrude, and this is the guide 
to the ligament. Grasp this fat with the tissue about it, 
unless the ligament is seen, in which case grasp the liga- 
ment, and tease it out of the ring, or slit up the aponeu- 
rosis a little way and tease the fat and tissue out of the 
canal. If one is careful to get hold of all the fat and 
tissue, the ligament will soon be seen after a little trac- 
tion on these tissues. Separate the nerve from the liga- 
ment, being careful not to injure it by rough handling or 
by sewing it to the aponeurosis when fastening the liga- 
ments. Draw out both ligaments until the uterus, by 
vaginal examination, is found to be in the desired posi- 
tion, then fasten them to the pillars of the ring or to the 
aponeurosis, if the canal has been slit up. (I have never 
seen the ligaments fastened to the pillars of the ring.) 
The slack of the ligament may be cut off near where it 
is fastened and entirely removed, or it may be folded 
into the wound and fastened there by the sutures that 
close the incision, or by separate sutures, or it may be 
tied in a hard knot to the slack of the opposite side, and 
both buried and sewed into the incisions that have been 
prolonged so as to meet. I prefer the second method, if 
the ligaments have not been crushed or bruised in getting 
them out. If I fear that their vitality has been impaired, 
the first method is employed. Attention to cleanliness 
should be the same as if coeliotomy was being done, as it 
may be necessary to free the ligaments from adhesions 
throughout the whole length of the canals, and the peri- 
toneal cavity may be opened ; then, too, healing by first 
intention is the desideratum. If a ligament should break, 
slit up the aponeurosis to the point where the ligament 
dips down to enter the internal ring, and at the internal 
ring search for it. If it cannot be found at the internal 
ring it will be necessary to do a coeliotomy to secure it. 
30 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Alexander-A dams 
Operation. 
Catgut, silk, and silkworm-gut may be used in suturing 
the ligaments. Silk, silkworm-gut, and wire may be 
used in closing the incisions. Wherever ligatures are 
needed I prefer silkworm-gut for three reasons : 1st, It 
■can be made perfectly aseptic ; 2d, it is never absorbed ; 
41d, it is less irritating than any other suture material. 
Whatever kind of suture material is used, four sutures 
.are needed to securely fasten each ligament, two on each 
side. These sutures are cut short and buried. Care 
should be exercised not to tie these ligament-sutures too 
tight, neither should they catch up too much of the liga- 
ment for fear of strangulation with following suppura- 
tion. 
Preparation of Ligatures.-Silk is soaked in ether for 
forty-eight hours, and it is then boiled for two hours in 
a 1 to 20 carbolic acid solution, or for the same length of 
time in filtered water. It is kept in absolute alcohol. 
Only as much as will be used at any one operation is 
taken from the alcohol and sterilized. If any of this is 
left over after having been handled, it is boiled again for 
two hours before being used. 
Catgut is soaked in ether for several days in the coils 
as it is bought. Then it is wound on glass buttons, each 
button taking one coil. It is then boiled in alcohol in a 
jar with the cover on, in an Arnold sterilizer, for one 
hour on three consecutive days. It is then removed 
from this alcohol with sterilized forceps and put in abso- 
lute alcohol. Only one button is taken from the alcohol 
for an Alexander-Adams. This is again sterilized by 
boiling in alcohol in an Arnold sterilizer for half an 
hour previous to the operation. 
Silkworm-gut is first thoroughly boiled for two hours in 
filtered water. Then it is put in absolute alcohol. Ten 
or twelve strands are put with the instruments in the 
sterilizer half an hour before the operation. 
After closing the incisions, powdered boric acid and 
iodoform are thickly dusted over both lines and kept in 
place by square pieces of baked gauze secured in position 
by corrosive collodion. Over this the powdered boric 
acid and iodoform are thickly dusted. Then a thick pad 
of baked gauze is placed on the lower abdomen and 
pubes. The whole is kept in place by an abdominal 
binder, or adhesive plaster, and perineal straps. The 
patient is kept in bed two weeks. At the end of a week 
the sutures are removed, and the lines of incision are cov- 
ered with powdered boric acid and iodoform, and sealed 
over with baked gauze held in place by corrosive collo- 
dion. If possible the catheter is dispensed with and the 
nurse is instructed to see that the patient passes her 
water every four or live hours. The moment any bladder 
trouble shows itself, saccharine, boric acid, and benzoate 
of ammonia are given. The bowels are moved on the 
third day by a large dose of magnesia, assisted by enema, 
so as to avoid straining. After this the bowels are moved 
every day. Slop diet is given until after the third day. 
If suppuration appears, a large opening is at once made 
down to the ligament ; at times it is necessary to open 
up the whole incision. Then poultices are applied for 
twenty-four to thirty-six hours, then the suppurating 
cavity is cleaned two or three times a day with peroxide 
of hydrogen and filled with powdered dermatol, aristol, 
or iodoform. The occurrence of suppuration does not 
prolong the patient's stay in bed. 
The following cases were operated on at the St. Eliza- 
beth's and Carney Hospitals, Boston, during the two 
years following December, 1889 : 
Tabulated Statement of Cases on which the Alexander-Adams Operation was Performed in the St. Elizabeth's and Carney Hos- 
pitals, Boston (1889-1891). 
1 Number. 
Date. 
Name. 
Age. 
Married. 
Single. 
Children. 
Abortions. 
Indication for operation. 
Operator. 
Other opera- 
tions. 
Relief 
of symptoms. 
Results. 
Remarks. 
1 
Dec., '89... 
A. H. 
22 
S. 
Retroversion. 
J. 
Dilated ; cu- 
retted. 
Yes. 
Perfect. 
2 
Jan., '90... 
M. C. 
24 
S. 
Retroversion ; prolapsed ova- 
ries. 
C. 
Perfect. 
3 
Feb., '90... 
R. N. 
25 
M. 
Retroversion. 
J. 
Cervix. 
Yes. 
Perfect. 
Pessary for a few months. 
4 
April, '90 .. 
H. C. 
27 
M. 
2 
Retroflexion; prolapsed ova- 
ries. 
J. 
Cervix; peri- 
neum. 
Yes. 
Perfect. 
5 
May, '90. .. 
K. D. 
18 
s. 
Retroversion with adhesions. 
J. 
No. 
Perfect. 
Pessary for a few months. 
6 
May, '90... 
C. F. 
29 
M. 
1 
Retroversion with adhesions. 
J. 
Cervix. 
Yes. 
Perfect. 
Pessary for a few months. 
Y 
J une, '90... 
M. I). 
21 
8. 
Retroversion with adhesions. 
J. 
Curetted. 
Died of acute sepsis. 
8 
June, '90... 
L. K. 
38 
W. 
2 
1 
Retroversion with adhesions. 
J. 
Yes. 
Perfect. 
Had pneumonia. 
9 
Sept., '90 .. 
W. 1'. 
30 
M. 
2 
1 
Retroversion. 
J. 
Cervix. 
Yes. 
Perfect. 
1(1 
Nov., '90... 
M. T. 
24 
M. 
Prolapse in second degree. 
K. 
Yes. 
Perfect. 
11 
Nov., '90... 
R. A. 
• • 
Retroversion with adhesions. 
J. 
Dig. on left side not found; 
operation abandoned. 
12 
Dec., '90. .. 
N. W. 
24 
S. 
Retroversion with adhesions. 
J. 
Perfect. 
13 
Dec., '90. .. 
B. C. 
40 
S. 
Retroversion. 
J. 
Perfect. 
14 
Dec., '90... 
J. C. 
25 
s. 
1 
Retroversion with adhesions. 
J. 
Cervix. 
No. 
Perfect. 
Abscess on both sides. 
15 
Dec., '90 .. 
F. D. 
23 
s. 
Retroversion. 
J. 
Curetted. 
Yes. 
Perfect. 
16 
Jan., '91... 
T. R. 
21 
8. 
Retroversion with adhesions. 
J. 
Curetted. 
Yes. 
Perfect. 
17 
Jan., '91... 
M. G. 
27 
M. 
Retroversion with adhesions. 
J. 
Curetted. 
Yes. 
Perfect. 
Abscess on both sides ; 
Confined at terra. 
18 
Jan,, '91... 
F. B. 
28 
W. 
2 
Retroversion. 
J. 
Curetted; cer- 
Yes. 
Perfect. 
Pregnant in a few months; 
aborted. 
19 
Jan., '91... 
F. B. 
34 
W. 
5 
Retroversion. 
J. 
Curetted: cer- 
vix. 
Yes. 
Perfect. 
Abscess on right side. 
2(1 
Jan., '91... 
E. L. 
26 
S. 
Retroversion. 
J. 
Curetted. 
Perfect. 
Abscess on both sides. 
21 
Feb., '91... 
A. C. 
25 
S. 
Retroversion : prolapsed ova- 
ries. 
J. 
Curetted. 
Perfect. 
22 
Feb.. '91... 
K. C. 
28 
M. 
Retroversion. 
J. 
Cervix. 
Perfect. 
Abscess on right side. 
23 
March, '91. 
E. 1'. 
30 
8. 
Retroversion; fibroid in pos- 
terior wall. 
J. 
Yes. 
Perfect. 
Fibroid in posterior uter- 
ine wall. 
24 
March, '91. 
8. L. 
32 
M. 
2 
2 
Retroversion with adhesions. 
C. 
Cervix ; peri- 
neum. 
Perfect. 
25 
April. '91... 
T. M. 
28 
M. 
Retroversion. 
c. 
Cervix. 
Perfect. 
26 
April, '91 .. 
N. D. 
24 
8. 
Retroversion with adhesions. 
c. 
Yes. 
Perfect. 
Abscess on right side. 
27 
April, '91 .. 
J. T. 
41 
S. 
Retroversion ; multiple fibroids 
J. 
Curetted. 
No. 
Not perfect. 
Uterus retrovei ted. 
2b 
April, '91 .. 
M. B. 
31 
S. 
Retroversion with adhesions. 
J. 
Curetted. 
Yes. 
Perfect. 
29 
April, '91 .. 
H s 
Retroversion. 
J. 
Curetting. 
Yes. 
Perfect. 
Full history of case lost. 
30 
April, '91 .. 
M. B. 
31 
S. 
Retroversion with adhesions. 
J. 
Curetted. 
Yes. 
Perfect. 
31 
April, '91 .. 
A. M. 
26 
s. 
Retroversion with adhesions. 
c. 
Curetting. 
Not perfect. 
32 
April, '91 .. 
M. E, 
46 
M. 
4 
2 
Retroversion with adhesions. 
J. 
Perineum. 
Died of pneumonia on the 
eighth day. 
33 
May, '91 ... 
A. J. 
30 
M. 
1 
8 
Retroversion with adhesions; 
left ovary prolapsed. 
c. 
Perfect. 
34 
May, '91 ... 
M. D. 
35 
s. 
Retroversion with adhesions. 
C. 
Perfect. 
35 
May, '91 ... 
A. F. 
21 
M. 
•• 
Retroflexion with adhesions; 
ovaries prolapsed. 
J. 
Curetted. 
Yes. 
Perfect. 
Delivered at term. 
31 Alexander-A dams 
Alvelos. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Tabulated Statement of Cases on which the Alexander-Adams Operation was Performed.-{Continued.) 
Number. 
Date. 
Name. 
Age. 
Married. 
Single. 
Children. 
Abortions. 
Indication for operation. 
Operator. 
Other opera- 
tions. 
Relief 
of symptoms. 
Results. 
Remarks. 
36 
June, '91.. 
M. K. 
32 
S. 
Retroversion with adhesions. 
K. 
Perfect. 
37 
June, "91 .. 
E. H. 
31 
M. 
Retroversion with adhesions. 
K. 
Perfect. 
38 
June, '91 .. 
M. B. 
23 
S. 
Retroversion with adhesions ; 
left ovary prolapsed 
J. 
Curetted. 
Perfect. 
39 
July, '91... 
II. H. 
25 
s. 
Retroversion with adhesions. 
J. 
Curetted. 
Perfect. 
Abscess on right side. 
40 
Aug., '91... 
P. M. 
Retroversion with adhesions ; 
prolapsed right ovarv. 
Bl. 
Perfect. 
41 
Sept., '91 „. 
K.W. 
27 
s. 
Retroversion. 
Bl. 
Curetted. 
Perfect. 
42 
Sept., '91 .. 
M. D. 
25 
s. 
Retroversion ; ovaries p r o - 
lapsed. 
J. 
Perfect 
43 
Oct., '91 ... 
J. D. 
30 
M. 
5 
Retroversion. 
J. 
Cystocele. 
Yes. 
Perfect. 
44 
Oct., '91 ... 
F. M. 
33 
M. 
1 
Retroversion with adhesions. 
K. 
Curetted. 
Not perfect. 
45 
Oct., '91 ... 
M. C. 
31 
M. 
2 
Retroversion with adhesions. 
K. 
Perfect. 
Abscess on both sides. 
46 
Oct., '91 ... 
M. T. 
21 
s. 
Retroversion ; ovaries p r o - 
lapsed. 
C. 
Curetted. 
Perfect. 
47 
Nov., '91... 
A. S. 
35 
s. 
Retroversion with adhesions. 
K. 
Curetted. 
Perfect, 
Abscess on right side. 
48 
Nov., '91... 
M. B. 
25 
M. 
Retroversion ; prolapsed ova- 
ries. 
K. 
Curetted; cer- 
vix. 
Perf^Qt. 
49 
Dec., '91... 
A. M. 
30 
s. 
Retroversion. 
c. 
Curetted. 
Perfect. 
Acute articular rheuma- 
tism. 
50 
Jan., '92.. . 
N. C. 
23 
M. 
•• 
Retroversion ; left ovary pro- 
lapsed. 
c. 
Perfect. 
Abscess on right side. 
51 
Jan., '92... 
E. O. 
32 
M. 
Retroversion ; left ovary and 
tube prolapsed. 
J. 
Cur. tted. 
Yes. 
Perfect. 
52 
Jan., '92... 
L. M. 
23 
S. 
Retroversion. 
c. 
Curetted. 
Perfect. 
53 
Jan.. '92. .. 
M. C. 
38 
s. 
Retroversion with prolapse. 
c. 
Curetted. 
Perfect. 
Abscess on right side. 
54 
Jan., '92... 
M.M 
34 
M. 
Retroversion with adhesions. 
J. 
Curetted. 
Perfect. 
55 
Jan., '92... 
J. O. 
23 
s. 
Retroflexion with adhesions. 
J. 
Curetted. 
Not perfect. 
56 
Jan.. '92... 
A. S. 
30 
s. 
Retroversion with adhesions. 
c. 
Curetted. 
Perfect. 
57 
Feb., '92... 
L. W. 
42 
M. 
Retroversion with adhesions; 
ovaries prolapsed. 
J. 
Curetted. 
Perfect. 
58 
59 
Feb.. '92... 
Feb., '92... 
M. F. 
J. H. 
40 
29 
M. 
M. 
2 
3 
Retroversion with adhesions. 
Retroversion with adhesions. 
J. 
c. 
Curetted. 
Curetted. 
Perfect. 
Perfect. 
60 
Feb., '92... 
L. S. 
19 
s. 
Retroversion with adhesions ; 
double inguinal hernia. 
c. 
Curetted. 
Perfect. 
Alexander-Adams for the 
radical cure of the her- 
nia. 
61 
Feb., '92 . . 
J. D. 
33 
M. 
Retroversion with adhesions. 
J. 
Curetted. 
Perfect. 
62 
March, '92 
A. M 
28 
M. 
2 
Retroversion. 
J 
Curetted. 
No. 
Perfect. 
63 
March, '92. 
J. D. 
26 
M. 
Retroversion with adhesions. 
J. 
Curetted. 
Yes. 
Not perfect. 
Has had two attacks of 
gonorrhoeal peritonitis. 
64 
March, '92. 
E. S. 
29 
.. 
s. 
Retroversion with adhesions. 
J. 
Curetted. 
Yes. 
Perfect. 
Abscess on both sides. 
65 
March, '92. 
M. H 
30 
M. 
.. 
Retroversion. 
B. 
Curetted. 
Not perfect. 
Abscess on left side. 
66 
March, '92. 
K. 0. 
32 
M. 
1 
Retroversion ; right ovary pro- 
lapsed. 
B. 
Curetted. 
Perfect. 
Abscess on both sides. 
67 
March, '92. 
J. H. 
22 
s. 
Retroversion. 
J. 
Curetted. 
Yes. 
Perfect. 
Abscess on both sides. 
68 
April, '92 .. 
H. S. 
34 
M. 
1 
Retroversion. 
B. 
Curetted; 
perineurti. 
.... 
Perfect. 
Abscess on both sides. 
69 
April, '92 .. 
A. D. 
27 
s. 
Retroversion with adhesions. 
K. 
Curetted. 
Not perfect. 
70 
April. '92 .. 
M. M. 
24 
M. 
Retroversion with adhesions. 
J. 
Curetted. 
Yes. 
Not perfect. 
Abscess on left side; wear- 
ing pessary. 
71 
May, '92 ... 
L. B. 
24 
M. 
1 
Retroversion. 
J. 
Curetted; 
perineum. 
Yes. 
Perfect. 
72 
May, '92 ... 
A. D. 
41 
M. 
3 
1 
Retroversion with adhesions. 
J. 
Curetted. 
Perfect. 
Abscess on both sides; 
both ligaments broke 
and retracted. 
73 
June, '92 .. 
N. Q. 
25 
s. 
Retroversion with adhesions. 
J. 
Curetted. 
Perfect. 
Abscess on both sides. 
74 
June, '92.. 
A. L. 
20 
s. 
Retroversion with adhesions. 
B. 
Curetted. 
Perfect. 
Abscess on both sides. 
75 
Jun^, '92 .. 
A. C. 
32 
s. 
Retroversion. 
B. 
Curetted. 
Perfect. 
Abscess on left side. 
76 
Julv, '92... 
M. S. 
23 
s. 
Retroversion. 
B. 
Curetted. 
Perfect. 
Abscess on both sides. 
77 
July, '92... 
M. N. 
24 
s. 
Retroversion. 
J. 
Curetted. 
Perfect. 
Abscess on both sides. 
78 
Aug., '92 .. 
M. C. 
26 
M. 
Retroversion. 
Bl. 
Curetted. 
Perfect. 
79 
Aug., '92... 
M. K. 
23 
s. 
Retroversion with adhesions. 
B. 
Curetted. 
Perfect. 
Abscess on both sides. 
80 
Aug., '92... 
M. 0. 
23 
.. 
s. 
Retroversion with adhesions. 
B. 
Curetted. 
Not perfect. 
81 
Aug., '92... 
K. S. 
30 
M. 
Retroversion. 
B. 
Curetted. 
Perfect. 
Abscess on both sides. 
82 
Sept., '92 . 
M. K. 
20 
s. 
Retroversion. 
S. 
Curetted. 
Not perfect. 
S3 
Sept., '92 .. 
M. M. 
22 
M. 
Retroversion. 
K. 
Perfect. 
84 
Oct., '92 ... 
F. M. 
30 
s. 
Retroversion with adhesions; 
ovaries prolapsed. 
J. 
Curetted. 
Not perfect. 
Left ligament broke and 
was lost. 
85 
Feb., '90 . 
E. K. 
30 
M. 
1 
4 
Retroversion ; left ovary pro- 
lapsed . 
J. 
Cervix. 
Perfect. 
Delivered at term, subse- 
quently. 
86 
March. '90. 
R. G. 
23 
M. 
Retroversion with adhesions. 
J. 
Perfect. 
Abscess on left side. 
87 
April. '90 .. 
O. G. 
42 
M. 
.. 
li 
2 
Retroversion. 
J. 
Cervix. 
Perfect. 
Abscess on left side. 
88 
May, '90... 
E. H. 
35 
M. 
4 
1 
Retroversion with adhesions. 
J. 
Cervix; peri- 
neum. 
Perfect. 
89 
May, '90... 
M.M. 
29 
M. 
Retroversion ; ovaries p r o - 
lapsed. 
J. 
Dilated. 
Yes. 
Perfect. 
Abscess on left side. 
90 
May, '90... 
M. R. 
35 
s. 
Retroflexion; left ovary pro- 
lapsed. 
J. 
Perfect. 
91 
July. '90. .. 
K. G. 
24 
M. 
Retroversion with adhesions. 
J. 
Perfect. 
92 
Sept., '90 .. 
C. B. 
35 
M. 
1 
Retroversion with adhesions; 
left ovary prolapsed. 
J. 
Cervix. 
Yes. 
Perfect. 
93 
Sept., 90 .. 
C. K. 
34 
M. 
Retroversion. 
J. 
Perfect. 
94 
April, '91 .. 
M. S. 
26 
s. 
Retroversion with adhesions. 
J. 
Dilated. 
.... 
Perfect. 
Abscess on right side. 
95 
May. '91... 
M. B. 
31 
s. 
Retroversion with adhesions. 
S. 
Perfect. 
96 
May, '91.. . 
M. S. 
38 
M. 
3 
2 
Retroversion with adhesions. 
S. 
Not perfect. 
97 
July, '91... 
A. C. 
32 
M. 
1 
Retroversion. 
J. 
Yes. 
Perfect. 
Tired of wearing a pessary. 
98 
July, '91. . 
E. G. 
39 
M. 
2 
Retroversion. 
J. 
Curetted. 
Yes. 
Perfect. 
99 
Aug., '91... 
L. G. 
31 
M. 
5 
Retroversion. 
J. 
Cervix : peri- 
neum ; hae- 
morrhoids. 
Yes. 
Perfect. 
100 
Aug., '91... 
Sept. '91 .. 
J. F. 
40 
s. 
Retroversion with adhesions. 
J. 
Curetted. 
No. 
Perfect. 
101 
E. M. 
28 
s. 
Retroversion with adhesions. 
J. 
Yes. 
Perfect. 
Abscess on right side. 
102 
Oct., '91 ... 
B. O. 
35 
M. 
* 
5 
Retroversion ; left ovary pro- 
lapsed. 
J. 
Perfect. 
32 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Alexander-A damn 
Alveios. 
Tabulated Statement of Cases on which the Alexander-Adams Operation was Performed.-(Continued.) 
1 
Number. 
Date. 
i 
A 
Age. 
Married. 
Single. 
Children. 
Abortions. 
Indication for operation. 
Operator. 
Other opera- 
tions. 
Relief 
of symptoms. 
Results. 
Remarks. 
103 
Nov., '91... 
N. S. 
26 
8. 
Retroversion with adhesions. 
J. 
Curetted. 
Yes. 
Perfect. 
Ligament on right side 
broke and was lost. 
104 
Nov., '91... 
M. It. 
20 
M. 
1 
Retroversion with adhesions. 
J- 
Yes. 
Perfect. 
Ligament on left side 
broke and was lost. 
105 
Nov., '91 .. 
E. S. 
19 
M. 
Retroversion with adhesions; 
left ovary prolapsed. 
J. 
Curetted. 
Yes. 
Perfect. 
Abscess on both sides. 
106 
Nov., '91... 
K. O. 
33 
M. 
2 
.. 
Retroflexion ; right ovary pro- 
lapsed. 
J. 
Curetted. 
Yes. 
Perfect. 
Pneumonia. 
107 
Nov., '91... 
B. K. 
27 
M. 
Retroversion. 
J. 
Cervix; peri- 
neum. 
Yes. 
Perfect. 
Pneumonia. 
108 
Nov., '91... 
N. D. 
21 
.. 
S. 
Retroversion with adhesions. 
J. 
Curetted. 
Perfect. 
109 
Dec., '91. .. 
N. H. 
27 
M. 
Retroversion. 
J. 
Curetted. 
Perfect. 
110 
Dec., '91... 
K. G. 
8. 
Retroflexion ; ovaries p r o - 
lapsed. 
J. 
Curetted. 
.... 
Not perfect. 
111 
Dec., '91... 
C. L. 
34 
8. 
Retroversion, 
J. 
Curetted. 
Yes. 
Perfect. 
112 
Dec., '91... 
M.W. 
44 
M. 
4 
2 
Retroversion. 
J. 
Curetted. 
Perfect. 
113 
Jan., '92... 
M. P. 
29 
•• 
Retroversion. 
Yes. 
Perfect. 
Fibroid on posterior uter- 
ine wall. 
114 
Jan., '92... 
M. II. 
41 
M. 
1 
•• 
Retroversion ; ovaries p r o - 
lapsed. 
J- 
Curetted. 
Yes. 
Perfect. 
115 
Jan., '92... 
M C. 
30 
M. 
Retroversion with adhesions ; 
salpingitis. 
J' 
Curetted. 
No. 
Perfect. 
Abscess on left side. 
116 
Jan., '92... 
S. L. 
43 
M. 
7 
Retroversion. 
J. 
No. 
Perfect. 
117 
Feb., '92... 
A. P. 
35 
s. 
Retroversion. 
s. 
Perfect. 
118 
Feb., '92 .. 
A. W. 
23 
M. 
.. 
1 
Retroversion with adhesions. 
8. 
Perfect. 
119 
Feb., '92.. . 
K. M. 
33 
8. 
Retroversion ; left ovary pro- 
lapsed. 
J. 
Curetted. 
Yes. 
Perfect. 
120 
March, '92. 
M. B. 
35 
M. 
.. 
Retroverted. 
8. 
Perfect. 
Abscess on left side. 
121 
March, '92. 
H. C. 
27 
M 
•• 
Retroversions with adhesions. 
J. 
Curetted. 
Yes. 
Not at all a 
success. 
Abscess on both sides 
122 
April, '92 .. 
K. C. 
19 
S. 
Retroversion with adhesions. 
S. 
Perfect. 
123 
April, '92 .. 
M. S. 
36 
M. 
5 
2 
Retroversion. 
s. 
Curetted. 
Perfect. 
Abscess on left side. 
124 
April, '92 .. 
M. K. 
29 
M. 
Retroversion. 
s. 
Perfect. 
125 
April, '92 .. 
M. D. 
42 
M. 
3 
6 
Retroversion. 
s. 
Cervix; peri- 
neum. 
Perfect. 
126 
April. '92 .. 
A. F. 
28 
M. 
Retroversion with adhesions. 
s. 
...... .... 
Perfect. 
Abscess on right side. 
127 
April, '92 .. 
M. B. 
25 
M. 
1 
Retroversion with adhesions; 
left ovary prolapsed. 
J. 
Cervix. 
Yes. 
Perfect. 
128 
May, '92... 
M. D. 
33 
M. 
1 
1 
Retroversion with adhesions ; 
left ovary prolapsed. 
J. 
Curetted. 
Perfect. 
129 
May, '92... 
S. B. 
30 
M. 
1 
1 
Retroversion ; left ovary pro- 
lapsed. 
J. 
Cervix. 
Yes. 
Perfect. . 
130 
May, '92... 
E. B. 
56 
M. 
3 
Procidentia. 
J. 
Curetted. 
Yes. 
Perfect. 
Abscess on both sides. 
131 
May, '92... 
S. O. 
34 
M. 
Retroversion. 
J. 
Curetted. 
Yes. 
Perfect. 
132 
May, '92... 
F. S. 
27 
M. 
Retroversion. 
s. 
Curetted. 
Perfect. 
Abscess on left side. 
133 
May, '92... 
A. M. 
39 
M. 
Retroversion with adhesions. 
K. 
Not perfect. 
134 
May, '92... 
C. M. 
32 
M. 
2 
3 
Retroversion ; left ovary pro- 
lapsed. 
J. 
Curetted. 
Not perfect. 
Pessary now keeps uterus 
in place. 
135 
May, '92... 
M. B. 
27 
8. 
Retroversion ; ovaries p r o - 
lapsed. 
K. 
.... 
Not perfect. 
Abscess on left side. 
136 
May, '92... 
E. K. 
29 
8. 
Retroversion; left ovarj' pro- 
lapsed. 
J. 
Curetted. 
Yes. 
Perfect. 
137 
Mav, '92... 
J. H. 
27 
S. 
Retroversions with adhesions. 
K 
Perfect. 
138 
May, '92... 
I. M. 
19 
S. 
Retroversion ; left ovary pro- 
lapsed. 
B. 
Perfect. 
Abscess on left side. 
139 
June, '92... 
M. C. 
26 
M. 
•• 
Retroversion; left ovary pro- 
lapsed. 
J. 
Curetted. 
Yes. 
Perfect. 
Pregnant. 
140 
June, '92... 
L. P. 
32 
M. 
3 
Retroversion. 
J. 
Curetted. 
Yes. 
Perfect. 
Fibroid in post - uterine 
wall. 
141 
June, '92.. . 
J. M. 
27 
M. 
2 
2 
Retroversion. 
J. 
Cervix. 
Yes. 
Perfect. 
142 
Aug., '92 .. 
J. 8.. 
27 
M. 
Retroversion. 
B. 
Curetted. 
Not perfect. 
Wearing pessary. 
143 
Sept.. '92 .. 
L. C. 
30 
8. 
.. 
Retroversion with adhesions. 
J. 
Curetted. 
Not perfect. 
Abscess on right side. 
144 
Sept., '92 .. 
N. S. 
49 
M. 
3 
Procidentia, five years' stand- 
ing. 
J. 
Perineum. 
Yes. 
Perfect. 
145 
Oct., '92... 
H.W. 
47 
M. 
5 
1 
Procidentia, one year. 
* 
Cervix; peri- 
neum. 
Perfect. 
146 
Oct., '92... 
A. B. 
49 
M. 
2 
Procidentia, two years. 
J. 
Perineum. 
Perfect. 
147 
Oct., '92... 
F. G. 
42 
M. 
10 
» 
Retroversion. 
s. 
Curetted. 
Perfect. 
Abscess on both sides. 
148 
Oct., '92... 
O. N. 
40 
M. 
7 
1 
Procidentia, six months ; left 
inguinal hernia. 
Perfect. 
Radical cure of hernia by 
the Alexander. 
149 
Oct., '92... 
K. D. 
34 
M. 
3 
Retroversion with adhesions. 
J. 
Not perfect. 
Both ligaments broke and 
were lost. 
150 
Oct., '92... 
L. W. 
32 
M. 
2 
Retroversion with adhesions. 
J. 
Curetted; cer- 
vix ; perine- 
um. 
Acute pleurisy with ef- 
fusion; phthisis. 
151 
Oct., '92... 
A. W. 
20 
S. 
Retroversion with adhesions ; 
ovaries prolapsed. 
J. 
Curetted. 
Not perfect. 
152 
Oct, '92... 
G. K. 
14 
8. 
•• 
Retroversion with adhesions ; 
ovaries prolapsed. 
J. 
Curetted. 
Perfect. 
ALVELOS. The milky, resinous juice of Euphorbia 
heterodoxa, Muller, belonging to the order Euphorbiacese, 
indigenous to Brazil. It is obtained by expression, is 
yellowish-white, of syrupy consistence, resembling vase- 
line, insoluble in water and alcohol, soluble in ether, 
miscible with fixed oils. 
It possesses powerful escharotic properties, together 
with a solvent action on organic tissues. It combines 
the effects of a caustic with that of papaine. It is rec- 
ommended for the treatment of syphilitic and cancerous 
growths. The part is painted with the drug once a day ; 
before the application the part is washed with carbolic acid 
or other antiseptic solution. The operation is repeated 
until the disease is removed. It is said the purity of the 
drug may be known by its imparting a pronounced color 
and odor to the urine due to its absorption. This effect 
has to be watched during its use as it exerts a decided irri- 
tant action in the renal tissue. Beaumont Small. 
F. IF. Johnson. 
33 Amputation. 
AmeMtlieties. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
AMPUTATION AT THE HIP JOINT. The mortality 
which until recently followed amputation at the hip- 
joint rendered this operation the most formidable in 
surgery. Within the last ten years this mortality has 
been greatly reduced. No great war has occurred within 
these years, so that it is difficult to estimate the present 
death-rate of traumatic cases. The reduction for such 
cases ought, however, to be proportionate with that of 
amputation for disease. For this latter class of cases, a 
dozen years ago, the mortality was estimated at over 
forty per cent. Now it varies from fifteen to twenty 
per cent. Formerly it was only on comparatively robust 
patients that the operation was performed ; now it can be 
done on delicate, sickly children with a fair chance of a 
successful issue. The reasons for these better results are, 
1st, the antiseptic treatment of the wound ; and 2d, the 
improved methods for the control of hemorrhage. The 
first cause has brought about an immense improvement 
in all operations, and the improvement is in almost 
direct proportion to the extent of the wound, and there- 
fore the difference between the present results and those 
of the pre-antiseptic times is more marked in this opera- 
tion than perhaps in any other. The second cause has 
very much added to the safety of the operation. It can- 
not be said that any one method is pre-eminent for the 
control of hemorrhage, but 
there are several admirable 
plans for the arrest of bleeding, 
which, in different hands, give 
almost equally good results. 
Shock continues to be the 
source of the greatest danger, 
but this has been very much 
lessened since the loss of blood 
has been diminished. Follow- 
ing the removal of so large a 
part of the human frame, there 
must always result consider- 
able shock. In this connection 
it is well to correct an errone- 
ous statement which has been 
handed down from text-book 
to text-book for scores of years. 
It is very commonly stated that 
amputation at the hip-joint re- 
moves about one-fourth of the 
body. This is incorrect. Re- 
cent observations estimate the 
loss of tissue as equal to about 
one-tenth or one-twelfth of the 
weight of the entire body. 
Methods. More than forty- 
five methods of amputation at 
this point have been described. Many of them are en- 
tirely obsolete. A very judicious choice has been made 
of the best methods in the original article on this 
subject, in Vol. I. Of the plans there described, several 
continue to be used with great success. The shape and 
position of the flaps are of less importance than the means 
for control of hemorrhage. In many patients the flaps 
must be adapted to each case, and especially is this true 
in amputations for injury. Some modification of the 
method known as. Furneaux Jordan's is perhaps as gen- 
erally useful as any other. The flaps are formed as fol- 
lows : the soft parts are drawn upward with the left 
hand and a circular incision is made through skin and 
cellular tissue around the middle third of the thigh. 
The cuff of skin is raised for about two and a half inches, 
and this flap being drawn strongly upward, the muscles 
are severed by circular sweeps of the knife down to the 
bone. The vessels are then secured. A second incision is 
made along the outer side of the thigh, starting from the 
circular wound and ending midway between the iliac 
crest and the top of the great trochanter. This incision 
divides everything down to the bone. The soft parts are 
then peeled off the femur, and the head of the bone dis- 
articulated. If the case is not suitable for this method 
an equally good stump can be obtained by one of the 
other methods. 
(SUPPLEMENT.) 
Means of Arresting Hemorrhage.-While several new 
devices for this purpose have been introduced, yet some 
of the older methods still give very satisfactory results ; 
of these may be mentioned control by means of the 
elastic bandage, according to the plan of Jordan Lloyd. 
In this method the Esmarch bandage is first applied, as 
far up the thigh as the tissues are healthy; a piece of 
strong rubber bandage is then passed between the thigh 
and trunk, its centre resting between the anus and 
tuberosity of ischium. A roller bandage is placed over 
the external iliac artery. The ends of the rubber band- 
age are drawn strongly upward and outward, one in 
front of the groin, and the other across the buttock, to a 
point above the crest of the ilium. They should be 
pulled until all pulsation in the femoral artery has 
ceased. The anterior band compresses by means of the 
roller bandage the external iliac, and the posterior the 
branches of the internal iliac artery. The ends of the 
bandage can either be held by an assistant, or crossed over- 
to the opposite side and tied below the crest of the ilium. 
Another plan, which in the hands of its inventor, and 
of others, gives excellent results, is Davy's rectal lever. 
Ten cases have recently been reported treated by Davy, 
with eight recoveries. Trendelenburg's method of 
passing a steel rod between the vessels and femur, and 
Fig. 15. 
compressing the artery by a rubber cord, is also a very 
serviceable device. The most satisfactory method is the 
one recently proposed by Dr. Wyeth. The patient is 
placed with the hip well over the end of the table, and 
an Esmarch bandage applied. With the bandage still 
in position, his needles are inserted as follows: " Two 
steel mattress-needles, three-sixteenths of an inch in di- 
ameter and a foot long, are used. The point of one is 
inserted an inch and a half below the anterior superior 
spine of the ilium and slightly to the inner side of this 
prominence, and is made to traverse the muscles and 
deep fascia, passing about half-way between the great 
trochanter and the iliac spine, external to the neck of the 
femur and through the substance of the tensor vaginae 
femoris, coming out just back of the trochanter. About 
four inches of the needle should be concealed by the tis- 
sues. The point of the second needle is entered an inch 
below the level of the crotch, internally to the saphenous 
opening, and passing through the adductors, comes out 
about an inch and a half in front of the tuber ischii. No 
vessels are endangered by these needles. The points are 
protected by corks to prevent injuries to the operator's 
hands. A piece of strong white rubber tube, half an inch 
in diameter, and long enough when tightened in position 
to go five or six times around the thigh, is now wound 
very tightly around and above the fixation-needles, and 
34 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Amputation. 
A n aesthetics. 
tied." The Esmarch bandage is then removed, and 
if the operation is to be completed according to Dr. 
Wyeth's plan, a circular incision is made, the skin-flap 
is turned up, the muscles are divided at the lesser tro- 
chanter, and the bone is sawn through. All vessels are 
then tied. The remaining portion of the femur is then 
removed by division of the attachments of the muscles. 
It is not, however, necessary to complete the operation in 
this manner. In one of my cases Wyeth's pins were ap- 
plied and the flaps were formed according to Furneaux 
Jordan's method, and the bone disarticulated while the 
pins and tubing were still in position, and before a vessel 
had been secured. The arrest of hemorrhage was per- 
fect, and not a drop of blood escaped from the upper 
ends of the cut vessels. I should add that in this case 
a roller bandage was placed over the iliac artery, but I 
do not know that it was necessary, as in another case no 
such compression was used, and no leakage occurred 
from the vessels. In both patients the complete arrest 
of hemorrhage was highly satisfactory, as has over and 
over again been testified to by the inventor of this ad- 
mirable method, and by others who have made use of it. 
taste and an aromatic odor somewhat resembling camphor. 
It is soluble in eight parts of water and in alcohol, ether, 
glycerine, and oils ; specific gravity .815. Recommended 
in 1888 by Professors Jolly and von Mering for its soporific 
properties. It is said to occupy a place between chloral 
and paraldehyde, two parts equalling one of the former 
and three of the latter. Its advantage over chloral is 
that it has no depressing effect on the heart; its smaller 
dose and less disagreeable odor make it preferable to 
paraldehyde in many cases. It produces a calm refresh- 
ing sleep, which lasts for six or eight hours, from which 
the patient awakens without any bad symptoms. Il is 
used in insomnia due to nervousness, debility, mental 
excitement, and delirium tremens, and in fevers. It has 
not proved of much use when the sleeplessness is due to 
pain. It does not cause headache, nausea, or deranged 
digestion. In very large doses it produces a lowered 
temperature, shallow respiration, feeble pulse, loss of re- 
flexes, paralysis of extremities. It is given in doses of 
thirty to forty-five minims. Its taste and odor often 
prove objectionable, and may be disguised by combining 
with extract of licorice, or some aromatic. It may also 
be used as an enema with mucil- 
age of acacia, in doses of forty 
to ninety minims. 
Beaumont Small. 
ANESTHETICS. The period 
■which has elapsed since the pub- 
lication of the first volume of 
this work shows no addition of 
value to our agents for the pro- 
duction of general anaesthesia, no 
change in the principles which 
govern the process, nor has there 
been any decided change in the 
relative standing of the agents 
employed. Yet it has been a 
period of marked activity. The 
leading societies of the world 
have debated the subject, many 
papers of value have been pub- 
lished, while experimental study 
has been prosecuted to a degree 
greater than ever before. Few 
conclusions, however, have been 
reached which are universally 
accepted. On the contrary, there 
is wide diversity of views upon 
some of the most important 
points. Even experimental in- 
vestigators have not agreed, and 
practical men have reached con- 
clusions diametrically opposite. 
The major part of the work 
done upon this subject during 
the last decade has had its origin 
in the contest between chloro- 
form and ether. This contest, 
which began in the early years of anaesthesia, still con- 
tinues, and without promise of early settlement. The 
advantages of each agent have been presented and urged 
sometimes with more warmth than judgment, and in 
more of a partisan than a scientific spirit. It needs but 
a glance through the literature of the period to show that 
this contest has been the inspiration of the work done, and 
that a record of the efforts of the advocates of the two 
great anaesthetics is a record of the progress of the subject. 
A strong plea for chloroform has been made by Dr. 
Lombe Atthill, of Dublin.1 At a debate held by the 
Medico-Chirurgical Society of Glasgow the weight of 
testimony was altogether on the side of this agent, both 
in the number of speakers and the amount of experience. 
Several men of high repute spoke in its favor. Dr. 
Hartley, of Leeds, stood almost alone as an advocate 
of ether.2 In this country Dr. Chisholm has advocated 
chloroform as the best anaesthetic,3 and Dr. Farrington 
has made a plea for it.4 The claims of ether have been 
presented in valuable papers by Comte, by Julliard,6 and 
Fig. 13. 
The accompanying diagrams, inserted with Dr. Wyeth's 
permission, illustrate the method of the introduction of 
the pins. 
In one of my cases, a very large man, I found that 
needles fifteen inches long were more serviceable than 
would have been the shorter ones.* 
Whatever method be adopted, the wound should be 
closed by suture and two or more drainage-tubes inserted. 
The entire operation should be carried out with the 
strictest antiseptic precautions. It is important that the 
patient should be enveloped in flannel, and that the room 
should be thoroughly warm. It is also useful, in weak 
patients, to adopt a modified Trendelenburg's position, 
with the pelvis elevated and the head low. 
Andrew J. McCosh. 
AMYLENE HYDRATE {Dimethylethyl carbinol). This 
is a clear, colorless, thin, neutral liquid, with a burning 
* The needles can be obtained from any large upholstering establish- 
ment. 
35 A n aesthetics. 
Aniesthetics. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
by Fueter, of Switzerland,6 and by Dr. Teale in the ad- 
dress on surgery before the British Medical Association 
in 1889, by Silex, of the Augenklinik of Berlin, based 
on two thousand five hundred administrations per an- 
num,1 and by Ormsby.8 In this country ether has been 
advocated by Knapp,4 an excellent and much needed 
paper on administration has been published by Shrady,9 
and one on the time and amount of ether required to 
produce anaesthesia by Lovett.10 Wood's address before 
the International Congress at Berlin, 1890, must be also 
considered as a plea for this agent. 
The use of various mixtures of anaesthetics may be 
said to be on the increase. The administration of ni- 
trous oxide first and then ether is confined to hospital 
practice from the necessity for complicated apparatus. 
It is resorted to a good deal in London. The plan of 
administering ether first and chloroform afterward, or 
vice versa, is followed to some extent in Europe, but 
statistics are wanting, as they also are as to several mixt- 
ures much used in Vienna. The A. C. E. mixture, which 
consists of alcohol one part, chloroform two parts, ether 
three parts, by measure, seems alone to deserve consid- 
eration. This preparation has certainly advanced very 
much in favor during the past few years. The increas- 
ing number of deaths from chloroform in England has 
excited alarm, and the A. C. E. has been chosen by 
those who would avoid the dangers of chloroform on one 
hand and the practical disadvantages of ether on the 
other. As preferable to chloroform, this mixture has 
had the powerful advocacy of the London Lancet, its 
merits have been recognized by Eastes,1" and the more 
recent authorities advise its use under many circum- 
stances, as do Buxton,11 and Hewitt, the author of the 
chapter on anaesthetics in " Treve's Operative Surgery." 
The experience of a lifetime with this mixture has been 
presented in a paper before the Ohio State Medical So- 
ciety,12 and the debate elicited upon it showed a very 
considerable use of it through at least one section of this 
country. 
The attempt to determine the relative safety or danger 
of the different anaesthetics by statistics has continued, 
but without greater success than in the past. The factors 
cannot all be given. All deaths are not reported. In a 
single city the coroner investigated fifteen deaths from 
ether, only three of which had been reported.13 No state- 
ment of the deaths from an anaesthetic in any city or 
country is of value in determining this question unless 
the number of administrations are also given. Again, 
the irregularity of occurrence of accident renders an im- 
mense array of numbers necessary. Thus, in the debate 
at Glasgow, while several speakers testified to many thou- 
sands of safe administrations of chloroform, one of the 
participants had met with four deaths. Bardeleben had no 
death in 30,000 administrations, then in one year he had 
four.14 Kollock had two deaths from ether in giving it 
200 times.'6 Richardson found in the records of eight 
hospitals 17,000 administrations of chloroform up to 1864, 
before there was a death ; in the same hospitals during 
the five subsequent years there were six deaths in 7,500 
administrations. Of two hospitals, under circumstances 
almost identical, there was in one 1,575 administrations 
without a death ; in the other there occurred one death 
to every 525 administrations.16 
The following, statistics, taken from the records of 
institutions, may be accepted as accurate. 
Admitns- D 
trations. 
Bristol Infirmary, seventeen years : '* 
Chloroform 5,902 3 
Ether 704 1 
St. Bartholomew's Hospital,8* 1878-87 : 
Chloroform 12,368 10 
Ether 5,509 2 
Ether, preceded by NOa 9,072 1 
[Both the ether deaths were in patients very feeble from prolonged in- 
testinal obstruction.] 
Richardson,1613 hospitals, 1848-69 inclusive : 
Chloroform 35,162 11 
(SUPPLEMENT.) 
Recently, very large collections of administrations and 
deaths have been made, and are presumably reliable : 
Adminis- 
trations. Deaths- 
Julliard :5 
Chloroform 524,507 161 
Ether 314,738 21 
Weir, New York Hospital :9c 
Ether 10,791 6 
Gurlt17 (XX. German Surgical Congress) : 
Chloroform 22,656 6 
Ether 470 0 
Ether and Chloroform 1,055 0 
Ether, Chloroform, and Alcohol.. 470 0 
Gurlt96 (XXI. Congress, including above): 
Chloroform 94,123 36 
Ether 8,431 1 
Ether and Chloroform 2,891 1 
„ Ether and Alcohol 1,380 0 
Bromide ethyl 2,179 0 
Gurlt presents the collective experience of German' 
surgeons. The value of his first series is increased by 
stating the relative occurrence of dangerous symptoms, 
which was : Chloroform, 71 ; ether, 0 ; ether and 
chloroform, 5 ; ether, chloroform, and alcohol, 4. The 
latter mixture is not the A. C. E., but one in which the- 
proportions are : Chloroform, 100 parts; alcohol and 
ether, each 30 parts. 
By the study of such statistics the relative danger of 
the different anaesthetic agents may be approximatively 
reached. The latest German writer accepts the statistics 
of Andrews, of this country, which make the mortality 
for chloroform, 0.37, and ether, 0.04.14 Wood gives 
the danger from chloroform as four or five times greater 
than that from ether,1' and this agrees very nearly with 
the conclusion reached by all who have studied the sub- 
ject statistically. Still, there are demurrers. A reviewer 
commenting upon the deaths reported in England, 1870- 
85, says that chloroform being used in so much larger a 
number of cases than ether, the deaths (chloroform, 184 ; 
ether, 28 deaths), do not show it to be the more danger- 
ous agent. Macewen, commenting on like statistics, 
computes that chloroform is given in Great Britain ten 
times to ether once, and takes the same position.2 Fur- 
ther, the advocates of chloroform maintain that deaths 
during the operation alone do not represent all the mor- 
tality from ether. They claim that this anaesthetic fre- 
quently causes death by inducing bronchial and pulmo- 
nary affections, especially in the old, and that such cases 
do not appear in the tables of comparative statistics. It 
must be admitted that the claim is just. Gerster saw 
three fatal cases of pneumonia after ether, and he reports- 
two more and one serious attack. Five serious attacks 
of bronchitis followed the administration of ether in one 
institution.9' 
Experiment upon animals as a means of determining 
the relative danger of the two great anaesthetics has been 
actively prosecuted during the last few years. The Hy- 
derabad Commission (see under Chloroform) began this 
work. In the number and variety of experiments made, 
this commission surpassed ail former efforts in this direc- 
tion. But the observations they reported and the conclu- 
sions they arrived at differed so widely, so diametrically, 
from those of all other experimental physiologists that a 
revision and repetition of former work was absolutely 
necessary. The Commission, in their experiments, saw 
no deaths from failure of cardiac action. The conclu- 
sions they reached were : 1, That chloroform never causes- 
death in dogs by affecting the heart ; 2, that death al- 
ways takes place by the respiratory organs and that dis- 
turbance of the function of respiration invariably gives 
warning of danger ; 3, that when the action of the heart 
does fail it is the result of asphyxia, i.e., of some inter- 
ference with breathing, and is not a direct effect of the 
chloroform. These doctrines, but especially the appli- 
cation of these doctrines to the human subject, together 
with the deduction that safety could always be insured 
by the simple measure of watching the respiration, threat- 
36 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
A n aesthetics. 
Anaesthetics. 
ened to revolutionize the clinical aspects of the subject. 
A number of experimental studies followed in rapid suc- 
cession. Wood and Hare came first with a repetition of 
experiments and of new ones devised.18 They arrived 
at the same conclusions as before, that chloroform is a 
powerful depressant poison, acting sometimes on the 
respiration, sometimes on cardiac action, and sometimes 
•on both together ; that it surely causes death by paralyz- 
ing the heart; that it sometimes does this at an early 
period of the administration when but a small quantity 
has been inhaled ; and that the danger of cardiac arrest 
by this agent is in direct proportion to the concentration 
•of the vapor and the rapidity of its administration. 
Dr. MacWilliam reported to the British Medical Asso- 
ciation an exceedingly interesting and important experi- 
mental study of the comparative effects of ether and 
chloroform.10 The results seem deserving of especial at- 
tention, because obtained by a method whereby the action 
of both ventricles and auricles were graphically recorded 
independent of, although with, tracings of the blood- 
pressure. Experiments showed, besides the usual fall of 
blood-pressure and marked diminution in force of the au- 
ricular and ventricular contractions, a decided dilatation 
of the organ. This dilatation was a constant feature ; it 
affected all the cavities ; they were imperfectly emptied. 
This change of form, too, was remarkable for the sud- 
denness of its occurrence and the early period at which 
it occurred. It was often seen when but a small amount 
of chloroform had been given. Crucial experiments were 
made to determine that this change was not the result 
of changes in the systemic blood-pressure, nor effected 
through the vagi, and were not dependent upon asphyxia, 
or any interference with respiration, but that it was the 
direct effect of chloroform upon the heart itself. The 
conclusions were that "chloroform acts directly upon 
the heart, causes a marked depression of the cardiac 
muscle, a reduction of its tone, a relaxation of its walls, 
and an impairment of its functional activity." It was 
also proved that changes in the circulation frequently 
first gave warning of danger, and often before the respi- 
ration was affected. This had been clinically established 
before, but was denied by the Hyderabad Commission. 
A further important point of this report is the proof it 
gives that the rate and depth of respiration influence 
the effect of chloroform more than any other factor. 
By rapid or deep breathing an overdose may speedily be 
taken, and due dilution of the vapor with air is not, 
therefore, a guarantee against accident. The effect of 
ether upon the heart was concurrently studied by Dr. 
MacWilliam. It was shown to be in marked contrast 
with that of chloroform. Given less carefully and less 
gradually it caused but little change in the action or the 
form of the organ. Dilatation sometimes occurred, but 
then only in slight degree and when the ether was given 
in large amount and suddenly. As a rule it was absent 
and no effect upon the heart was manifested, while when 
chloroform was administered to the same animal in the 
same manner marked dilatation occurred and the force 
of the contractions was lessened. 
Kappeler made a sphygmographic study of the various 
anaesthetics on patients and obtained results which cor- 
respond closely with those of Dr. MacWilliam, and which 
are more favorable to ether than those given in his work 
published in 1880.19 He observed a noteworthy differ- 
ence in the pulse-curves under ether and chloroform. 
The depression which always took place in greater or 
less degree with the latter, only occurred with the former 
in half the cases and then but in slight degree. With 
•ether the curves showed any considerable change from 
the normal only when narcotism was pushed to complete 
abolition of reflex action and entire muscular relaxation. 
The observations showed that in its slight effect upon the 
pulse ether is an exception to all other anaesthetics. Yet 
in deep and prolonged administration similar changes 
occurred with both, so that " while death from syncope 
will occur less frequently under ether than under chloro- 
form, such a death is, from the pulse-curve in ether nar- 
cosis, very possible." 
All experiments, then, with the sole exception of those 
(SUPPLEMENT.) 
of the Hyderabad Commission, concur in supporting 
the conclusions reached by Wood, that "ether usually 
acts very much more powerfully upon the respiration 
than upon the circulation, but occasionally, and especi- 
ally when the heart is feeble, ether is capable of acting 
as a cardiac paralysant, and may produce death by car- 
diac arrest at a time when the respirations are fully 
maintained ; that chloroform is capable of causing death 
either by primarily arresting the respiration, or by pri- 
marily stopping the heart, but that commonly both respir- 
atory and cardiac functions are abolished at or about the 
same time." Shore devised and executed a series of in- 
genious experiments wherein chloroform-carrying blood 
was restricted to the head of an animal, and in another 
to the body, the head receiving none. In the one case 
the fall of blood-pressure took place, in the other it did 
not; it was thereby proved that this fall was the effect 
of a direct action of chloroform on the heart and not on 
the vaso-motor centre.1* 
By recent experimental study, then, we have gained 
much, but rather in confirmation of doctrines already 
accepted than in addition to our knowledge. The dila- 
tation of the' heart under chloroform, and the slight 
effect upon its action by ether had been observed by the 
first committee of the British Medical Association.10 
But now an essential difference of action upon the heart 
by the two agents is accepted no longer as a matter of 
clinical deduction, but stands proved beyond question. 
The doctrine of Bernard, endorsed by the Hyderabad 
Commission, that ether and chloroform are similar in 
action and differ only in degree, is no longer tenable. 
Notwithstanding the proof of an essential difference in 
mode of action between the two anaesthetics their relative 
standing has not much changed during the period under 
consideration. Chloroform still holds the leading posi- 
tion. Ether has gained considerably in England and 
still more in Switzerland. It has not made any advance 
in France ; there, " chloroform reigns almost without a 
rival."20 The A. C. E. mixture has advanced in favor, 
and is now largely used, especially in some sections 
of this country and in England. The estimate given 
at the Glasgow debate was that chloroform is given 
in Great Britain ten times to ether once. The statis- 
tics of the Twentieth German Surgical Congress showed 
22,656 administrations of chloroform and 1,472 of mixt- 
ures to only 470 of ether.14 The second series of Guilt's 
statistics shows a great advance of ether. Chloroform 
is, then, still the leading anaesthetic of the world, despite 
its greater danger, proved by experiment and deduced 
from clinical experience. 
The tendency of the practice of the present time is to 
a choice of anaesthetic, rather than to the banishment of 
either. The doctrine is gaining ground that each agent 
is better adapted to certain cases than the other, and 
that it is the duty of the surgeon to choose the anaes- 
thetic according to the patient or to the operation to be 
performed. In this country Gerster and Hunter Mc- 
Guire have ably supported this course. Dastre likens 
the adhesion to either chloroform or ether alone to the 
attempt made in the Academy of Medicine in 1833 to de- 
termine whether the treatment of pneumonia should be 
by venesection or by cathartics.21 
The operation may determine the choice. For opera- 
tions upon the nose, mouth, and pharynx chloroform is 
the best, and especially when the actual cautery is to be 
used. Tooth-drawing is an exception, however. Nearly 
ten per cent, of deaths under chloroform have occurred 
in dental practice, a proportion enormously high when 
the relative number of administrations for other pur- 
poses is considered. Nance says that chloroform should 
never, upon any consideration, be given for the extrac- 
tion of teeth.8* Dastre emphasizes the different effect of 
the two agents upon the capillary circulation, chloro- 
form restricting, ether increasing it. For operations 
after which much capillary hemorrhage may be expect- 
ed he would therefore prefer the former. For protract- 
ed operations testimony differs as to which is the safer 
agent. The preceding administration of morphine, or 
morphine with atropine, by subcutaneous injection, best 
37 Anaesthetics. 
Anaesthetics. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
promotes the prolongation of anaesthesia with a mini- 
mum of the agent. xYs to operations the success of 
which may be prevented by vomiting, there is a singular 
discrepancy of testimony. Thomas has seen such bad 
effects from this symptom after ether given for laparot- 
omy that he thinks its abandonment for such cases wor- 
thy of serious consideration.22 Cameron bad the same 
experience in two out of four Caesarean sections and 
would not use ether again in that operation.2 On the 
contrary, one of the speakers at the same debate main- 
tained that there was much less vomiting after ether than 
chloroform, an opinion also expressed by Zweifel.1" The 
influence of morphine and atropine is undoubtedly the 
best means of preventing vomiting and securing quiet 
after operations. Dastre is strongly in favor of this 
plan, supporting his opinion by the practical experience 
of Aubert of Lyons, and by citing the well-known influ- 
ence of atropine upon the action of morphine as first 
shown by Brown-Sequard. So far as the experience of 
the writer goes it has not furnished a single case of severe 
vomiting after laparotomy for which anaesthesia had been 
effected by the A. C. E. mixture preceded by an injection 
of morphine and atropine. 
Certain surrounding conditions may determine the 
anaesthetic. Artificial light, if in open flame, would 
banish ether on account of the inflammability of its 
vapor. Both McGuire and Gerster would prefer ether, 
and justly so, when obliged to entrust the anaesthetic to 
an unskilled assistant. The limits of safety are more 
easily passed through inattention, carelessness, or want of 
skill, with chloroform than with ether. When the pa- 
tient cannot be fully anaesthetized with ether of course 
chloroform should be given. Gerster found 11 such 
cases in 125 administrations. 
The state of the patient has an important bearing upon 
the choice of the anaesthetic. During pregnancy the in- 
jurious effect of coughing and vomiting should be con- 
sidered. Hewitt makes obesity a contra-indication to 
ether.21 Arterial sclerosis should also forbid ether on ac- 
count of the greater increase of blood-pressure under this 
agent. Dr. Agnew's fatal case is an instructive example. 
Atheroma is also, for the same reason, a contra-indication 
to nitrous oxide.18 When the patient is very feeble, or 
has suffered from severe hemorrhage, or when shock is 
present, ether should be preferred. The opinion prevails 
that chloroform is the safer anaesthetic for the extremes 
of age. For the old this is correct, on account of the lia- 
bility of the aged to diseases of the respiratory organs. 
That chloroform is especially safe with young children is 
open to the gravest doubts. No precise statistics can be 
given, but numerous deaths have occurred while the num- 
ber of administrations is comparatively small. Of 67 
deaths reported in The Lancet, 1880-90 inclusive, more 
than twenty per cent, were of children under fifteen ; 
some three, four, and five years old. Chloroform is bet- 
ter for young subjects on account of its manageability 
and promptness of effect, while its vapor is far less un- 
pleasant and less irritating than that of ether ; that it is 
safer remains unproven. There is great unanimity of 
opinion as to the administration of antesthetics to patients 
suffering from heart disease. Valvular disease, compen- 
sation being maintained, is no bar to their administration. 
Fatty degeneration, if diagnosed, would contra-indicate 
chloroform. Richardson says he knows of but one condi- 
tion of exceptional danger with chloroform, " a dilated 
and weakened right heart." 16 There is no question that a 
patient with valvular disease will go through the strain of 
an operation or of a severe labor better with an anaesthetic, 
even with chloroform, than without. The .autopsies of 
deaths under chloroform have not revealed lesions of the 
valves. McGuire has given chloroform to " hundreds of 
cases " of valvular disease without accident.24 For pa- 
tients with a "nervously weak heart," feeble in action 
from fear, he and some others would reject chloroform. 
The effect of morphine and atropine is best adapted to 
this condition, quieting the emotional element, which has 
sometimes alone been the source of danger and death. 
There is like unanimity of opinion as to disease of the 
respiratory organs. Here chloroform should be preferred. 
(SUPPLEMENT.) 
Hyperaemia of the larynx, bronchitis, and pneumonia, ora 
tendency to these diseases, forbid the use of ether. Pleu- 
ritic effusions add very much to the dangers. Three cases 
of death from ether in patients with empyema were re- 
ported at one society.9 In some cases, as of emphysema 
with enlarged heart, judgment is difficult; there is dan- 
ger on either hand. Here, as in many other cases, Bux- 
ton and Hewitt advise the A. C. E. Disease of the kid- 
neys has been held to be a contra-indication to ether since 
Emmet, in 1872, first called attention to the subject. In 
recent years, however, the injurious effect of ether in 
patients thus affected has not only been questioned but 
denied, and at present very considerable difference of 
opinion prevails. Fueter reports a series of experiments 
with results wholly negative. He reports also four cases 
of patients with albuminuria to whom ether was adminis- 
tered without increase of albumin afterward.6 Weir also 
reports five cases of patients who presented evidence of 
diseased kidneys before operation and without injurious 
effect.40 Buxton says that a considerable experience with 
operations on the kidneys in which he had given ether, 
induces him to attach less importance to this point than 
formerly.10 This is negative testimony. Looking over 
the positive evidence, such as that presented by Carpen- 
ter,94 the number of cases in which nephritis followed 
the administration of ether, those of death under ether 
in which the autopsy showed diseased kidneys, and it 
must be conceded that the weight of testimony sustains 
the view that ether exerts an unfavorable influence upon 
the kidneys and should not be given when they are dis- 
eased. To support this proposition Weir's statement may 
be quoted, that he found nine cases of transitory albumi- 
nuria after thirty-four administrations of ether. 
Various measures have always been resorted to before 
inducing anaesthesia to modify the process, and with a 
view of lessening its dangers. The one most generally' 
used, and in which the utmost confidence has been ex- 
pressed, is a dose of some alcoholic stimulant. Clinical 
proof of the inefficiency of this measure is abundant. In 
about five per cent, of the deaths from chloroform this 
plan was followed. Since both Wood and McGuire have 
recently expressed the opinion that the influence of al- 
cohol rather increases than lessens the danger from 
chloroform this plan will probably be abandoned. The 
sole excuse for resort to it would be great fear on the 
part of the patient, and this condition is much better 
met by the influence of narcotics. This latter modifica- 
tion of the anaesthesia is the most important measure of 
the kind. The method consists in giving hypodermati- 
cally £ to | grain of morphine (0.0108 to 0.0162), and from 
T6o to tIo grain of atropine (0.0004 to 0.0005) about fifteen 
minutes before the administration of the anaesthetic. 
Much additional testimony in favor of this " mixed 
anaesthesia," or "mixed narcosis," has been recently 
given. A paper lias been published in this country ad- 
vocating it and presenting its especial advantages in 
gynecological practice.26 Dastre has warmly advocated 
it, and given both physiological and clinical evidence in 
support of it. His testimony is very strong : " With 
chloroform alone we lost one dog out of three, and often 
had dangerous symptoms in the other two. During ten 
years with the mixed method I have not seen a single 
one die." Dastre supports the method in the human 
subject theoretically by7 claiming that "it is equivalent 
to a section of the vagi ; " that " all arrests of cardiac 
action under chloroform are certainly active, not para- 
lytic ; they are due to the action of the pneumogastric 
nerve, and may be prevented by the suppression of the 
activity of this nerve." However this may be, sound 
physiological support of the measure is to be found in 
the stimulating influence of atropine on respiration and 
cardiac action, as first shown by Harley and by Bartholow. 
Dastre presents a large amount of favorable clinical 
evidence from the surgeons of Lyons, where the practice 
has been followed for eight years, and in " several thou- 
sand cases " without accident. The plan is advised and 
followed by Buxton and McGuire. Pozzi20 says that to 
this method " can scarcely be awarded too much praise in 
operations of any considerable length. ... It pre- 
38 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
A n aesthetics. 
Anaesthetics. 
vents the initial excitement, diminishes the nausea, limits 
the amount of chloroform used, and consequently lessens 
the chances of chloroform-poisoning in operations of long 
duration."* The changes, then, which have occurred in 
this branch of artificial anaesthesia in the past few years 
may be said to be : 1. The presentation of a large amount 
of evidence, both experimental and clinical, in favor of 
its greater safety. 2. An increase of evidence as to its 
influence in lessening vomiting. 3. The great probabil- 
ity that the benefits of the measure are not restricted to 
chloroform. Kappeler26 had given his opinion against 
the administration of narcotics before ether, believing 
that they increased the danger. Experience has not sus- 
tained this. Julliard gives morphine and atropine before 
ether. The writer has used them before the A. C. E. 
during a lifetime, and has not once seen dangerous symp- 
toms. Shrady advises morphine before ether in drinkers. 
The latter writer also presents strong testimony as to 
great economy of anaesthetic and of time by this method. 
Plastic operations under ether which required one hour 
were performed in half that time when morphine was 
given first.9 Adverse opinion has been expressed upon 
this method ; adverse testimony, however, is not strong. 
The Hyderabad Commission is not favorable to atropine, 
but advises the use of small doses of morphine under 
some circumstances. Macewen states that " the action 
of morphine becomes intensified in the presence of chlo- 
roform." Yet there has been such an amount of clinical 
experience with this method that if it added to the dan- 
ger the fact would be apparent. Some deaths have been 
reported ;25 one recently in this country after the ad- 
ministration of a quarter of a grain of morphine,46 pre- 
ceding chloroform. 
Two points in regard to anaesthesia may be considered 
settled : 1. There is no especial mode of death under 
either anaesthetic ; that ether always causes death by the 
respiration, and chloroform always by the heart, is no 
longer tenable. Wood's statement (v. ante) gives our 
present knowledge as to modes of death and their relative 
frequency. 2. All anaesthetics are dangerous ; no care, 
no precaution, no particular apparatus or method of ad- 
ministration insures absolute safety. This is the ex- 
pression of all recent authorities, the Hyderabad Com- 
mission alone excepted. 
In measures for resuscitation of patientSfin danger 
from anaesthetics some changes have taken place. The 
beneficial effect of galvanism remains unproven. Two 
remedies generally resorted to have been shown by 
Wood to be not only useless but injurious ; they are 
the administration of ether and of alcohol. Unsupport- 
ed by reason, experiment shows that they should be 
abandoned. Digitalis, given hypodermically, exercises a 
marked influence upon the circulation, and Wood saw, 
several times, the death of animals averted by it. 
Strychnine also produces a marked stimulating effect 
upon the respiration with a rise of blood-pressure ;13 
but Reichert's experimental studies do not sustain 
Wood's opinion of the value of strychnine as a respira- 
tory stimulant.21 Hankel recommends it, however, "as 
the strongest stimulant of the respiratory centre and of 
the motor cardiac nerves." As to nitrite of amyl, the 
testimony is conflicting. Wood found its effect nega- 
tive. Buxton says it is not a physiological antidote to 
chloroform. On the other hand, Shrady and others 
report having used it with benefit, and Burrall has pub- 
lished a paper with a collection of cases in its support.911 
Inversion of the body scarcely holds the confidence it 
once had. The existence of cerebral anaemia, upon 
which this measure is theoretically based, is doubted by 
Wood. Dastre says that ether causes cerebral hyperae- 
mia, and that therefore, with this agent, the dependent 
position of the head is likely to aggravate the symptoms. 
The measure originated from observation of its good 
effect on animals, and experiment still sustains it. Wood 
saw its good effect frequently, and in some cases repeat- 
ed so often that it could not be attributed to accident. 
There is very strong clinical evidence in its favor. 
Chisholm has reported cases of recovery quite as striking 
as the one first described by Sims in Nelaton's practice. 
He gives four successful cases ; in one the measure was 
repeated three times before the completion of the opera- 
tion.9' Artificial respiration still maintains the leading 
position it has always held. Authorities are unanimous 
as to the superiority of this measure. It has the strong- 
est support from experiment. In man, if respiration be 
in abeyance, this is the direct and only way to restore it. 
If the heart is paralyzed nothing can restore its vitality, 
but its action may be so reduced as to be imperceptible, 
and then the manipulation of the chest-walls is an effec- 
tive means of increasing it. Early resort to it is impor- 
tant. The Hyderabad Commission found it successful 
almost without exception if not more than thirty seconds 
had elapsed before it was commenced, and almost useless 
if not begun until after fifty seconds. Nussbaum em- 
phasized the importance of the first minute. Whatever 
method be followed thorough expiration should be first 
effected. By this means the anaesthetic vapor of the 
residual air is expelled. Again, expiration is much 
more affected by anaesthetics than inspiration.21 In 
deep anaesthesia expiration is purely passive, very feeble, 
and danger to respiration comes in this way. Nuss- 
baum's plan was, thorough slow compression of the 
thorax and abdomen with both hands, and this repeated 
every three or four seconds. He had 15,000 adminis- 
trations of chloroform without a death ; nine times, 
however, the escape was narrow, and once ten minutes 
elapsed before the first breath was drawn, and thirteen 
more before respiration was established;14 Konig's plan 
is similar; it consists in compression of the cardiac 
region, repeated thirty to fifty times in the minute, one 
thumb pushing deeply into the space between the ribs 
and left edge of the sternum. Maas reports two striking 
recoveries by this method.16 The patients were nine and 
a half and thirteen years old ; both were pulseless, with 
suspended respiration and dilated pupils; in one artifi- 
cial respiration by Sylvester's method and inversion of 
the body was tried ; in both there was opportunity to 
observe the good effects of the measure Several times, 
and over an hour of perseverance was required before 
recovery was assured. McWilliam found that the most 
powerful way of increasing the carotid blood-pressure 
in animals deeply narcotised by chloroform was by firm 
intermittent compression of the abdomen.16 
Considerable attention has been directed of late to the 
purity of chloroform. Probably very few, if any, deaths 
have been caused by an impure article. Dastre found 
no instance in 132 fatal cases which occurred from 1865 
to 1880, and he thinks this a convenient explanation of 
death for the relief of the administrator. Recently, 
however, DuBois-Reymond has made a study of this 
subject. He has followed a plan devised by Pictet, of 
Geneva, whereby chloroform is submitted to the influ- 
ence of intense cold and impurities in it thus removed. 
Chloroform thus purified showed far greater stability ;21 
exposed to air and light it remained unchanged for a 
week, while ordinary chloroform showed signs of decom- 
position within two days, sometimes in a few hours. 
Anaesthesia was produced by the purified article more 
promptly and was more enduring. Experiments were 
made on animals with the residue and the injurious 
effect of the impurities thus demonstrated.'8 In Ger- 
many, according to Foy,29 great impurity of chloroform 
is not rare. In England chloroform is likely to be con- 
taminated with the methyl compounds from the use of 
methylated spirit in its manufacture.8' Reynier found 
necessity for investigating the purity of chloroform in 
France.30 He attributes cough, vomiting, bronchial 
hypersecretion and arrest of respiration to impure chlo- 
roform. He had observed a far less mortality in dogs 
experimented on since he had used only chloroform rec- 
tified the evening before and kept in colored bottles. In 
the debate M. Lucas-Champonniere maintained the 
importance of this point ; with pure chloroform anaes- 
thesia is regular ; with impure there are irregularities 
* This writer claims it as " the method of Dastre and Morat." It 
was used in this country from 1870, continuously since, and publicly 
advocated as early as 1876.25 Dastre's work appeared in 1890. 
39 Anaesthetics. 
Anenionine. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
and accidents. In obstetrical practice he had found it 
of especial importance. "If I have good chloroform I 
effect readily that demi-ansesthesia desired in natural 
labor; if not, I fail; I narcotise too much or not 
enough." DuBois-Reymond's chemical position has 
been called in question by Schacht.21 In this country 
pure chloroform, the product of reliable manufacturers, 
is everywhere at command, yet the necessity of care in 
selection is shown by the following official table of 
examinations of the articles :31 
use of Junker's inhaler, a closed apparatus, which in- 
fluences both the other factors. 
The bromide of ethyl seems to be actively recovering 
from the neglect into which it fell about a decade ago. 
The reaction began in 1888. and has been the work of 
German dentists. Strong testimony in its favor, experi- 
mental and clinical, was presented to the Tenth Interna- 
tional Congress by Hollander and Abonyi. A paper em- 
bodying the experience of 1,500 administrations is given 
by Gilles."d It is stated that there have been 20,000 
safe administrations in Germany, the accidents being at- 
tributed to impurity of the article used. In this country 
it has been advocated by Montgomery, 500 cases, by Kuy- 
kendall, 250 cases,S14" and it is stated that Chisholm and 
Prince have administered it to several thousand cases.21 
It has been opposed by Mittenzweig, who gives three 
cases of poisoning in Berlin, two fatal.14 Brinton was 
led to abandon its use from unpleasant experience.81 
Dastre says : "If physiological analogies do not deceive 
us, the bromide of ethyl, for long operations, offers 
greater dangers than ether or chloroform." Kappeler 
found that it exercised a marked influence upon the 
pulse-curve, and hopes that it will be " consigned to for- 
getfulness."19 The writer inhaled it three times, under 
the supervision of medical friends; its effect upon the 
pulse was so marked that he decided never to administer 
it.32 To all previous adverse experience the friends of 
this agent urge that the purity of the article is essential ; 
and it is an article very difficult to obtain pure. Never- 
theless Witzel, who terms it " the safest narcotic for hu- 
man beings," saw, in 465 administrations, disagreeable 
symptoms 28 times, asphyxia in a number of cases, and 
twice artificial respiration was required.21' Gilles urges 
the importance of a special technique : it should be given 
more freely than chloroform ; the mask should consist 
of several folds of gauze, so as to carry considerable 
liquid, and over this should be an impermeable cover. 
Anaesthesia by this agent is exceedingly pleasant, very 
rapid, with equal rapidity of recovery. The writer can 
testify to these points from personal trial, and, if safe, he 
would term it the ideal anaesthetic. The time required 
for complete anaesthesia is fifteen to ninety seconds, aver- 
age eighteen. The following points are derived from 
the writings of advocates as well as opponents : 1. Bro- 
mide of ethyl is adapted only to very short operations, 
those lasting not over a minute or two. 2. Not more 
than five to ten grammes should be administered. 3. Mus- 
cular relaxation is not obtained ; a gag is necessary for 
tooth-extraction. 4. Muscular rigidity is frequent, some- 
times tetanic, with opisthotonos. 5. Excitement, al- 
though unusual, is sometimes greater than with chloro- 
form. 6. Dreams are extremely vivid and sometimes 
erotic. Gilles denies that they are of this character " in 
one-third of all cases." He saw sexual movements in 
one case, and Wetzel saw them in women several times 
in 465 administrations. 7. In some cases it is followed 
by distressing vomiting, even when but a small amount 
has been given. 8. Arterial hemorrhage is favored. 9. 
An unpleasant odor of garlic is present for some days in 
the breath of those who have inhaled it. In view of the 
conflicting experience, this agent should be submitted to 
further careful chemical and experimental investigation. 
The authors of the papers above quoted concur in the 
statement that neither pulse nor respiration are materi- 
ally affected in patients submitted to its influence. 
There has been no change worthy of note in either the 
theory or practice of anaesthesia in obstetrics. No addi- 
tion to the mortality in natural labor, the anaesthetic be- 
ing administered by a medical man, can be recorded. A 
brief treatise upon the subject has been published in this 
country as part of an obstetrical work." Baldwin has 
made a plea for a more general resort to chloroform in 
labor,124 and Barker has published an inquiry as to the 
influence of anaesthetics in causing post-partum hemor- 
rhage.184 This paper is based upon the observation of 
several thousand cases, and the author's conclusion is 
that chloroform, properly administered, need never be 
withheld on account of hemorrhage. The experience 
given in support of the doctrine that valvular disease of 
Number of 
examina- 
tions. 
Good qual- 
ity. 
Fair. 
Inferior. 
Not ether 
at all. 
,Qcn 1 Chloroform 
21 
15 
5 
1 
18o!H Ether 
6S 
40 
4 
22 
2 
13 
8 
4 
1 
16!,°- 1 Ether 
30 
17 
12 
1 
ion< i Chloroform 
17 
15 
i 
1 
I39k i Ether 
61 
38 
4 
19 
The vapor of chloroform undergoes decomposition 
when exposed to the flame of artificial lights. Zweifel 
first called attention to this fact in a paper on pneumonia 
after laparotomy from decomposition of chloroform in 
gas-light.1' He maintained that gases are formed which 
are very irritating to the respiratory organs, occasion 
cough, and may be the cause of inflammatory affections. 
By the contrast of daylight operations and of those con- 
ducted under ether he furnished abundant clinical proof. 
Basshard studied the subject chemically and demonstrated 
that free chlorine and phosgene gas are formed when 
chloroform is exposed to gas-light.18' Eisenlohr and 
Fermi furnished experimental proof that injurious and 
dangerous gases may be thus generated.114 Amidon read 
a paper upon the subject which called forth reports of 
other cases from New York surgeons.4' 
Fatty degeneration of the tissues is occasioned by pro- 
longed and repeated inhalation of chloroform. The fact 
was noticed by Nothnagel in 1866. Attention was di- 
rected to it again by Unger in 1887, and his observations 
have been confirmed by Strassman and by Ostertag.83 
The experiments of these observers showed that in ani- 
mals exposed to prolonged inhalation of chloroform the 
internal organs had undergone fatty degeneration ; that 
certain individuals exhibited a greater susceptibility to 
this change than others ; and that in these animals death 
took place by paralysis of the heart. The fact should be 
known as one having clinical possibilities. 
Bichloride of methylene, introduced by Richardson in 
1867, has not succeeded in gaining a footing in this 
country. Nor has it advanced in favor elsewhere, not- 
withstanding Wells's experience of twelve hundred 
administrations without a sign of danger. Pleas have 
recently been made in its favor by Day,13 and by Rich- 
ardson,164 the latter giving a large, varied, and suc- 
cessful experience. Bichloride of methylene, pure, is a 
"convulsive anaesthetic," not adapted to surgical use. 
The liquid which passes under this name as methylene 
is a mixture of chloroform 10 parts and alcohol 30 
parts.21 Kappeler obtained several specimens from the 
best English sources and found them to consist of "a 
mixture of chloroform and methyl alcohol, with traces 
of chloromethyl." 19 Richardson does not claim that it 
is pure, but that "a less refined product answers even 
better for anaesthesia than the real CH2C12." The rate 
of mortality of this agent has been high. Kappeler refers 
to 14 deaths collected by himself in 1879, and gives 5 
more. Hankel says that the few leading English jour- 
nals, 1869-80, contain reports of 11 deaths from it, 7 by 
syncope. This was the same mortality as that from ether 
during the same period with a very far greater number 
of administrations. Dastre attempts to reconcile the high 
rate of mortality in general with Wells' and Richardson's 
successful experience. He believes an explanation may 
be found in the different temperatures at which the agent 
was administered, in changes which take place in the 
liquid even during administration, and especially in the 
40 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Anrestlielics. 
Anemouine. 
the heart is no bar to the use of chloroform is especially 
valuable. Montgomery has advocated the use of bro- 
mide of ethyl in labor, and reported cases.27' The ad- 
ministration of this agent is restricted by its best friends 
•to very brief periods. Charpentier presented the subject 
■of anaesthetics in natural labor to the Obstetrical Society 
of Paris.'*0 He recognized the undoubted tendency of 
chloroform to diminish the contractile and retractile 
power of the uterus, and that in some cases it " has been 
■the cause of more or less severe hemorrhage after labor.'' 
It is indicated " in primiparae who are nervous and excit- 
able, and in whom the pain may even cause delirium ; in 
those in whom the labor is greatly prolonged ; in all 
cases in which there is spasm, contraction, or rigidity of 
the neck or body of the uterus." It is contra-indicated 
in " absence of severe suffering, the existence of placenta 
praevia, general prostration, diseases of the circulatory or 
respiratory organs, cerebral disease, and alcoholism." In 
regard to cardiac disease, he is not in accord with Barker 
nor with the general testimony of authorities. 
The occurrence of insanity after the administration of 
anaesthetics has been observed. This is the subject of a 
paper by Savage, read before the British Medical Associ- 
ation.1' Mental aberration has followed all the anaes- 
thetics, as well as other deliriants, such as alcohol and 
belladonna. Such a result is rare, but its possibility may 
bear upon the use of these agents with patientshaving an 
hereditary disposition to insanity. One case with such 
disposition was related, in which insanity followed the 
first confinement, chloroform not having been given, 
while several times subsequently the anaesthetic was ad- 
ministered and no bad effect followed. Homans 106 has 
reported two cases of insanity following ether, and sev- 
eral others are mentioned.9 Papers upon insanity follow- 
ing operations, especially laparotomy, have been pub- 
lished by Baldy16 and by Ill?4 How far the mental 
■disturbance in these cases should be attributed to the 
operation or to the anaesthetic it is impossible to deter- 
mine. 
Pental (q. v.) has recently been used in Germany as an 
anaesthetic for short operations, and several hundred ad- 
ministrations have been reported. As it caused cyanosis 
with absence of pulse and suspension of respiration in a 
healthy student, who submitted to its influence, as Gurlt 
reported to the Twenty-first German Surgical Congress 
one death in 215 administrations, and as Brewer, of 
Vienna, found measures of resuscitation necessary in one 
of every hundred administrations,35 the future of this 
agent is not promising. 
Local anaesthesia has been revolutionized within about 
a decade by the extension of the application of cocaine 
(q. v.). Menthol is also an efficient addition to our means 
of lessening sensation locally. The following, used with 
Richardson's spray apparatus, renders good service : 
B. Menthol gr. 2.5 
Chloroform gr. 25.0 
Ether gr. 37.50 
M. 
With the means now at command for local anaesthesia 
a death from chloroform, given for opening a mammary 
abscess,36 could not be considered less than criminal. 
J. C. Beeve. 
1 Brit. Med. Jour., ii., 1892; a, ii., 1891 ; b, ii., 1890 ; c, i., 1879, ii., 
1880 ; d, ii.. 1888 ; e, ii., 1887. 
2 Discussion on Anaesthetics. Glasgow. 1891. 
3 Chloroform the Best Anaesthetic. Baltimore. 1S88. 
4 N. Y. Med. Jour., i., 1887; a, i„ 1890 ; b, i., 1892 ; c, i., 1891. 
6 Rev. Med. de la Suisse Romande, February, 1890-91. 
8 Deutsche Zeit. fiir Ghir., Bd. xxix., 1888. 
7 Berlin klin. Wochenschrift, No. 8, 1890; a, 15, 1889 ; b, 12. 1892 ; c, 
15. 1889; d, 8, 1892. 
8 London Lancet, ii., 1891 ; a, ii., 1890 ; b, ii., 1890 ; c, i., 1888 ; d, 
ii., 1889. 
* Med. Rec., i., 1889; a, i„ 1891: b, ii., 1892 ; c, i„ 1887; d, i., 1886 ; 
e, i., 1888. 
10 Boston Med. and Surgical Jour., ii., 1888 ; b, cxxi., 1889. 
11 Anaesthetics. Philadelphia. 1888. 
12 Trans. Ohio State Med. Soc., 1891; b. 1890. 
' 13 Wood's Address, International Congress, 1890. 
14 Hankel : Handbuch der Inhalations-Anojsthetica. 1891. 
16 Am. Jour. Obstet., xxiv., p 1461. 
16 Asclepiad, 1892; b, 1888. 
17 Ther. Monatschrift, August, 1891. 
Med. News, i., 1890 ; a. ii., 1887 ; b, i., 1887; c, ii. 1889. 
J1 Archiv. f. klin. Chir. 1888. 
20 Pozzi: Treat, on Gynaecology. New York. 1892. 
21 Les Anaesthetiques. Paris. 1890. 
22 Med. and Surg. Rep., 1889. 
23 Treves : Op. Surg. 1892. 
21 The Choice of General Anaesthetics. Richmond. 1887. 
25 Trans. Am. Gyn. Soc., 1891. 
28 Anaesthetica, Deutsche Chir., 1880. 
27 Ther. Gaz., April, May, June, 1892 ; b, May, 1892 ; c, June, 1892; 
d, April, 1892, e, January, 1892. 
27("« Southern Med. Rec.. 1891. 
28 Amer. Jour. Med. Sc., April, 1892. 
2:1 Anaesthetics, Ancient and Modern. London. 1889. 
80 Bull, et Mem. de la Soc. de Chir. de Paris, xv., 1889. 
31 State Board of Health, of N. Y., Dr. W. G. Tucker, Albany. 
32 Cin. Lancet and Clinic, 1880. 
33 Amer. System Obst.. vol. i. 1888. 
34 Pittsburg Med. Review, 1888. 
36 Annals of Surgery, January, 1893. 
38 Jour. Am. Med. Assoc., March 7, 1891. 
[Since this article was prepared there has been published a large col- 
lection of statistics in the Medical News, October 29,1892, and a valuable 
article on " Recent Physiological and Chemical Research on Anaes- 
thesia " in the British Medical Journal of same date. A second edition 
of Buxton's work on Anaesthetics has also appeared, Philadelphia, 1892.] 
ANCHYLOSIS. A new use of the terms true and false 
anchylosis, based upon the symptomatology and treat- 
ment, has recently been employed by a few orthopedic 
surgeons. They would have true anchylosis embrace 
both bony and fibrous union, provided it be complete, 
sound, and uninfluenced by use ; false anchylosis would 
then be applied to those stiff joints in which some degree 
of motion is present, those in which disease (unsound- 
ness) still remains, and all joints which by use become 
more deformed and more stiff, or less deformed and less 
stiff. 
The justification of this terminology rests chiefly in the 
treatment. True anchylosis should only be subjected 
to treatment for the correction of existing deformity. 
Brisement force, osteoclasis, osteotomy, and excision are 
demanded, according to the nature of the deformity. 
False anchylosis, existing without deformity, should be 
treated by immobilization until the joint is quite sound ; 
if the.result is true anchylosis no further treatment is de- 
manded ; but if the joint recovers soundness with some 
degree of motion, the fullest possible restoration of func- 
tion will be gained in time without further treatment. 
Brisement force and passive motion cannot be employed 
without a risk of rendering the joint once more unsound. 
If false anchylosis be present in a deformed joint, the 
deformity should be corrected under an anaesthetic, the 
surgeon using as much force as can safely be risked, at 
one or more sittings ; after each forced correction the 
joint should be kept at rest until all pain has ceased, 
when the attempt to reduce the deformity should again 
be made. When the deformity has been fully corrected, 
the joint should be immobilized until it has become 
wholly sound, after which the rules applicable to a straight 
limb should govern the management of the case. 
It is no longer believed that true anchylosis can be 
produced by immobilization alone, no matter how pro- 
longed. The fact that anchylosis is present in a joint is 
a positive indication that it has been, or still is, the seat 
of some pathological process, and from this the logical 
conclusion follows that the treatment which will most 
rapidly cure the disease must result in the fewest cases of 
true anchylosis. 
John Bidion. 
ANEMONINE. The active principle of anemone pul- 
satilla, L., CisHisOe. It crystallizes in needles, has an 
acrid taste, is slightly soluble in water, soluble in alcohol 
and chloroform. It is decomposed by alkalies. 
It is recommended as a substitute for pulsatilla. Dose, 
from to | grain. In large doses it is a powerful poi- 
son. 
It is used in painful inflammatory affections of the 
ovaries and other pelvic organs, in orchitis and epi- 
didymitis, and in all other affections in which pulsatilla 
is indicated. 
41 Anemonine. 
Aug.-Neuro. (Edema. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
The alkaloid requires to be prepared with care, as the 
presence ot' anemonic acid converts it into anemone 
camphor, which produces its irritant and poisonous 
properties. Beaumont Small. 
ANGEIO-NEUROTIC (EDEMA. Definition: A vaso- 
motor neurosis, characterized by the appearance of cir- 
cumscribed swellings on various portions of the body, by 
preference the face, throat, and extremities, without ap- 
parent cause or premonition, and non-inflammatory in 
character. 
Synonyms: Acute circumscribed oedema ; acute idio- 
pathic oedema ; periodic swelling ; urticaria tuberosa, or 
giant swelling ; acute non-inflammatory oedema ; Austra- 
lian blight. 
Histoky.-Although references to this affection may 
be found here and there in medical literature since 1827, 
it is only within the past ten years that it has been 
recognized as a disease having sufficient individual char- 
acteristics to have a history and special designation of its 
own. It is to Quincke, and his pupil, Dinkelacker, that 
we are indebted for calling the attention of the profession 
to this disease, in such a lucid manner that it was at once 
recognized by other physicians. 
Etiology.-Age.-The period of early life furnishes 
the greatest number of cases; the average age in a 
series of seventy-five cases examined by the author being 
twenty-seven. It rarely occurs for the first time in indi- 
viduals upward of sixty years of age. Childhood, 
however, is by no means exempt; a case is reported by 
Dinkelacker, in which a child, whose father suffered 
from the disease, had an attack for the first time when it 
was three months old. 
Sex.-It occurs nearly twice as often in males as in 
females, except in this country, where the proportion 
would seem to be reversed. 
Occupation.-Those whose occupation tends to the pro- 
duction of excessive bodily and mental fatigue, are the 
only persons who show an increased susceptibility to the 
disease. 
Heredity.-This is one of the most important and in- 
teresting elements in the genesis of the disease. It has 
been seen to run in families one generation after another. 
In a remarkable series, reported by Osler, the disease was 
demonstrated to be present in five generations, including 
in that time twenty individuals. 
Previous and Present Condition of Bodily Health.-No 
relationship can be traced to previous, immediate, or re- 
mote disease, and the majority of the cases presenting 
themselves with this disease are in fairly good health. 
Exciting Causes.-Of the directly exciting causes cold 
and traumatism are the most obvious. Others, such as 
fright, grief, anxiety, worry, and the ingestion of certain 
kinds of food, such as apples or fish, have all been found 
to be exciting causes in some patients. An attack is 
most commonly excited by cold, as in passing from a 
warm into a cold atmosphere, although it does result 
after severe muscular exercise with consequent sweating 
and then becoming cool very rapidly. The period in the 
twenty-four hours when attacks are most liable to show 
themselves, is during the time between 1 and 5 a.m., 
when the tide of life is at its lowest ebb, and the parts 
are least resistant. 
Area of Distribution and Primary Point of Manifesta- 
tion.-In a total of seventy-one cases the swelling showed 
itself for the first time: in the face, in twenty-nine cases; 
on the extremities, in twenty-two; in the larynx, in five; 
on the genitals, penis, and scrotum, in three; on the body, 
in six; on the gums and palate, in one; in the stomach, 
in three; on the neck, in one ; and behind the ears, in 
one. Of the cases in which the swelling showed itself 
upon the face, three were restricted to the forehead ; 
three occurred first on the eyelids ; seven on the lips, and 
the remainder were distributed over various portions of 
the face. On the extremities the hands were by far the 
most often attacked, and after these the forearms were 
the next most frequent seat. 
The occurrence of the swelling in one spot seems to 
predispose the place for future attacks, and it is the ex- 
(SUPPLEMENT.) 
ception for it to be once seen in a place which thereafter 
remains free. Parts of the body which have received in- 
jury or have been the seat of protracted pain seem occa- 
sionally to be favorite places for the development of the 
swellings. Occasionally there seems to be a periodicity 
in the appearance of the swelling. 
Symptomatology and Clinical Course.-The mani- 
festations of the disease generally present themselves with- 
out warning, and the suddenness of their appearance and 
departure are rather characteristic. Possibly the patient 
may complain for a short time before the appearance of 
the swelling, of vague feelings of malaise, general disincli- 
nation to do anything, and a feeling of depression associ- 
ated with ill-defined gastro intestinal symptoms. The 
oedema conies on quickly, generally reaching its full de- 
velopment in a few hours, and gives the patient very little 
trouble, except by its mere presence; there is a feeling of 
stiffness and unwieldiness and a sensation as if the parts 
were on the stretch, but this sensation is not attended 
with pain or distressing throbbing, or any of the subject- 
ive symptoms of inflammatory swelling. The swelling is 
generally clearly circumscribed and plainly differentiated 
from the surrounding surface, and of a varying color. In 
some cases, but probably not in the majority of them, the 
skin is of a dark-red, dull roseate hue, while in others the 
marked contrast between the pale, almost waxy color of 
the swollen surface and the skin around it, is very strik- 
ing. As has already been stated, the swellings have 
marked predilections for certain parts of the body. The 
oedematous part does not pit on pressure, or, if it does, 
only in a few cases, and in these not to any marked ex- 
tent, so that the indentation produced by the forcible 
pressure of the finger is quickly effaced. 
The subjective symptoms complained of by the patients 
are a sense of scalding or burning as the swelling is show- 
ing itself, these sensations being probably due to the 
marked tension under which the skin is suddenly placed ; 
and after this, there is generally a feeling of itchiness.. 
Outside of these, if the swelling does not encroach on 
any organ, such as the eye, the stomach, the penis and! 
testicles, or does not block up the conductivity of a pas- 
sage, as it sometimes does, and so produce trouble, there- 
will be hardly any other subjective symptoms com- 
plained of. Frequently the surface temperature of the 
swollen part has been found to be slightly elevated, while 
on the other hand carefully made observations have de- 
monstrated that the specific heat of these parts was con- 
siderably lowered. It is probable that at the beginning 
of an attack the surface temperature of the part is some- 
what elevated, while later, or just before the swelling is 
going to wane, the temperature falls. 
The swelling generally reaches its height in any one- 
part in a few hours after its appearance, in some cases in 
a few minutes, while in others from six to eight hours will 
elapse. After remaining for a period varying from a few 
hours to as many days, it will begin to disappear, ordi- 
narily with a rapidity corresponding to that with which 
it showed itself, and frequently its disappearance from 
one part is the signal for its appearance in another,which 
may have no anatomical or physiological relation to the- 
part previously affected. As a rule it does not show 
itself in more than two or three localities at one visitation,, 
and frequently only in one. The disease recurs, and in 
the analysis of the cases spoken of above, the time be- 
tween the attacks averaged nineteen days. Occasionally 
a patient will have three or four attacks in a month, 
while others go for three and four months, and even 
longer, before they have a recurrence. 
The symptoms of the disease when some of the mucous 
membranes are attacked are well marked and suggestive. 
As has already been said, the mucous surfaces most often 
attacked are those of the stomach and of the larynx. In 
about one-third of the cases gastro-intestinal symptoms are 
prominent. These symptoms are first a feeling of unea- 
siness and tension, as if something undigestible had been 
taken and had remained in the stomach. With this there 
is loss of appetite generally associated with constipation, 
which is soon followed by a distended appearance of 
the epigastrium ; and then follows a sharp colicky pain. 
42 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
A iienioiiine. 
Aug.-Neuro. <E de in a. 
often attended with profuse vomiting and great thirst. 
The pain is often so severe as to demand the administra- 
tion of morphia. The character of the material vomited 
depends at first upon the contents of the stomach, but 
later on it becomes watery and somewhat stringy from 
the mucus which it contains, and frequently profuse in 
quantity. When this continues for any length of time 
the thirst becomes greater, and large quantities of urine 
are frequently passed, which, however, contains nothing 
abnormal with the exception of increased quantities of 
earthy phosphates. After this exacerbation in the symp- 
toms has ceased, the reaction sets in, and there is fre- 
quently a diarrhoea of a colliquative nature, w ith an ap- 
parent retraction of the abdomen and a general feeling of 
lassitude and prostration, and the characteristic symptom 
of the disease shows itself in another part of the body, 
or, if it has already done so, it now' begins to disappear. 
When the swelling appears in the larynx it of course 
produces symptoms in proportion to the amount of 
encroachment that it makes. This is often so great that 
distressing symptoms of suffocation are produced, and, 
indeed^ in some instances, in consequence of the oedema, 
death has taken place, and in many others the symptoms 
are so severe as to demand liberal scarification, or, more 
rarely, tracheotomy. As a rule the swelling does not pass 
by any continuity from the pharynx into the larynx, but 
when it is to attack the latter it shows itself with the 
same degree of abruptness and vigor there as in other 
parts of the body, and as a consequence the horrible sen- 
sation of choking to death is added to the patient's misery. 
Difficulty in swallowing when the seat of swelling is in 
the pharynx, is not so common as the corresponding 
symptom in the larynx, nor does it ever become so dis- 
tressing. If it be granted that the oedema in question 
may manifest itself in the lungs, as many good observers 
would have us believe, the symptoms resulting will not 
differ materially from those of acute pulmonary oedema, 
except in the suddenness of its onset, the urgency of the 
symptoms, and the abrupt mode of departure. 
Of the general health between the attacks but little 
is to be said. Generally there is nothing noticeably 
wrong ; for a day or two after an attack there may be a 
slight feeling of prostration, especially if the gastric or 
intestinal mucous membrane has been attacked, but this 
soon passes away and the condition of the body is excel- 
lent until the next attack shows itself. Frequently there 
is not even this feeling of lassitude. 
Diagnosis.-The diagnosis of a case of angeio-neurotic 
oedema will be attended with little or no difficulty if 
arrived at by the process of exclusion. The spontaneous 
appearance of the oedema, its recurrence at certain 
intervals, the absence of inflammatory symptoms, either 
local or constitutional, and the abruptness of its dis- 
appearance, are generally sufficient to enable us to. rec- 
ognize the disease at once. 
It may be confounded with the blue oedema of hysteria, 
as described by Sydenham, or the white oedematous 
swellings occurring with the same disease, as described 
by Charcot. In hysteria, however, and especially if the 
hysterical attack is sufficiently profound to have oedema 
as one of its attendants, there will always be found the 
well-known stigmata which will be sufficient to make the 
diagnosis. Other factors, such as the abruptness of onset 
and the mode of departure, as well as the distribution of 
swelling in angeio-neurotic oedema, will corroborate the 
diagnosis. 
There are a certain number of affections described 
under other names which are in all probability modified 
forms of this disease. They are, urticaria tuberosa, Aus- 
tralian blight, malarial oedema, etc. As will be seen at 
the beginning of this article these terms are considered 
as synonyms of the disease in question, and therefore 
require no further description. 
Duration and Prognosis.-The duration of the 
disease varies from a period sufficient for one attack to 
a lifetime. The statistics bearing on prognosis do not 
allow us to draw conclusions that are of any great value 
on account of the fact that the patients do not often re- 
main under the same physician's care sufficiently long to 
(SUPPLEMENT.) 
enable him to study the natural termination of the disease. 
From the evidence in our possession I am inclined to 
believe that the disease disappears after lasting a variable 
time, of from two to three years, in about one-half the 
instances. In the other half it may remain dormant for 
prolonged periods, but you can never prognosticate when 
or where it is next going to manifest itself. In others it 
continues to recur with varying intervals during the 
patient's entire life, which may not, however, be percep- 
tibly shortened by the exhibition of these attacks. In 
some cases the manifestations cease to present themselves 
when the exciting cause can be obviated. It rarely 
causes death, and then almost alone by the involvement 
of the larynx and consequent suffocation. Whether or 
not the possession of this infirmity tends to shorten life by 
predisposing to other conditions which destroy the life of 
the patient, nothing definite has been observed, and there 
must necessarily be a greater number of observations 
before any justifiable conclusions could be drawn in re- 
gard to this point. 
Pathology.-The pathology of the disease is as yet 
rather obscure. The nature of the lesion is unquestionably 
that of a non-inflammatory oedema circumscribed in 
form. The fact that the epidermis is not involved is an 
important corroborative fact, even if it was not so evident 
clinically that the oedema is in no way connected with 
an inflammatory condition. The seat of the oedema is- 
probably most often in the connective tissue of the 
derma, beneath the papillae, and in the subdermal tissue ; 
very rarely the oedema confines itself to the more super- 
ficial parts. It is probable that although the lesions or 
the irritants on-which the disease is dependent may 
attack the other parts of the system, yet the result di- 
rectly appears through the sympathetic system of nerves. 
Furthermore, the nerves affected are undoubtedly the 
vaso-motor nerves. The disease in its development has a 
close relation to other vaso-motor neuroses, such as 
morbid blushing and flushing, exophthalmic goitre, and 
to many of the arthropathies as yet not well understood. 
An oedema very similar to it is associated with tic dou- 
loureux, migraine, nerve-stretching, and the oedema oc- 
curring in hypnotizable subjects, following a seance. 
Treatment.-Therapeutic measures are of little avail, 
either in mitigating the length or the severity of an attack, 
or in increasing the intervals between their occurrence. 
The greatest success will be obtained by adopting such 
measures as give tone and stability to the nervous 
system. As an all-round vaso-motor and general tonic 
to the nervous system of the body strychnia most nearly 
reaches the mark. It should be given in large doses and 
until its full physiological effects are manifest, particu- 
larly on the spinal cord ; for although the affection is one 
indicating defect in the sympathetic nervous system, we 
must not forget that the origin of that system is in close 
relation genetically with the spinal cord. The next most 
important drug in the treatment is atropia ; it should be 
likewise given in moderately large doses, and its adminis- 
tration continued during the intervals between the attacks. 
Tonics, invigorating baths, exercise, massage, and the 
prevention of trauma are the most important factors in 
the treatment of this disease. It is unnecessary to enter 
into details concerning the treatment for symptoms as 
they arise. If there be an excess of uric acid in the 
blood, as manifested by a disproportionate relation to the 
urea in the urine, this condition demands regulating. 
The same may be said of constipation, menstrual irregu- 
larities, and the like. The treatment at the time of an 
attack will depend somewhat on the part of the body 
where the disease is manifest. If the dermal surface of 
the body be involved, the most satisfactory plan of treat- 
ment is to keep the patient quiet, in an equable tempera- 
ture, and apply dry heat to the swelling ; and if there be 
much uneasiness or restlessness, a mild anodyne should 
be administered. Compression by means of a bandage or 
a Gamgee dressing is occasionally of benefit. When the 
disease manifests itself in the mucous membranes the 
treatment is entirely symptomatic. As has been before 
said, when the gastro-intestinal symptoms are prominent, 
morphia fulfils two conditions: it relieves the severe 
43 Ang.-Neiiro. W de m a. 
Arsenical Paralysis. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
pain and distention, and checks the vomiting for the 
time being. When the disease shows itself in the throat 
and larynx, it will occasionally be necessary to scarify 
and sometimes, but rarely, to perform the operation of 
laryngotomy. The use of electricity, although recom- 
mended, has not been attended with any better success 
than has followed the employment of the other remedies 
mentioned. 
Bibliography. 
Bawke: Berlin, klin. Wochensehr., February 8, 1892. 
Borner : Sainmluug klin. Vortrage von Volkman, No. 312. 
Castelli: These de Lyon, 1886. 
Cenas: La Loire Med., December 16, 1886. 
Charcot: Collected Works. Paris. 1885. 
Chauvet : Soc. Med. des Hopitaux, February 8, 1884. 
Collins : American Journ. Med. Sciences, December, 1892. 
Conty : Gaz. Hebdomadaire, 1886, p. 579. 
Conty : These de Paris, 1884. 
Courtoix et Suflit : Annul de Dermatol, et de Syph., Paris, 1880 ; 2e ser., 
x., 859. 
Crocq: Presse Med. Beige, vol. xliii., p. 298. 
Cuntz : Archiv. f. Heilkunde, vol. xv. 
Curtis: Boston Med. and Surg. Journ., 1880, xi., 556. 
Dinkelacker ; Ipaug. Dissertation, Kiel, 1882. 
Dubosquet: Paris Med., May 15, 1886. 
Edtvards: Internal. Med. Mag., vol. i., p. 242. 
Elliott: Journ. Cutan. and Genito-urin. Dis., 1888, vol. xix. 
Elliott: N. Y. Med Rec., 1891, p. 559. 
Falcone : Rivista Veneta, Venezia, 1887, vii. 
Falcone : Gaz. Degli. Ospitali, February 24, 1886. 
Goltz : Deutsche Med. Wochenschrift, 1880, No. 17. 
Graham : Canadian Practitioner, 1885, p. 33. 
Hartzell: Univ. Med. Mag., 1890. 
Hehn : Centralbl. f. d. med. Wise., 1873, p. 625. 
Henoch: Berlin, klin. Wochensehr., 1874. p. 641. 
Holmes: Bost. Med. and Surg. Journ., 1891, cxxix., p. 481. 
Jamieson : Edinburgh Med. Journ., 1883, p. 1090. 
Johnston : Archiv. fiir Kinderheilkunde, vii., p. 126. 
Juler: Cincin. Lancet, 1878. p. 30. 
Kirsch : Inaug. Dissertation, Greifswald, 1889. 
Klemensiewicz: Silzb. d. k-k. Akad. d. Wiss., July, 1887, Ixxiv., No. 111. 
Lacher: Berlin, klin. Wochensehr., 1885, No. 40. 
Landon : Berlin, klin. Wochensehr., January 12, 1880. 
Lawinski : Berlin, klin. Wochensehr., 1885, No. 31; Ibid., p. 537. 
Leyden: Zeitschr. f. klin. Med., vol. iv., p. 605. 
Lovett: Boston Med. and Surg. Journal, 1890, cxxiii., p. 409. 
Mackenzie: Trans. Path. Soc., London, xl., 403. 
Malgaine : Gaz. des Hopitaux, 1840. 
Matas: New Orleans Med. Journ,, October, 1887. 
Mathieu et Weill : Archiv. gen. de Med., 1885, vol. civ.-clvi. 
Milton : Edinburgh Med. Journ.. 1876, p. 513. 
Mixon : Med. Times and Gaz., February 9, 1878. 
Mumford : Boston Med. and Surg. Journ., vol. exxiv., p. 235. 
Negel: Prog. Med., 1884, p. 846. 
Orville-Horwitz: Med. News, April 10, 1892, p. 432. 
Osler: Amer. Journ. Med. Sci., April, 1888. 
Quincke : Monatschr. f. prakt. Derm., 1882, i. 
Rapin : Revue med. de la Suisse Romande, December 15, 1886. 
Riehl: Wien. Med. Presse, 1888, xxix., 353. 
Rott: Berlin, klin. Wochensehr., 1874, No. 9. 
Simon: Johns Hopkins Hosp. Rep., 1891, p. 339. 
Smith : Medical News, 1889, liv., p. 320. 
Sotnitschefsky : Virchow's Archiv., Ixxvii., p. 85. 
Starr : N. Y. Med. Journ., September 17, 1892. 
Strobing: Zeitschr. f. klin. Med., ix.. p. 389. 
Sydenham: Lectures. London. 1848. 
Troisier: Prog. Med., 1884, p. 3. 
Unna: Monatschr. f. prakt. Dermatol., viii., 446. 
Verneuil et Potain : Archiv. gen. de Med., 1885, p. 656. 
Vulpian : Lejons sur les Vasomoteurs. 
Weill : These de Paris, 1885. 
Weiss : Wien Med. Wochensehr., 1882, No. 14. 
Widonitz: Jahrbuch f. Kinderheilk., 1889, N. F., xxix., 388, xxv., p. 
252. 
Wilcox : St. Louis Med. and Surg. Journ., vol. Iv., p. 273. 
Joseph Collins. 
ANISIC ACID, an isomer of methyl salicylic acid, is 
obtained by the oxidation of oil of anise. It crystallizes 
in brilliant, colorless crystals, slightly soluble in hot 
water, very soluble in alcohol and ether. It forms alka- 
line salts, which are freely soluble. 
It possesses antiseptic and antipyretic properties re- 
sembling those of salicylic acid, but it is free from any 
of its disagreeable effects. 
Locally applied as a powder to wounds or ulcerating 
surfaces it checks the secretion of pus and hastens re- 
pair. 
Internally, the anisate of sodium is employed in all 
conditions in which salicylic acid is used. As an anti- 
rheumatic it is highly recommended. It is easily taken, 
and may be administered in doses similar to those of 
salicylate of sodium. Beaumont Small. 
(SUPPLEMENT.) 
ANTHRAX, SYMPTOMATIC. The bacillus of symp- 
tomatic* anthrax was first obtained, in cultures which 
were known to be absolutely pure, by Kitasato. At first 
he was able to cultivate it only in a liquid medium made 
of the flesh of a susceptible animal f-i.e., bouillon made 
from a guinea-pig. Subsequently ; he was able to culti- 
vate the organism in ordinary neutral agar and gelatin. 
In order to obtain pure cultures he resorted to a special 
form of apparatus, also used in isolating the bacillus of 
tetanus (see under the heading Tetanus). The bacillus 
is an exquisite anaerobe. It will grow in deep stabs, in 
tubes containing a large amount of agar or gelatin, to 
within a finger's breadth of the upper surface. The col- 
onies in gelatin are irregularly spherical, w ith a warty 
surface. Subseqeuntly they have a ray-like zone of 
liquefaction and a dark centre. There is a production 
of gas, with a peculiar penetrating odor. Spores are 
formed at the temperature of the human body in thirty 
hours. These are oval, and have one side somewhat flat- 
tened, and form near to, but not quite in, the centre of 
the rods, which become spindle-shaped. Addition of 
grape-sugar, eikonogen, or other reducing agents to cult- 
ure media, helps the growth of the organism. The 
bacilli have independent motion, but only when they do 
not contain spores. They do not lose virulence on solid 
media, but they do in guinea-pig bouillon. 
Mea.de Bolton. 
ANTOGAST. A thermal and climatic station in the 
Black Forest, Germany. 
Location.-Antogast is situated in a narrow valley of 
the Black Forest of Baden, about 1,500 feet above the 
level of the sea. Fine promenades in the surrounding 
pine woods make the place attractive. The springs are 
alkaline chalybeate ones, containing traces of arsenic. 
The waters are cold and pleasant to the taste. 
Access.-By omnibus from Oppenau, a station on the 
Oppenweier branch of the Baden Railroad. 
Indications.-The waters are used both for baths 
and internally in cases of anaemia, neurasthenia, catarrhal 
affections of the organs of digestion and respiration. 
The Kuranstalt is equipped with modern appliances for 
the various hydrotherapeutic procedures. Season, June 
to October. 
Accommodation.-There is a new7 Trinkhalle and 
some small hotels, and a number of lodging-houses. It 
is a quiet and cheap resort, but quite popular. 
Edmund C. Wendt. 
APOCODEINE is a reddish amorphous powder, almost 
insoluble in water, soluble in alcohol, ether, and chloro- 
form. The hydrochlorate of apocodeine is a grayish 
amorphous powder, very soluble in water. It is ob- 
tained by heating hydrochlorate of codeine for fifteen 
minutes with a concentrated solution of chloride of zinc, 
at a temperature of 170° or 180° C. On cooling, a 
yellowish-brown mass separates from the liquid. This 
is drawn in thin, silk-like threads, and is almost pure 
hydrochlorate of apocodeine. The preparation is easy, 
and there is yielded a much greater product than the 
morphine salt; it is also much more stable. The base 
may be obtained by precipitating it from a solution by 
the addition of carbonate of sodium and extracting with 
ether. 
The reaction of reagents upon apomorphine and apo- 
codeine is almost identical, with the exception that the 
blood-red coloration produced by nitric acid is much 
more permanent with the latter. 
This drug has recently been introduced as an expect- 
orant and emetic. The dose is from to 1 grain. It is 
recommended in the treatment of chronic bronchitis, 
croup, whooping-cough, etc. A one or two per cent. 
* Read symptomatic anthrax for sympathetic anthrax wherever this 
latter occurs in the article Scbizomycetes. See this Handbook, vol. vi., 
p. 336, 2, eleventh line from the bottom. 
t S. Kitasato : Zeitschrift fiir Hygiene, vol. vi., 1889, p. 105, 
Uber den Rauschbrand-bacillns und sein Culturverfahren. 
J Ibid., vol. viii., 1890, p. 55. 
44 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Ang.-Netiro. (Edema. 
Arsenical Paralysis. 
solution may be prepared, and from five to ten minims 
administered. It acts rapidly, and the effect is pro- 
longed. It may also be used hypodermically. 
Beaumont Small. 
ARISTOL is the registered trade name of dithymol- 
diiodide. It is prepared from thymol, C10H13HO, by sub- 
stituting two molecules of iodoxyl, IO, for two of hy- 
droxyl, HO. It contains forty-five per cent, of iodine. 
A moniodid and a triiodide have also been prepared. 
The latter has been called annidalin, and is used for the 
same purposes. Aristol may be made as follows: 1J 
drachm each of thymol and caustic soda and 1| drachm 
of potassium iodide are gently heated with enough dis- 
tilled water to make 1 ounce 4| drachms, and then 
cooled. This solution is added to eight ounces of a con- 
centrated solution of hypochlorite of soda and agitated. 
The solution is then filtered and the precipitate washed 
with water and dried. 
It is a light, reddish-brown powder, with a very faint 
odor, insoluble in water, slightly soluble in alcohol, 
soluble in ether, collodion, and oils. It should be care- 
fully preserved, as it is decomposed by light and heat. 
Therapeutically it is recommended for the same pur- 
poses as iodoform, but it is less active. Its advantages 
are that it is devoid of the disagreeable odor, and does 
not possess the toxic properties of the latter drug. It 
has been used in the treatment of eczema, psoriasis, 
scabies, chronic inflammation of the mucous membranes 
of the nose and pharynx, erosions of the os uteri, condy- 
lomata, granulating wounds, and ulcerating surfaces. It 
possesses the power of causing rapid cicatrization in a 
marked degree, and has proved of greatest service in the 
latter class of cases, particularly in the treatment of 
varicose ulcers. In lupus, tubercular and syphilitic 
ulcerations it was supposed to possess specific powers, 
but experience has not supported this view. 
The powder is best applied by dusting on the part, or 
by insufflation ; it may be used as an ointment, one part 
in ten, or dissolved in ether or collodion. 
As it is partly eliminated through the lungs, it has 
been used in phthisis by hypodermic injections of a one 
per cent, solution in sterilized oil of sweet almonds. It 
is said to lessen the cough and night-sweats. 
Beaumont Small. 
ARSENICAL PARALYSIS.-Paralysis from arsenical 
poisoning has received little attention in treatises on 
nervous diseases. Most classical works on the subject 
do not even mention it. The most recent text-book on 
medicine, by Osler, gives it a short description. And yet 
this, though not the commonest symptom of arsenical 
poisoning, is not very rare. It was spoken of by Albani 
in the thirteenth century, and by others at an almost 
equally early period. Dana,1 in giving the bibliography 
of this subject, cites more than one hundred articles 
published prior to 1887. Since Dana's publication I find 
about fifteen further articles, simply reports of cases, or 
more or less extensive dissertations on the subject. The 
absence of pathological data and the uncertain nosolog- 
ical position of the disease in part account for its ap- 
parent neglect. The last few years have partly removed 
these difficulties. 
Etiology.-The largest number of cases of arsenical 
paralysis are due to acute poisoning, the poison being 
taken either by the mouth, designedly, or accidentally, 
or introduced into the system by external applications, 
as in the use of arsenical plaster. In all such cases the 
paralysis develops subsequently to the appearance of or- 
dinary symptoms of acute arsenical poisoning. Paralysis 
from chronic arsenical poisoning is less frequent, but 
this statement must be accepted as applied to recognized 
arsenical paralysis, for doubtless many cases of chronic 
arsenical paralysis occur which are not recognized as 
such. The largest number of cases of paralysis from 
chronic poisoning are due to the internal administration 
of the drug. In some instances the quantity taken was 
quite small. Semple2 reports the case of a boy of six, 
suffering with chorea, in whom, after the use of from 
three to ten drops of Fowler's solution three times a day 
for one month, there were brown pigmentation of the 
body, paralysis of the legs, chiefly of the toes and feet, 
with reaction of degeneration in the affected muscles 
and loss of the knee-jerks. Two months after the with- 
drawal of the drug the pigmentation had disappeared 
and the paralysis was better. A case of Hastings's,3 who 
had taken three to five drops of Fowler's solution for 
some weeks, had burning pain in his feet and partial 
paralysis of the four extremities. A case of Hooper's3 
took five drops of Fowler's solution three times a day 
for six months. The drug was then discontinued on ac- 
count of ophthalmia, but nevertheless the patient began 
to suffer with headaches and progressive paralysis, and 
died within a few months. Similar cases of paralysis- 
following medicinal doses of arsenic have been reported 
by Jones,3 Gaillard,3 Dana,1 and Ferguson.4 These are 
the only cases in which I have found decided paralytic 
manifestations reported after the internal administration 
of medicinal doses, though less marked nervous disturb- 
ances are more common. It is noteworthy'that in these- 
instances such marked disturbances followed the ad- 
ministration of comparatively small quantities, whereas 
this remedy is so commonly used, often in large doses- 
and for long periods, without toxic manifestations, and 
among the peasantry of Styria, who are accustomed tu 
take arsenic regularly and continuously in quantities or- 
dinarily toxic, no case of paralysis has been recorded. 
We are, therefore, justified in assuming that, in such in- 
stances, there is either some special predisposition to the 
symptoms manifested, or a special idiosyncrasy to the 
drug.* Other modes of chronic poisoning are from the 
external use of arsenic in salves, baths, etc., or contact 
with the poison as used in the arts and found in many 
fabrics employed in clothing, wall-paper, carpets, artifi- 
cial flowers, etc. Barton5 reports two cases, husband 
and wife, with almost typical histories of paralysis fol- 
lowing acute poisoning - first the gastric symptoms, 
then pains and paralysis of the four extremities-where 
the man had for seven years been rubbing a mixture of 
four parts of arsenic to three parts of plaster-of-Paris- 
into the skins of animals and birds, and the wife cleaned 
the room twice a week. Similar cases from dealing in 
stuffed birds, from working with arsenical draperies, or 
living in rooms where there were draperies or wall-paper 
containing arsenic, are recorded by Seeligmueller,8 
M'Clure,1 Holm,8 and Malmsten.8 
Symptomatology.-The symptoms vary to some ex- 
tent, according to the amount of arsenic taken and the 
manner of poisoning, that is, whether it were acute or 
chronic. But where well-marked paralyses have devel- 
oped there is usually considerable uniformity in the clin- 
ical pictures presented. In cases of acute poisoning the- 
paralytic manifestations appear shortly after the disap- 
pearance of the severe gastro-intestinal disturbance. Pa- 
ralysis of twenty-four hours' duration immediately after 
the ingestion of the arsenic has been spoken of, but must 
be rare or escape detection. The onset of the paralysis 
occurs usually from several days to several weeks after 
the poison has been taken. It is commonly preceded by 
sensory symptoms, tingling, numbness, intense pains, 
etc. The paralysis itself begins more or less gradually. 
Not uncommonly its onset is not observed, but when tbe- 
acute symptoms have subsided and the patient attempts 
to get out of bed it is found that he cannot walk or cannot 
hold anything in his hands. Occasionally the paralysis 
is complete, or at least no longer progressive, at an early 
period, but usually some weeks elapse before it has 
reached its greatest intensity. Almost always, when ob- 
served from the beginning, it has been found to com- 
mence at the distal ends of the extremities, the fingers 
and toes-usually first in the lower extremities,-and 
* Jaccoud (Brissaud, Des Paralysies toxiques, 1887) says alcoholic ex- 
cesses constitute one of the most active predisposing causes of arsenic- 
poisoning, but in the study of the literature I have found no cases to 
substantiate this view. According to Putnam, while arsenic is usually 
eliminated in from twelve to twenty days, there are cases in which it is 
found months after it had been taken. Possibly it is this slow elimina- 
tion that favors chronic poisoning from ordinary medicinal doses. 
45 Arsenical Paralysis. 
Arsenical Paralysis. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
thence extends upward. The parts below the knees and 
elbows are most profoundly paralyzed. Some writers 
state that the paralysis does not extend above the knees 
and elbows, but, possibly, in all cases where the paral- 
ysis has been profound, other muscles, especially of the 
thighs, have been at least paretic. I shall report a case 
below where the legs were completely paralyzed and 
even the muscles of the trunk were affected. The ex- 
tensor muscles-the radial group in the upper, and an- 
terior tibial group in the lower, extremities-are as a 
rule most profoundly affected. When the paralysis is 
complete the paralyzed muscles are quite flaccid, and 
we find wrist-drop, foot-drop, etc. At a later period 
there are very frequently contractures, more or less 
strong, affecting particularly the least paralyzed muscles. 
Tremor, often fibrillary in character, is not infrequently 
observed in the affected muscles. The paralysis just 
described, affecting the four extremities, the lower more 
than the upper, is that usually found. In rare instances 
it is otherwise distributed ; sometimes in hemiplegic, 
and more rarely in monoplegic form. In almost all in- 
stances there is a great loss of flesh, a general wasting, 
but in addition there is special and pronounced atrophy 
of the paralyzed muscles. The electrical reactions are 
those of peripheral paralysis. The reaction of degenera- 
tion-no muscular contraction when either current is ap- 
plied to the nerves, or when the faradic current is 
applied to the muscles, contraction of the muscles, but 
a reversal of the normal formula, when the galvanic cur- 
rent is applied to them, that is, the anode closure con- 
traction occurs more readily than the kathode closure 
contraction, and the resulting contractions are tardy, 
sluggish, not the quick, lightning-like contractions of 
normal muscles-becomes more or less pronounced a few 
days, or a few weeks, after the occurrence of the paral- 
ysis. At a later period, if the paralysis be profound, 
all electrical reactions may cease. In some instances 
slight changes in electrical reactions may be observed 
before there is any manifest paralysis, particularly that 
it requires a stronger faradic current than usual to pro- 
duce muscular contractions. In lighter cases such elec- 
trical responses, especially in the anterior tibial group of 
muscles, may be the only indication of incipient paral- 
ysis. 
The sensory symptoms are at times even more pro- 
nounced than the motor paralysis. These symptoms 
are paraesthesiie of various kinds, tingling, numbness, 
" deadness," coldness, etc. ; pains, tenderness, and 
anaesthesiae. As a rule the tingling and numbness, and 
very frequently the pains, precede the paralysis. The 
pains are often intense and the most distressing element 
in the disease. They are usually described as burning, 
cutting, boring, etc., and are often accompanied by sud- 
den starts, cramps, or spasmodic movements of many 
muscles of the body. They are usually more or less par- 
oxysmal, and are likely to be worse at night and keep 
the patient awake. They occur most frequently in the 
feet and hands, sometimes appear to be in the joints or 
bones, and occasionally in the course of the nerves. 
Tenderness of the affected muscles is also a common and 
prominent symptom. The tenderness may be so great 
as to make the handling of the patient extremely painful, 
and, on account of the suffering produced, electrical ex- 
aminations become very difficult. In some instances 
the tenderness is observed to be in the course of the 
nerves, but generally it is so diffused that it is hard to 
state that it is especially over the nerve-tracts. Often 
hypenesthesia or hyperalgesia is observed, although this 
may be only an expression of the great tenderness. Loss 
of, or Impaired sensation, anaesthesia, is also a common 
symptom. It is found most frequently in the feet and 
hands, and especially the finger-tips and toes or soles of 
the feet, although it corresponds somewhat to' the extent 
of the motor paralysis. It has been found to follow the 
distribution of certain nerves. For instance, in a case of 
Seligmueller's it was limited in the upper extremities to 
the distribution of the median nerves. Probably in all 
cases where there is extensive paralysis, anaesthesia oc- 
curs, but it is likely to disappear much sooner than the 
paralysis, so that it may be reported as absent, when 
the patient is seen some time subsequent to the incep- 
tion of the nervous symptoms. Sometimes there is only 
loss of cutaneous sensation-sensation of touch is im- 
paired and the patient cannot feel things with his fin- 
gers, does not know that he is holding something in his 
hands, etc. With the loss of tactile sensation there is 
likely to be loss of the sensation of temperature and 
pain. Sometimes loss of muscular sense is very marked, 
the patient does not know the position of his limbs, etc. 
In all cases of marked paralysis, the patellar tendon re- 
flex, if spoken of at all, was reported to be absent. It 
was also found to be absent, or lessened, when the para- 
lytic manifestations w-ere not very pronounced. When 
once lost, the knee-jerk is slow to return. Various vaso- 
motor and trophic changes are common, as slight oedema, 
particularly of the feet, profuse perspiration, loss of the 
nails and hair, and desquamation of the epidermis. Not 
rarely there is a brownish pigmentation of the skin ; 
even herpes zoster has been observed. Muscular atro- 
phy has already been mentioned. The clinical picture 
would not be complete without the statement of some 
symptoms that are as invariably absent. That is, the 
cranial nerves are never affected, there is no decubitus, 
and the functions of the bladder are always found to be 
intact.* 
As has already been stated, usually several days or 
several weeks elapse before the disease reaches its acme. 
Then, after an interval, which may be of onjy a few 
days' duration, but sometimes runs into months, the pa- 
tient begins to improve. The anaesthesia almost always 
begins to disappear before the motor paralysis. It dis- 
appears in the reverse order of its appearance ; first from 
the trunk and the upper part of the extremities, remain- 
ing longest in the fingers and toes. The motor paralysis 
disappears in the same manner-first in the upper part 
of the extremities, then in the muscles below the knees 
and elbows. The flexors usually improve more rapidly 
than the extensors, leaving the only motor symptoms 
manifested in slight cases, paralysis of the extensors of 
the feet and toes, and of the extensors and small muscles 
of the hand. At a late period there are liable to be con- 
tractures in the still paralyzed parts. The pains also 
become modified in intensity after the lapse of some 
time, but unfortunately they are likely to persist with a 
greater or less degree of severity throughout the whole 
course of the disease. The vaso-motor symptoms, 
oedema, pigmentation of the skin, etc., usually disap- 
pear at a comparatively early period. The whole dura- 
tion of the disease is extremely variable. Alexander 
puts it as from eight days to a number of years. It may be 
stated in general that mild cases usually get well within 
six months, possibly in a few months, whereas in severe 
cases one or two years elapse before there is complete re- 
covery. or, in those cases in which a cure remains incom- 
plete, before there is a definite cessation of improvement. 
Dana has described a form of arsenical paralysis as 
pseudo-tabes, in which ataxic manifestations are promi- 
nent. In a few cases the symptoms of motor incoordina- 
tion are more prominent than those of paralysis, so that 
to these, as there are also sensory symptoms, the term 
pseudo-tabes seems quite appropriate. But ataxia is 
spoken of in many cases after the motor paralysis is 
beginning to disappear, when it is really the remains of 
the paralysis. In fact, a degree of paralysis has been, or- 
is, present in all these cases of pseudo-tabes, distinguish- 
ing it in this respect from true tabes, but it may be in so 
far deserving of a special name as the motor incoordina- 
tion may, in part at least, be due to sensory disturbances, 
impaired muscular sense, etc., which doubtless in part 
explain true ataxia. 
The disease, as so far described, is that following acute 
arsenical poisoning. In some cases following chronic 
poisoning the symptoms are much the same, only the 
* Optic neuritis is spoken of in two cases, that of Dana (Brain, Jan- 
uary, 1887) and of DaCos^a (Medical Times, 1881. p. 385). Putzel 
(Medical Record, June 2, 18S8) merely mentions, without further de- 
tail, that he had seen a case of acute arsenical paralysis in which there 
was paralysis of the bladder and rectum. 
46 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Arsenical Paralysis. 
Arsenical Paralysis. 
■onset is likely to be less sudden and the symptoms less 
profound. In other chronic cases the symptoms are 
very slow in appearing, and may have been in part 
masked by the symptoms of gastric irritation. The 
pains are likely to be proportionately greater, and the 
paralysis slight in degree. But, even when the paraly- 
sis is slight, the changes in the electrical reactions are 
likely to be found. In such instances the motor manifes- 
tations may be rather like those of ataxia than of paraly- 
sis. Sometimes a sense of profound prostration is the 
only indication of motor impairment. 
There is another class of cases in which the poisoning 
appears to have been exceedingly slow and insidious, 
the symptoms usually very obscure, the cause arsenical 
wall-papers or the like. Among the symptoms in these 
instances are, gastro-intestinal irritation, neuralgia, head- 
ache, insomnia, general prostration, mental depression, 
impairment of memory and mental endurance, and epi- 
leptiform convulsions. As this article is devoted to 
arsenical paralysis no further attention will be here given 
to this class. 
In order to illustrate the picture of arsenical paralysis, 
and inasmuch as such cases are comparatively rare, I 
shall give the history of two cases which have come 
under my own observation. The report of the first, of 
which I have few notes, will be necessarily fragmentary. 
A drayman, seventeen years of age, on September 8, 
1886, ate by mistake a piece of bread on which " Rough 
on Rats " had been spread. For four days he had acute 
gastro-intestinal symptoms, vomiting, prostration, etc. 
A few days afterward he was again driving his team, 
though he was feeling very weak. Between two and 
three weeks after the arsenic had been taken he observed 
that his legs were getting weak, and some time later the 
same condition was observed in the arms, though he 
worked for a week after these symptoms began to ap- 
pear. Six weeks after the poisoning he was unable to 
walk alone ; there was paralysis of muscles of the leg, 
■especially of the dorsal extensors of the feet and toes, 
paralysis of the extensors of the fingers, and impaired 
•cutaneous sensation in the same parts. He suffered with 
severe pains in the arms and legs, and there was exces- 
sive tenderness over the paralyzed muscles. He also 
complained of a sense of numbness and tingling in his 
extremities. His hands felt numb ; he could not tell by 
the sense of touch that he had anything in his hands. 
Patellar tendon reflex absent on both sides. The par- 
alyzed muscles did not respond to the faradic current. 
About a month later he had improved so much that he 
was able to walk without assistance. His own statement 
is that he began working nine months after he had been 
poisoned, but he thinks it was fully a year, or a year and 
a half, before he had regained his full strength. At 
present he is again acting as drayman, does heavy work, 
lifts heavy loads, showing a full restoration from the 
disease. Its only traces are that he becomes fatigued 
more easily than before the accident, and is somewhat 
constipated, which had not been his former habit. 
The second case, a man, thirty-five years of age, con- 
tractor, on account of financial losses, took Paris green 
with suicidal intent. He suffered for several weeks with 
violent gastro-intestinal disturbance, and six days after 
the poisoning he became violently maniacal, and remained 
so for several days. It was observed when he got out 
of bed, several weeks after he had taken the poison, that 
he was weak on his legs, and that his hands trembled. 
One week before I saw him, which was seven weeks 
after the poisoning, he became bedridden on account of 
his inability to walk. He began suffering with severe 
pains in his arms and legs, even before the paralysis was 
observed. When I saw him, June 6, 1892, there was 
absolute paralysis of the feet and ankles, muscles flaccid, 
foot-drop, considerable weakness of the extensors and 
flexors of the knee, and some weakness, though less, in 
the hips. The upper extremities were quite paretic ; 
fingers and hands almost paralyzed, pronation and su- 
pination very feeble, the flexors and extensors of the el- 
bows also much weaker than normally, and the muscles 
of the shoulder slightly paretic. 
(SUPPLEMENT.) 
There was more or less anaesthesia in the paralyzed 
parts, most profound in the legs. Over the latter firm 
pressure could not be felt, as far as the gluteal region. 
A pin prick was recognized but was not painful. In the 
upper extremities anaesthesia was most pronounced in 
the hands and back of the forearms. There was con- 
siderable tremor of the fingers on attempted movement. 
Patellar tendon-reflex absent on both sides. All the 
muscles respond to the faradic current, but the left 
peroneal group requires a stronger current than nor- 
mally. There was considerable tenderness over the left 
calf and over both crural nerves. He suffered intensely 
with pains, either burning or boring in character, some- 
times feeling as though the limbs were in a vise, the 
pains being often attended with starts and spasmodic 
movements. The pains were worse at night and kept 
him awake. The muscles of the trunk seemed normal, 
and sensation was normal in the same part. No symp- 
toms on the part of the cranial nerves, bladder, or rec- 
tum. The optic disks were normal. 
June 17, 1892.-No pow er in the legs whatever. Pa- 
resis of the muscles of the trunk and slight anaesthesia. 
Upper extremities weaker than at last note. Some oedema 
of the right fingers. The pains appear to be worse and 
are often attended by spasms, opisthotonic in character. 
A great tenderness over all the paralyzed muscles and 
joints, movements of the joints excruciatingly painful. 
This tenderness makes the electrical examination very 
painful and difficult. Only the left peroneal group of 
muscles was examined. They do not respond to the 
faradic current; the anode closure contraction obtained 
before the kathode closure contraction. 
June 28th.-Sensation decidedly better, pains and 
motor paralysis unchanged. 
July 12th.-Sensation much improved. He has some 
power in the knees and hips, there is increased strength 
in the upper extremities, and the pains are less severe. 
On the date of this writing, November 26th, a little 
over seven months after the date of the poisoning, cuta- 
neous sensibility is normal, or nearly so, everywhere. 
The left arm and hand have almost regained their nor- 
mal strength. In the right upper extremity the fingers, 
especially the extensors, are quite weak ; muscles of the 
elbow have a fair amount of strength, though weaker 
than normal; those of the shoulder are more paretic 
than those of the elbow. In the lower extremities there 
is some power in the muscles of the hips and knees, but 
very slight, while the ankles and feet are still completely 
paralyzed, and the feet are held rather firmly in the 
position of talipes equinus. There is still a little tender- 
ness about the right upper extremity, especially over the 
muscles of the hand, far more over the muscles of the 
legs, though the latter does not compare in intensity with 
what it was some months ago. The pains are also far 
less severe and less frequent. They are still worse at 
night, and often keep him awake. 
Pathology.-Leyden in his classical work on "Dis- 
eases of the Spinal Cord," published in 1875, spoke of 
neuritis as the cause of arsenical paralysis. Subsequent- 
ly a number of writers (DaCosta, Mills, Seguin) attribut- 
ed it to myelitis. Of late years there has been a certain 
unanimity of opinion that neuritis is the real pathology, 
an opinion with some experimental and post-mortem ob- 
servations to substantiate it; but quite recently in one 
case decided changes were found in the central nervous 
system, and it is yet to be seen to what extent the views 
on the subject will thereby be revolutionized. 
The experimental investigations in this direction are 
not all in accord. Popow, experimenting upon dogs, 
produced acute or chronic poisoning by means of larger 
or smaller doses of arsenic, and found thereafter my- 
elitis, especially of the anterior cornua. Kreyssig and 
Schulze, repeating Popow's experiment, did not find 
any pathological changes in the cord. Some control 
experiments, showing how easily methods of harden- 
ing and staining may give the appearance of morbid 
changes in nerve-tissues, lead them to infer that Popow's 
description was, chiefly, of such artificial products. More 
recently, Alexander experimented on rabbits. After pro- 
47 Arsenical Paralysis. 
Artificial Feeding. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
ducing paralysis of the posterior extremities by means 
of arsenical poisoning, he found the cord to be normal, 
while there was extensive neuritis and primary disease 
of the muscles. He attributed the inflammation in mus- 
cles and nerves to the occlusion of innumerable capilla- 
ries, which he supposed were primarily attacked by the 
poison. 
Two post-mortem examinations in man have been 
reported.* The first was a case of Ferguson's.4 The 
patient, a consumptive, took for a lengthy period Fow- 
ler's solution, twenty to thirty drops three times a day, 
which had been recommended as a cure for consump- 
tion, and was not discontinued when diarrhoea and 
headache came on. When seen by Ferguson the face 
was brown and mottled, there was impairment of cuta- 
neous and muscular sensation, tenderness and intense 
pain in the legs, extending to other parts of the body ; 
the gait was paretic, the most marked paralysis being in 
the anterior tibial group of muscles, in which the re- 
action of degeneration could be obtained. She died 
shortly afterward of phthisis. At the post-mortem ex- 
amination evidence of neuritis was found in many of 
the peripheral nerves-the nerve-sheaths and connective 
tissue swollen and infiltrated, the medullary sheaths and 
axis-cylinders broken up-as well as marked degenera- 
tion of the muscles. In the very brief report there is 
also a simple statement of disorganized cells being found 
in the cord. The second case, the one above referred to 
as possibly having a revolutionizing effect on the present 
views of the pathology of this condition, is one of Er- 
licke and Rybalkin's,9 a man of fifty, who died twenty-six 
months after the arsenical poisoning. Shortly after the 
poisoning there was paralysis of the four extremities, 
and at the time of his death-due to a subsequent 
chronic lung disease-there were still paralysis and con- 
tractures in the hands and feet, attendant muscular 
atrophy, pains in the feet, and absent knee-jerks. The 
post-mortem revealed distinct changes in the anterior cor- 
nua throughout the cord-the morbid appearances not 
extending above the pyramidal crossing-especially in 
the cervical and lumbar enlargements, affecting both the 
nerve-cells and the fine net-work of fibres. There was a 
great reduction in the number of cells, both in the ante- 
rior cornua and in the area between the anterior and 
posterior cornua. The cells remaining were not nor- 
mal, their protoplasm was altered, and they were either 
rounded in outline, reduced in size, had fewer processes, 
or were without nuclei. Some cells had vacuoles in 
them, others contained leucocytes. The nerve net-work 
in the anterior cornuse was mostly replaced by fine neu- 
roglia. Of the nerves, only the radial and perineal were 
examined, and presented distinct evidence of neuritis. 
The nerves were found to contain normal and degen- 
erated fibres, as well as regenerated ones. The authors 
conclude that there was a chronic pathological process 
in both cord and nerves, and that it began about the same 
time in each. They suppose that the cause was, not the 
entrance of the poison into the cells, but the changes 
produced by the arsenic in the circulation and the blood. 
The clinical manifestations of arsenical paralysis, and 
it is chiefly upon these that the views of its pathology 
have hitherto been based,f point strongly to neuritis 
as the basis of the paralysis. The paralysis, evidently 
of a peripheral character, with rapid development of 
atrophy, and the reaction of degeneration, as well as the 
sensory symptoms, are very easily explained by neuritis. 
It is true that a poliomyelitis produces the same kind 
of paralysis, but the sensory disturbances cannot be ex- 
plained by poliomyelitis and scarcely by a more dif- 
fuse myelitis. The full restoration to health, as occurs 
in most instances, is altogether at variance with such an 
explanation, and the invariable absence of paralysis of 
the bladder and decubitus, symptoms so common in ex- 
tensive myelitis, is strong evidence that myelitis does not 
account for the symptoms. Furthermore, the occasional 
impairment of a single nerve, as anaesthesia limited to the 
area supplied by the median nerve, and the presence of 
herpes zoster, are proofs that neuritis must be present in 
such instances. In the foregoing is sufficient proof that 
there must be neuritis in these cases, but it does not fol- 
low that we have only neuritis. The post-mortem men- 
tioned, as well as some clinical data, indicates that there 
are, sometimes, at least, also changes in the cord, my- 
elitis. The clinical manifestations force the belief that 
neuritis is the chief and most extensive pathological con- 
dition, and largely the cause of the symptoms, but, it is 
not improbable that in those cases where there is per- 
manent paralysis there has been more extensive myelitis, 
which in itself has produced many, if not most, of the 
symptoms. In the case of Erlicke and Rybalkin, with 
such extensive changes in the cord, the permanent paral- 
ysis was greater than in any other case I have seen re- 
ported. In some cases of chronic neuritis it is probable 
that the latter is due to changes in the trophic centres of 
the cord, and, possibly, a similar relationship exists in 
many cases of multiple neuritis. As arsenical paralysis 
sets in, as a rule, a few weeks after the poisoning, and 
both the post-mortem examination of Popow above given, 
and the frequent occurrence of delirium soon after the 
poisoning, indicate that the central nervous system may 
be affected at a much earlier period, the thought occurs 
that the extensive neuritis in these cases may be really 
due to prior and slighter changes in the cord. With 
this view, morbid changes in the cord would be the rule, 
but they would, usually, be slight and their effects 
transitory. But it is more probable that so far as the 
two conditions, neuritis and myelitis, occur together, 
they are independent of one another, and each due to the 
circulatory and blood disturbances produced by the 
arsenic. 
We may then summarize the foregoing by saying that 
neuritis is the chief pathological condition producing 
arsenical paralysis, that where there is permanent pa- 
ralysis there is more or less extensive myelitis, while in 
curable cases, if myelitis be at all present, it must be of 
a mild grade. 
Diagnosis.-When it is known that the patient was 
poisoned with arsenic, as is usual in acute cases, the 
cause of the resulting paralysis is apparent. When there 
is no such knowledge the history of severe acute gastro- 
intestinal disturbance preceding the kind of paralysis 
just depicted should be almost enough to make the di- 
agnosis certain. The picture of the paralysis is almost 
characteristic : the four extremities usually affected-the 
lower more frequently and more extensively,-the paraly- 
sis being always greatest in the digital extremities and 
attended by atrophy and altered electrical reactions, the 
absent knee-jerks, the intense pain and extreme tender- 
ness, and the absence of bladder symptoms and decubi- 
tus. 
When the paralysis is less marked, and the whole ar- 
ray of symptoms less conclusive, the greater prominence 
of the sensory symptoms and the presence of altered 
electrical reactions in the slightly paralyzed muscles-in 
this instance it requires a very careful examination to 
reveal such reactions-may arouse a suspicion of the true 
condition. 
The cases with ataxic gait may resemble locomotor 
ataxia, and Seeligmueller mentions a case of his own 
which was falsely looked upon as one of locomotor 
ataxia. The severe pains and lost knee-jerks heighten 
the resemblances of the two diseases. But with careful 
examination such errors will rarely occur, for it will usu- 
ally be found that the difficult gait is rather paretic than 
ataxic, and, furthermore, symptoms on the part of the- 
bladder and the eyes, such common and early manifesta- 
tions in locomotor ataxia, are absent. 
* A case of Popow's (Virchow's Archiv, cxii.. 2) should be mentioned, 
though not strictly belonging here, as the man died thirty-two hours 
after the poisoning. The vessels of the cord were distended, there were 
numerous smaller or larger hemorrhages into the cord, and, in some 
parts, plastic exudation, the changes being chiefly in the cervical and 
dorsal regions, especially their central parts. Some cells were clouded, 
their nuclei indistinguishable, and were nearly or altogether without 
processes. 
t The similarity of the clinical picture to that of alcoholic neuritis has 
also furnished a strong ground for pronouncing this neuritis. But it has 
recently been denied that all the lesions in alcoholic paralysis are periph- 
eral ones. 
48 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Arsenical Paralysis. 
Artificial Feeding. 
In cases of chronic poisoning the detection of arsenic 
in the urine may assist materially in diagnosis. In acute 
cases the arsenic has usually been eliminated before or 
soon after the paralysis appeared. 
Prognosis.-Mild cases may get well in a few months, 
though rarely less than six, but when there has been pro- 
found paralysis recovery cannot be expected in less than 
one or two years. 
The prognosis is always favorable in so far that most 
cases recover, and all, if they survive, improve very 
much, but there is prevalent a too favorable opinion of 
the curability of the disease. For instance, Dana says 
almost all cases recover. I have carefully examined all 
the reports of cases made in recent years ; twenty-two in 
number. Of these, two died, two recovered, and the 
other eighteen were still uncured at the time of the re- 
ports, from two months to several years after the incep- 
tion of the paralysis. It may be assumed that of those 
reported at an early period most, or all, recovered. But 
a number were reported after more than a year had 
elapsed, and in four cases-those of Putzel,11 Peterson,10 
Erlicke and Rybalkin9-after a lapse of two years or 
more, paralysis, more or less extensive, remained, indi- 
cating permanent impairment. 
If we can draw any conclusions from such small num- 
bers we may say that in twenty per cent, of the cases, or 
more, there will not be full restoration to health. I have 
already ventured the opinion that in the latter cases my- 
elitis is present. 
Treatment.-The first object must be to eliminate the 
arsenic from the system as rapidly as possible, for which 
purpose iodide of potassium seems to promise most, and 
has been almost universally used in such cases. Only 
moderate doses are indicated. Leyden suggests warm 
and sulphur baths. For the pains, often excruciating, 
opium or morphia is demanded. 
Further than this the indications are, the toning of the 
general system-for poor nutrition and great prostration 
are rarely missing-by careful feeding, strychnia, iron, 
and the direct treatment of the paralysis by electric- 
ity, massage, counter-irritation, etc. It can scarcely be 
doubted that in the most cases the tendency is to recov- 
ery, and the patient gets well quite irrespective of treat- 
ment. Philip Zenner. 
1 Bram, January, 1887. 
2 The Lancet, June 14, 1887. 
3 Quoted by Putnam, Boston Medical and Surgical Journal, July 5, 
1888. 
4 Canada Medical and Surgical Journal, July, 1887. 
6 The Lancet, July 19, 1890. 
6 Dent. Med. Wochensch., 1881, p. 217. 
7 The Lancet, June 22, 1889. 
8 Quoted by Seeligmueller. 
9 Archiv f. Psych, ii Nervenkr., xxiii., p. 861. 
10 Medical Record, August 4, 1888, and personal communication. 
11 Medical Record, June 2, 1888. 
ARTHRITIS DEFORMANS. In the differential diag- 
nosis it is important to keep in mind that this disease, 
beginning its destructive work with the articular carti- 
lage, and progressing without suppuration, will lead to 
gradual but very considerable diminution of the articu- 
lating surfaces, and to osseous proliferation with ex- 
crescences at the periphery of the joint. The form and 
shape of the affected joint, particularly of the caput fe- 
moris, will consequently be considerably altered, flattened 
sometimes like a mushroom, but the mobility is generally 
not abolished, and anchylosis, as we see it in certain cases 
of chronic rheumatism, does not occur. While at the 
commencement of the disease it will often be difficult to 
distinguish the same from chronic rheumatism, a correct 
diagnosis will be obtainable later on. Arthritis urica, 
real gout, which produces alterations of the small joints 
of the hands and feet, similar to those made by arthri- 
tis deformans, has its periodical, often intensely pain- 
ful, paroxysms, quite different from the mild exacerba- 
tions of arthritis deformans. 
Aside from the great value of prolonged and often re- 
peated plain warm baths at home, or in thermal water- 
ing places, in the general management of the disorder, 
steam-baths, steam - douches, sulphur- and mud-baths 
may also be used. In overcoming or correcting and im- 
proving contractures and false positions, and relative im- 
mobility of the joints, it is well to employ massage and 
mechanico-therapeutics, the action of which may again 
be supported and maintained by orthopedic apparatus. 
Intercurrent exacerbations are to be treated by mild an- 
tiphlogistics and counter-irritants. In extreme cases of 
deformity the question of surgical interference, i.e., re- 
section of joint, might come up, but there is not as yet 
sufficient experience to serve as a guide in that direction. 
Leonard Weber. 
ARTIFICIAL FEEDING OF INFANTS. During the 
past few years the subject of the artificial feeding of 
infants has still claimed much attention from the profes- 
sion, both in Europe and in this country, and several 
distinct advances may be noted. The various lines of 
investigation mentioned in my previous article, Vol. 
VIII., had made us aware of many of the difficulties 
which lay in the way of obtaining a perfect substitute for 
mother's milk. Cow's milk, or some preparation of it, 
was universally regarded as the only efficient basis for a 
good working substitute, and it was hoped that the 
difficulties, which had previously been encountered in its 
administration, could now be overcome. At the date of 
the previous paper the situation might be briefly stated 
as follows : 
1. Our more definite knowledge of the chemical com- 
position of the two milks enabled us to alter the substi- 
tute so as to render it the chemical analogue of mother's 
milk. 
2. By means of the process of sterilization at the tem- 
perature of 212° F., we were able to secure a practically 
sterile food, and thus to avoid the introduction of myriads 
of bacteria, with all their poisonous possibilities, into the 
infant's stomach. 
3. Our more exact knowledge of the capacity of the 
infant's stomach enabled us to regulate the proper amount 
of food to be given at a time, and thus to guard against 
the evils of over-feeding. 
Thus, theoretically, we appeared to be able to supply 
the infant with an ideal food, a close approximation in 
chemical 'composition to mother's milk, absolutely sterile, 
in proper amounts, and at sufficient intervals to insure 
due digestion and nutrition. In practice these measures, 
carefully carried out, yielded gratifying results in some 
cases, but in many others hopes were disappointed. 
Among those reporting results we may mention Dr. 
Koplik,1 of New York, who, with a large experience 
among dispensary patients, found milk thus prepared and 
sterilized of distinct benefit in acute cases, but was dis- 
appointed with the results obtained in chronic cases of 
gastro-intestinal disease. Dr. Davis,2 of Philadelphia, 
found nutrition under its use distinctly fail. Corroborat- 
ing this clinical experience were the results obtained by 
Dr. Leeds 3 from investigations in the laboratory on the 
changes produced in milk by the prolonged heat necessi- 
tated by this absolute sterilization. His results were 
stated as follows : 
1. The starch - liquefying ferment, galactozymase, 
which exists in normal cow's milk in minute quantities, 
is destroyed when the heat rises much above 165° F. 
(75° C.). 
2. A portion of the lactalbumin is coagulated, thicken- 
ing the milk and intensifying its colloidal properties. 
3. The casein, after the action of the prolonged heat, is 
less readily coagulated by rennet, and yields only slowly 
and imperfectly to the action of pepsin and pancreatin. 
4. The fat-globules are injuriously affected by this 
heat. The fat, to some extent, is freed, and, after stand- 
ing, small lumps of butter-fat are sometimes observed on 
the'surface of the milk ; while the portion not freed has 
a decidedly lessened tendency to coalesce. This is pos- 
sibly owing to the coagulated proteid matters attaching 
themselves to the minute fat-globules, thus preventing 
their coalescence. It was also found that when sterilized 
and unsterilized portions of milk were churned, and a 
note made of the time required to form appreciable 
49 Artificial Feeding. 
Artificial Immunity. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
amounts of butter, the unsterilized yielded a larger 
amount in considerably less time than the sterilized. 
5. Milk-sugar by long-continued heating is completely 
destroyed ; that it undergoes some change during the 
process of sterilization, is shown by a lessened dextro- 
rotatory power. 
It would appear, therefore, that milk sterilized for any 
prolonged period at a temperature of 212° F. must be 
regarded as distinctly less readily and less perfectly 
digestible than raw milk. The destruction of the galac- 
tozymase, the coagulation of the lactalbumin, and the 
alteration of the casein, so that it becomes more slowly 
acted on by rennet, all presumably diminish its digest- 
ibility by the gastric juice of the infant; while the 
changes in the fat-globules can be shown to interfere to 
a large extent with their digestion and assimilation. 
The question arose, therefore, whether it was not pos- 
sible to avoid the disadvantages of this prolonged and ab- 
solute sterilization, and yet obtain a practically sterile 
food, the importance of having such being recognized on 
all sides. This was answered in the affirmative by Dr. 
Leeds. He found that milk rendered feebly alkaline, and 
heated, as soon as received in the morning, to a temper- 
ature of about 155° F. (somewhat short of the degree of 
heat necessary to coagulate the galactozymase) is rendered 
practically sterile. " It is evident,'' he says, " in the first 
place, that no milk having an acid reaction is in a proper 
condition to be heated, because of the effect of acidity 
upon coagulation, and inasmuch as cow's milk, as deliv- 
ered to consumers, has usually developed a notable 
acidity, the addition of the requisite amount of a suitable 
alkali is the first point to be considered." 
By experiments he found that to neutralize this acidity 
it required about 2^ grains sodium carbonate, or 9 
drachms ordinary lime-water, to the pint of milk. Even 
this appeared to limit the development of some of the 
bacteria. Dr. Leeds says : "On making gelatine-peptone 
cultures, one drop of the original milk yielded 400 col- 
onies of bacteria after five days' culture at, common 
temperatures, while the same milk rendered feebly 
alkaline with lime-water yielded only 250 colonies. In 
some other experiments that he quotes the result was 
even more striking. After the milk was thus rendered 
slightly alkaline he tried the effects of lower- temper- 
atures. It was found that such milk maintained at a 
temperature of 155° F. (68° C.) for an hour proved prac- 
tically sterile. Shorter periods were then tried, and an 
equally good result was obtained at the end of twenty 
minutes (only one to two colonies per drop). On cooling 
and diffusing the cream, which the heating had brought to 
the surface, the appearance and properties of the milk 
thus heated and prepared in nowise differed noticeably 
from raw milk. 
A difficulty arises in securing the proper amount of 
heat, if we are to have this degree of sterilization carried 
on in the household. At my suggestion, a series of 
experiments were made with milk contained in glass 
flasks and heated in an Arnold sterilizer. It was found 
that with the water in the sterilizer and the milk in the 
flasks at ordinary temperatures, on placing the sterilizer 
over an ordinary Bunsen gas-burner it took about twelve 
minutes for the milk in the flask to reach the temperature 
of 155° F. If now the gas be turned out, and the milk 
be left in the sterilizer for another ten minutes and then 
removed to a cool place, all the sterilization necessary 
will have been effected and none of the deleterious 
changes will have taken place. 
More lately, however, Dr. Freeman,4 of New York, has 
devised a very simple apparatus, by which the milk to 
be sterilized is immersed in water at the boiling-point, 
the amounts being so proportioned that as the temper- 
ature of the water is lowered the milk is raised to the 
necessary heat of 165° F. The apparatus consists of two 
parts, a pail for the water and a tray containing a set of 
zinc cylinders which are to hold the bottles of milk. The 
pail is a simple tin pail with a cover. On its side is a 
groove indicating the level up to which it is to be filled 
with water. The tray is made in two sizes; one which 
will hold ten six-ounce bottles, the other seven eight- 
ounce bottles. The first is suitable for infants below six 
months of age, the second for those older. The pail is 
tilled with water up to the groove, and placed on the 
stove to boil. The bottles are filled with milk and 
stoppered with a pledget of cotton, and then dropped into 
their places in the cylinders. Sufficient water is now 
poured into each cylinder to surround the body of the 
bottle. This is necessary for the conduction of the heat. 
When the water in the pail boils briskly, it is taken 
off the stove, and placed on a mat or table ; the lid 
is removed, the tray containing the bottles of milk is 
placed inside and the lid replaced. The whole is al- 
lowed to stand half an hour, after which the bottles of 
milk are to be taken out and cooled rapidly, either by 
placing them on ice in a refrigerator, or by standing them 
in cold or ice water, which should be changed occasion- 
ally as it becomes heated. Milk thus prepared shows no 
change for several days. 
Air. Dyer, a pharmaceutical chemist in this city, has 
made a sterilizer for me, according to these instructions, 
and, after careful experimentation to obtain the correct 
size, has furnished me with the following dimensions: 
The tin pail should be inches deep, 10£ inches in 
diameter, 5J inches to water-line. The zinc cylinders 
should be €4 inches deep, 2f inches in diameter. There 
are seven cylinders in the tray ; the bottles of milk hold 
eight ounces each. With the milk and the water in the 
zinc cylinders at a temperature of 65° F., the following 
is the memorandum of the temperatures obtained in this 
apparatus : 
In ten minutes the milk in the bottle reached the aver- 
age temperature of 164° F. ; in twenty minutes, 166° F. ; 
in thirty minutes, 164° F. ; in forty minutes, 161° F. ; 
in fifty minutes, 158° F. ; in sixty minutes, 154° F. 
Dr. Freeman in his paper says, " I have made a series 
of experiments at the Bacteriological Laboratory of the 
College of Physicians and Surgeons, to test the efficiency 
of this apparatus in the pasteurization of milk. Speci- 
mens of milk obtained from different sources and at dif- 
ferent times have been examined to determine the num- 
ber of bacteria contained in one cubic centimetre before 
and after pasteurization. And while the raw milk used 
contained from 8,000 to 230,000 to each cubic centimetre, 
the same milk after this pasteurization practically con- 
tained none." This process he finds quite sufficient to 
destroy most of the ordinary bacilli found in milk, and 
tubercle bacilli. He quotes Van Gruns as stating that it 
also kills the typhoid bacillus, the cholera bacillus, and 
the pneumococcus of Friedlander. It does not appear 
in any way to affect the milk. 
Dr. Rotch,® of Boston, has reduced the artificial feeding 
of infants to a still more exact system. As the result of 
much clinical experience he concludes that slight changes 
in the percentages of the three elements of milk of which 
we have the most accurate knowledge, namely, the fat, 
sugar, and albuminoids, are of real practical value in 
managing the digestion and nutrition of the infant. 
Infants, like adults, require special modification in 
their food to suit the particular digestion of the individ- 
ual. To prove this he presented the analyses of several 
human milks. In these analyses the fat, sugar, and al- 
buminoids varied to a marked degree, and yet the in- 
fants all digested and throve well on their special per- 
centage, while what agreed with one produced at times 
serious symptoms in another. He considered, therefore, 
that, so far as milk is counted upon as a food, it should 
be understood as a general name for a composite meal, 
the special ingredients of which should be modified to 
suit the digestion of the individual infant. To obtain 
this possibility Dr. Rotch established a milk laboratory 
where physicians could send prescriptions for milk of a 
definite formula, and have them dispensed accurately. 
The milk used in this laboratory is obtained from a herd 
of cows, of special breed, and so systematically fed that 
the analysis of their milk is of almost unvarying percent- 
age. The morning milk of these cows, milked into glass, 
and kept scrupulously clean, is rapidly cooled, and is 
delivered at an early hour at the laboratory. Here, by 
means of a separator, a stable sixteen per cent, cream is 
50 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Artificial Feeding. 
Artificial Immunity. 
separated from the milk. The amount of albuminoids 
in the separated milk is known, and by means of a sug- 
ar-of-milk solution of definite strength, the amount of 
the sugar is carefully adjusted. As the chemistry of the 
mineral matter in woman's milk is little known, for the 
present that element is ignored. In writing a prescrip- 
tion, therefore, the three average percentages, namely, 
those of the fat, sugar, and albuminoids-4, 7, and 1.50- 
have only to be remembered, and starting with these 
figures any of the ingredients can be increased or de- 
creased according to the need of the special infant. 
In dispensing the prescription, the superintendent of 
the laboratory from the above materials is able, by a 
comparatively simple calculation, to dispense a milk con- 
taining the exact proportions ordered. The quantity re- 
quired for each feeding is placed in bottles corresponding 
in number to the number of times that the infant is to be 
fed in the twenty-four hours. The day's food, each 
feeding in its own bottle, is then placed in a basket, or 
suitable receptacle, and sterilized for half an hour at a 
temperature of 167° F. It is then ready to be sent out to 
the infant. When the time for feeding arrives, the nurse 
takes a bottle from the basket, warms it, replaces the 
stopper by a suitable nipple, and gives it to the infant. 
The following are given by Dr. Rotch as examples of 
suitable prescriptions for infants at varying ages, and 
under varying conditions : 
1. For a healthy baby, four months old and normal 
weight, milk to be of following composition: 
Fat 4.0 
Milk-sugar 7.0 
Albuminoids 1.0 
Send six tubes, each four ounces, with lime-water one- 
twentieth. To be sterilized at 167° F., for twenty min- 
utes. Feed every three hours. 
2. For the same baby sick, albuminoid digestion weak, 
as evinced by vomiting, colic, and curds seen in the de- 
jections, milk of following composition : 
Fat 3.0 
Milk-sugar 6.0 
Albuminoids 0.50 
Send eight tubes, each containing three ounces, with 
lime-water one-tenth. Sterilize as above. Feed every 
three hours. 
3. For an infant six months old in whom the sugai di- 
gestion is weak, milk of following composition : 
Fat 3.0 
Milk-sugar .. 4.0 
Albuminoids 2.0 
Send six tubes, each containing six ounces, with lime- 
water one-twentieth. Sterilize as before. Feed every 
three hours and a half. 
4. For an infant twelve months old with duodenal 
jaundice, milk of following composition : 
Fat 0.50 
Milk-sugar 5.00 
Albuminoids 4.00 
Send five tubes, each containing eight ounces, with lime- 
water one-eighth. Sterilize as above. Feed every four 
hours. 
The exact capacity of the infant stomach, as regulating 
the quantity of food to be allowed at each time of feed- 
ing, is a matter of much importance. At the meeting of 
the American Pediatric Society in 1890, Dr. L. Emmett 
Holt6 read a paper on this subject, in which he gave the 
result of his observations at one hundred and forty-two 
autopsies. Very careful precautions were taken to in- 
sure as accurate data as possible. The measurements 
obtained in ninety-one cases he tabulates as follows ; the 
others, most of them his earlier cases, being discarded on 
account of imperfections in the methods employed :- 
(SUPPLEMENT.) 
Table showing Average Capacity of the Stomach in Ninety- 
one Cases. 
Age. 
Number 
of cases. 
Average capacity. 
Ounces. 
Birth 
5 
1.2 
Half month 
7 
1.5 
One month 
4 
2.0 
One and a half month 
11 
2.27 
Two months 
4 
3.37 
Two and a half months 
2 
4.25 
Three months 
6 
4.50 
Three and a half months 
3 
5.00 1 
Four months 
4 
5.02 > = 5 average. 
Four and a half months 
5 
Five month- 
4 
5.02 ) 
Five and a half months 
2 
5.25 > = 5.75 average. 
Six months 
8 
5.94 ) 
Seven months 
« 
7.00 I c QC 
Eight months 
3 
(> f - 6.88 average. 
Nine months 
Ten months 
5 
8.40| 
Eleven months 
2 
7 60 C - average. 
Twelve months 
1 
9.00 
Thirteen months 
4 
8.75 > = 8.9 average. 
Fourteen months 
5 
9.00 ) 
These facts he summarizes as follows : 
1. A very general correspondence between the age and 
capacity of the stomach is clearly shown. 
2. Starting at birth with a capacity of about one ounce, 
the stomach increases in size, at the rate of one ounce a 
month during the first three months, reaching at this 
time about one-half the capacity seen at one year. 
3. From three to eight months its growth is much 
slower, being on an average half an ounce a month. 
4. From eight to fourteen months the rate of growth 
is still less, being on an average about one-third of an 
ounce a month. 
These statements of course express only averages, and 
it is to be expected that unusually large, or unusually 
small, children will be either a little above or a little be- 
low these figures. Dilatation of the stomach in healthy 
infants appears to take place readily. 
We may safely infer that the amount of food to be 
given at a single feeding should not much exceed the ca- 
pacity of the average stomach at that age, as it does not 
seem at all likely that any considerable portion of the 
food leaves the stomach during the few minutes that 
elapse while the infant is feeding. Dr. Holt also found 
by experiment with stomach-washing that in infants of 
one or two months, with apparently good digestion, two 
hours usually elapsed before all the milk left the stomach; 
in infants of five to eight months, the time required was 
generally about three hours. It is evident, therefore, 
that no feeding should be repeated short of these periods, 
and it is better in most instances to allow a short interval 
of rest. A. D. Blackader. 
1 New York Medical Journal, January 31. 1891. 
2 Am. Journal of the Medical Sciences, June, 1891. 
3 Ibid., June, 1891. 
4 New York Medical Record. July 2. 1892. 
5 Trans. Am. Pediatric Society, 1892. 
• Ibid., 1890. 
ARTIFICIAL IMMUNITY. In the study of immunity 
trom infectious diseases two questions present them- 
selves, viz. : How to explain natural or racial immunity 
on the one hand, and acquired or individual immunity 
on the other. In the first place, how is it that in some 
cases a whole race of animals enjoys immunity from a dis- 
ease which kills other animals ; why is it that certain 
human races are exempt, or nearly so, from diseases 
which carry off thousands of individuals of other races? 
In the second place, how is it that susceptible individu- 
als on recovery from an attack often acquire immunity 
from a disease ? It is clear that where animals are ex- 
posed alike to infection, those which do not take the dis- 
ease must have a natural or acquired power of resisting 
the attacks of the micro-organisms, and the problem is 
to find out wherein this power lies. In times of an epi- 
demic the micro-organisms of a disease must surely find 
51 Artificial Immunity. 
Artificial Immunity. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
entrance into insusceptible as well as susceptible races 
of animals or individuals of the same race, in one case 
doing no harm and in the other producing disease. Why 
do they find unfavorable conditions for their growth in 
one case and not in the other ? How does the immune 
race differ from other races, and the immune individual 
from susceptible individuals ? 
Two explanations have been offered for the first of 
these questions, but neither of them has been generally 
accepted as sufficient. One of these is advocated by 
Metchnikoff, and bears the name of Metchnikoff's 
phagocyte theory. According to this theory the white 
corpuscles of the blood eat up the bacteria, and in 
animals which have no blood the cells of the connec- 
tive tissue destroy the bacteria. Metchnikoff 1 bases his 
theory upon a large number of experiments with differ- 
ent micro-organisms on a great variety of animals. He 
found that in sponges, mollusks, daphnise, and earth- 
worms, also in frogs, and in rabbits and other mammalia, 
the introduction of small foreign bodies, such as car- 
minegranules, or bacteria, was followed by a massing to- 
gether of the cells, and that these cells either take up 
the foreign bodies, or surround them. He also verified 
the observation often made previously, that destructible 
foreign bodies become dissolved and disappear in the 
interior of the cells which have taken them up. This 
theory has attracted a great deal of attention, but has 
been shown, to be inadequate. As pointed out by Zieg- 
ler and others the cause of the massing of leucocytes 
about a foreign body is not due to an intentionally defen- 
sive attitude on the part of the animal tissues. Certain 
substances have the power of attracting leucocytes by so- 
called chemotaxis,2 and any foreign bodies which happen 
to lie in the path of the wandering leucocytes are taken 
up by these, and may be assimilated. The chemical and 
physical characters of the tissues and juices determine 
the direction in which the leucocytes wander, and if the 
leucocytes are not actively attracted in one direction they 
wander in the direction of the least resistance. If they 
are repelled or lamed by the chemical character of a 
foreign body, they are actually driven away or remain 
stationary instead of grouping themselves around the for- 
eign body. The idea of an active warfare between bac- 
teria and leucocytes, i.e., phagocytes, must therefore be 
abandoned. Phagocytosis is a frequent but not charac- 
teristic partial phenomenon of inflammatory processes, 
and not always has the same significance. In some 
cases phagocytosis results in the destruction of foreign 
bodies, such as bacteria. In other cases it results in the 
spreading of the disease to different parts of the body, as 
in leprosy and mouse septicaemia, where the bacilli grow 
specially well in the leucocytes, and become subsequently 
liberated. Phagocytosis must consequently be regarded 
as merely an incidental process which is often useful, 
but not always so. 
The germicidal properties of the serum of the blood 
devoid of the cells has also been offered as an explana- 
tion of natural immunity. Nuttall, v. Fodor, Buchner, 
and others have demonstrated the powerful germicidal 
properties of extra-vascular blood-serum, and there is 
every reason to believe that the serum in the animal has 
the same power. This is a most important discovery, 
but it does not suffice to explain immunity. If natural 
immunity were to be explained in this way, it is evident 
that the blood-serum of the immune animals should pos- 
sess germicidal properties, and the blood-serum from sus- 
ceptible animals should be devoid of these properties ; 
animals should be immune just in proportion to the de- 
gree of the germicidal power possessed by the blood- 
serum. Such, however, is not always the case. The 
blood-serum of a susceptible animal often has as much 
germicidal value as serum from an immune animal. 
This property of the blood varies, it is true, and in some 
cases there does seem to be a direct proportion between 
the extent to which the blood-serum possesses the power 
of killing the bacteria on the one hand and the degree of 
immunity on the other. 
It is evident from the foregoing that natural immunity 
is at best but imperfectly understood. On the other 
hand, artificial or acquired immunity from certain dis- 
eases has recently been made the subject of a great 
amount of experimental research, and many important, 
facts in regard to it have been established. 
It is now known that in this kind of immunity the 
fluid portion of the blood, the blood-serum, acquires tlie- 
power of neutralizing the disease-producing property of 
certain micro-organisms. This power of the serum of 
the blood is acquired on inoculating with cultures of the 
micro-organisms treated in a special manner beforehand, 
the details of which are given below. Blood-serum 
which has acquired this power not only protects the ani- 
mal in which it is formed, but it also protects or cures- 
other animals when drawn and injected into these. The 
protective property lies in the serum of the blood and 
not in the corpuscles. 
Immunity that has been conferred in the manner re- 
ferred to above is also transmitted to the offspring by the 
mother. Such offspring not only acquire a certain 
amount of immunity while in utero, but they derive a 
still larger amount from the mother's milk. 
The establishment of these facts is largely due to 
the investigations of Brieger, Kitasato, and Wassermann, 
working together, of Behring and his colaborateurs, and 
Ehrlich. The first of these, Brieger, Kitasato, and Was- 
sermann, emphasize the distinction between infection and 
intoxication as first made by Koch. Whether the dis- 
tinction can be sharply drawn in all cases or not, it is 
important for the understanding of their work to know 
just what is meant by these terms. The definition be- 
low is essentially that given by these authors. 
In infection the micro-organisms of a disease gain en- 
trance into the body of a susceptible animal, it may be 
in very small numbers, and spread and multiply through 
all the tissues and organs of the animal, plugging up 
capillaries, depriving the parts of oxygen, and offering a 
mechanical hindrance to the functions of life. In intox- 
ication the micro-organisms when inoculated in small 
quantities often produce no disease ; they tend to remain 
more or less confined to one part of the body, their seat 
of multiplication is localized ; they often do not spread 
to other parts, and are sometimes incapable of growing 
except on certain tissues ; but once having formed a. 
focus they produce a poison which is the cause of the 
disease. There are two kinds of these poisons found in 
cultures of bacteria, viz. : ptomaines and toxalbumins. 
The ptomaines are crystalline alkaloidal bodies ; the tox- 
albumins are colloidal. The former were obtained first 
by Brieger, the latter by Brieger and Fraenkel working 
together, and appear to be the disease-producing constitu- 
ents of pathogenic cultures. Animals inoculated with 
them alone show the same symptoms as animals inocu- 
lated with ordinary cultures. 
The micro-organisms of anthrax produce a typically 
infectious disease. They find entrance into the body, 
possibly in very small numbers and only at one minute 
spot, but if the animal is susceptible they rapidly spread 
to all parts, so that in one day or less they can be found 
with the microscope in the smallest drop of blood drawn 
from any part of the body, and from the smallest bit of 
any of the soft tissues. The organisms of tetanus, typhoid 
fever, diphtheria, and cholera, are examples of the bac- 
teria which produce intoxication. They set up a local 
disease at first, but sooner or later produce specific poi- 
sons which cause general intoxication. They are some- 
times found in parts of the body remote from the point 
of original infection, it is true, but not in sufficient num- 
bers or so widespread as to account for the general symp- 
toms of the disease, and moreover, the symptoms are 
those of profound intoxication. In tetanus the local 
trouble is often very insignificant and the number of tet- 
anus bacilli, even at the point of infection, surprisingly 
small, often disappearing entirely before the death of 
the animal. In diphtheria the bacilli are usually con- 
fined to the throat, though they have been found dis- 
tributed through the blood in other regions of the body. 
Typhoid fever bacilli are found in the spleen and 
blood, but are found most extensively in the ulcers of 
the large intestines. Cholera bacilli are found for the 
52 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Artificial Immunity. 
Artificial Immunity. 
(SUPPLEMENT.) 
lowed to act for a short time, or if used in relatively small 
quantities, will produce attenuation. Carbolic acid, in 
the strength of 1 to 600, deprives anthrax cultures of all 
virulence without killing the organism if allowed to act 
on the cultures twenty-four days. Bichromate of potas- 
sium, if used in solution of 1 to 1,700 of water, kills an- 
thrax bacilli; if used in more dilute solution, 1 to 2,000 
or 1 to 5,000, it weakens the virulence of these bacilli 
to such an extent that they will no longer produce the 
disease in sheep, but are still capable of killing guinea- 
pigs and rabbits. Again, cultures of anthrax bacilli may 
be attenuated by subjecting them to temperatures be- 
tween 42° and 55° C. for lengths of time varying from 
ten minutes to four weeks or more, the length of time 
varying in inverse ratio to the degree of heat. A com- 
bination of heat with the action of chemicals on the 
cultures has also been successfully used. But whatever 
method is employed, the object is the same, viz.: to ob- 
tain cultures which produce on inoculation little or no 
disturbance in the health of the animal, but enable the 
latter to resist more and more virulent cultures, to bring 
about such a condition that the micro-organisms are in- 
capable of growing in the tissues of the animal. Recent 
experiments of Brieger, Kitasato, and Wassermann have 
shown, however, that with anthrax increased resistance, 
but not full immunity, may be produced in this way. 
Animals so treated resist inoculations of somewhat 
weakened hut still virulent cultures, but they succumb 
without fail to inoculations with tissues of animals dead 
of anthrax. In mouse septicaemia complete immunity 
can be produced by combining these methods with 
those described below for the toxic diseases, making the 
animals so treated incapable of infection, and also poi- 
son-proof. 
The bacterial protei'ds or toxalbumins are unstable and 
easily destroyed. This might lead to the supposition 
that they can be as readily destroyed within the animal 
body as outside, but such is not the case. Many of the 
chemical and physical means so efficacious in rendering 
cultures harmless are either inapplicable or powerless in 
the animals. Some of them, however, give good results. 
The efficacy of Pasteur's inoculations for hydrophobia 
will now probably be universally conceded. The etiology 
of this disease is still obscure ; there is every probability 
that it is caused by a micro-organism, but this has not yet 
been discovered. Pasteur found that the poison of hy- 
drophobia is contained in greatest amount, if not ex- 
clusively, in the central nervous system, and moreover 
that the surest way to produce the disease is by subdural 
application of cerebro-spinal substance from an animal 
suffering from rabies. Animals inoculated in this way 
always have violent hydrophobia in from fourteen to 
twenty-one days. The virulence of the material is weak- 
ened by passage through apes, but is increased on passage 
through rabbits. By inoculation from rabbit to rabbit 
through forty or fifty of these animals successively, Pas- 
teur obtained a " virus fixe" which had a period of in- 
cubation of only seven days, and differed from ordinary 
" street hydrophobia " not only in the shorter period of 
incubation, but also in that it produced the disease on 
subcutaneous injection. A series of exactly graduated 
virulence was obtained by successive inoculations of the 
material which had been weakened by passage through 
an ape. By inoculations with the series so obtained dogs 
were given immunity. Pasteur subsequently changed 
this method of attenuation, and has used it for several 
years upon human beings. The method Pasteur now em- 
ploys consists in using the dried spinal cord of animals 
suffering from rabies. It was observed that the spinal 
cord of such animals gradually loses its virulence if dried 
at 20° C., and ceases to act if dried for sixteen or eighteen 
days. Starting with cord that has been dried for fourteen 
days, the injections are made in more or less quick suc- 
cession, often several a day. till material of full virulence 
is used. The injections are made in the abdominal wall 
above the groin. 
Koch prepared a lymph which was successfully used 
in some cases of tuberculosis. This lymph, or tubercu- 
lin, was made by extracting cultures of tubercle bacilli 
most part exclusively in the intestines, but occasionally 
also in the stomach. The bacteria of these diseases are 
therefore seen to have a tendency to remain localized. 
The general symptoms are brought about by poisonous 
products which these bacteria produce. It is not even 
necessary that these bacteria themselves shall be intro- 
duced to produce any of the diseases in question artifi- 
cially. They may be grown outside the body and their 
products alone successfully used to produce disease; the 
bacteria themselves may be killed or entirely removed 
from such cultures, and still the substance which re- 
mains will produce the disease. From the above enu- 
meration of these diseases it is clear that the production 
of immunity from them is of prime importance in human 
medicine, and it is precisely in these diseases that recent 
experiments give the best hope of early practical results. 
This difference between infection and intoxication has 
made it necessary to discriminate between immunity from 
infection and immunity from intoxication, and for immu- 
nity from intoxication the very appropriate term " gift- 
fest," poison-proof, has been introduced. If the micro-or- 
ganisms of a strictly infectious disease are incapable of 
increasing in the tissues of any given animal this animal 
has immunity from the disease in question. Not so with 
the strictly toxic diseases ; for the micro-organisms of 
these may be incapable of growing in the tissues of an 
animal, but their toxic products contained in a culture 
may still be poisonous for this same animal. The animal 
may acquire the power of preventing the growth of 
toxic organisms in its tissues, yet be unable to resist the 
toxic albumin produced outside of its body in cultures. 
Such an animal resists the inoculation of small amounts 
■of a culture, because the micro-organisms are unable to 
grow and produce the poison, and there is too little of 
the ready-formed poison in the small amount of the cult- 
ure introduced-to produce disease. If larger amounts 
of the culture are introduced, so that enough of the 
poison already formed is present, the animal dies with 
all the symptoms of the disease. The animal is not 
poison-proof, though it may be, strictly speaking, im- 
mune from ordinary infection with the micro-organism. 
But, on the other hand, an animal may be made to resist 
the poisonous products of a given micro-organism, and 
still allow the micro-organism itself to grow in its tissues. 
The animal is poison-proof against the toxic products of 
the micro-organism in question ; the micro-organism has 
become harmless, or nearly harmless, for this particular 
animal, and can produce at most slight local trouble, but 
can no longer exert any general specific action. Con- 
sequently, in the artificial production of immunity the 
object to be attained with infectious diseases is to make 
the animal incapable of supporting the life of the micro- 
organisms in its tissues. The object in the toxic diseases 
is to make the animal capable of withstanding otherwise 
fatal amounts of the toxalbumins; in other words, to 
make the animal poison-proof. 
The procedure for the production of artificial immu- 
nity from the strictly infectious diseases is essentially the 
same in all cases. It consists in inoculating with atten- 
uated cultures-i.e., with cultures of micro-organisms 
■of weakened pathogenic power-and gradually passing on 
to cultures of increased virulence, finally using cultures 
of full strength. Several methods for the attenuation of 
the virulence of a culture are employed. One method, 
the practical efficacy of which is doubtful, is to pass the 
micro-organism through animals of slight natural sus- 
ceptibility. Pasteur advocated this method to produce 
immunity in hogs from the so-called swine erysipelas. 
He found that by inoculating from rabbit to rabbit the 
virulence of the micro-organisms of this disease increases 
for rabbits, but, on the contrary, decreases for hogs. In- 
oculations of the bacilli of hog erysipelas, which have 
thus been " acclimated " to rabbits, produce slight sick- 
ness in hogs, and, after recovery, these animals resist in- 
oculations of cultures of full virulence for about a year. 
Other methods of decreasing the virulence of pathogenic 
micro-organisms are the use of certain chemicals, and of 
heat, on the cultures. In general, it holds true that all 
Agencies which are injurious to the micro-organisms, if al- 
53 Artificial Immunity. 
Artificial Immunity. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
with glycerin. The cultures were made in glycerin bouil- 
lon, and the bacilli which accumulated on the surface 
of such cultures were skimmed off, extracted with gly- 
cerin, and sterilized. Individuals suffering from tubercu- 
losis react in a characteristic manner when inoculated 
with this lymph, but the expectations in regard to its 
curative value at first aroused have not been fulfilled. 
Similar lymph has been prepared from cultures of glan- 
ders, and used for diagnostic purposes. This so-called 
mallein was prepared by Kalming, Preusse, and Pear- 
son, each independently.3 
The application of certain substances at the seat of in- 
oculation prevents infection. The most potent substances 
of this kind are the trichloride of iodine and the double 
chloride of gold and sodium. These substances must be 
applied shortly after inoculation, they fail to act a few 
hours later. They also fail when injected at a place re- 
mote from the seat of inoculation. 
These substances also destroy the pathogenic power of 
bacteria when put into the cultures, or when mixed with 
the culture-medium upon which the bacteria are grown. 
Behring was the first to observe these facts,4 and he has 
shown that better results are obtained by using cultures 
containing the trichloride of iodine than with any other 
method.6 
But cultures containing watery extracts of the thymus 
gland were employed by Brieger, Kitasato, and Wasser- 
mann in a number of diseases with satisfactory results.6 
These authors succeeded, by the use of cultures grown in 
thymus bouillon, or by mixing the thymus extract with 
cultures, in producing in animals immunity from teta- 
nus, cholera, diphtheria, typhoid fever, erysipelas. A 
certain amount of resistance was also obtained with an- 
thrax, i.e., animals resisted somewhat weakened but still 
virulent cultures, but not tissues from animals dead of 
anthrax. It could hardly be expected that immunity 
from anthrax could be obtained in this way, as it is a 
typically infectious, and not a toxic, disease. Immunity 
from mouse septicaemia could only be obtained by using 
cultures of the organism in thymus bouillon, and after- 
ward inoculating with old weakened, but still somewhat 
virulent cultures, i.e., combining the method for the 
toxic diseases with that for the infectious.6 There are 
several theoretical considerations which led to the em- 
ployment of the extracts of thymus gland. There is a 
certain analogy between the enzymes or physiological 
ferments and the bacterial proteids : the former, like 
the latter, are albuminoid poisons. Gautier, Bouchard, 
and others have shown that the physiological ferments 
act as poisons ; this being the case, they could not circu- 
late as they do in the blood without injury to the animal 
unless there be some arrangement for neutralizing their 
toxic qualities. This arrangement, it is held, probably 
lies in the protoplasm of the cells of the tissues, and for 
this reason those organs which are richest in cells and 
blood seem best adapted to this function. It would ap- 
pear for this reason that the thymus, thyroid, and lym- 
phatic glands act as purifiers of the blood that streams so 
abundantly through them, and direct observations go to 
show that the thyroid gland has the power of destroying 
this kind of poisons to a remarkable degree, for, as 
pointed out by Horsley and others, extirpation of the 
thyroid is followed by symptoms closely resembling 
those of chronic intoxication, and these symptoms, as 
shown by Vassale, can be successfully combated with in- 
jections of the juice from the thyroid gland of other ani- 
mals. Transplantations of the thyroid gland in man and 
animals are also followed by improvement in the symp- 
toms where the transplanted gland grows. The lym- 
phatic glands appear also to possess this quality. They 
seem to be inserted into the lymphatic circulation for the 
purpose of arresting poisons contained in the lymph, for 
it often happens that a local affection spreads to the 
nearest lymphatic glands and there ceases. It is believed 
that this power of the glands to counteract poisons con- 
sists in the production of specific antitoxins which are 
given up to the blood on its passage. The antitoxins are 
supposed to be formed in the animal when the poisons 
are introduced. If the amount of poison introduced, or 
(SUPPLEMENT.) 
formed by the growth of bacteria in the body, is not suf- 
ficient to kill the animal, it brings about the production 
in the animal cells of an antitoxin, and after complete re- 
covery the animal is able to bear larger doses. But in 
every case inoculations must finally be made with in- 
creasing amounts of cultures of full virulence.6 
In this way the antitoxic property of the blood can be 
produced, and greatly, perhaps indefinitely, increased by 
the cautious introduction of larger and larger amounts of 
cultures, which have been modified by heat,* by the ad- 
dition of trichloride of iodine or extracts of the thymus 
gland, or by increasing doses of the toxalbumins them- 
selves. 
The latter method has been clearly demonstrated by 
Ehrlich.1 Vallet8 in this connection produced immunity 
from intoxication with cultures of B. coli communis by 
feeding rabbits with diluted sewage. It is true that 
Ehrlich at first used toxalbumins derived from higher 
plants, and not bacterial proteids, but the analogy is very 
close between the two kinds of poisons, and Ehrlich's re- 
sults have been found to agree with results obtained 
subsequently with bacterial toxalbumins. The sub- 
stances which Ehrlich used are more easily procured, 
and the amounts can be more accurately determined than 
with the indefinite mixtures found in cultures of bacteria, 
and for this reason the experiments with the former are 
not complicated by variability in the action of given 
amounts. The advantage of working with definite 
quantities is evident, and this is clearly impossible with 
bacterial proteids till these have been obtained pure. In 
the one case the effects produced by a given quantity are 
the same in all cases, in the other the effect has to be de- 
termined in every case beforehand, because the amount 
of toxalbumin varies in different cultures. For this rea- 
son Ehrlich decided to study the production of immunity 
from abrin, a toxalbumin derived from the jequirity 
bean ; risin, a similar poison obtained from the castor-oil 
bean ; and, in a different set of experiments, robin,9 from 
acacia bark. Ehrlich found that by feeding mice at the 
start with biscuits containing much less than the fatal 
doses of these poisons, the animals gradually bore greater 
and greater amounts till they could be inoculated without 
injury with amounts of the poisons sufficient to kill a 
great number of mice. The mice were made " abrin- 
proof," " risin-proof," or "robin-proof." In every case 
the process is specific, an animal which is abrin-proof is 
not proof against poisonous doses of risin or robin, and 
vice versa. This is also true for the bacterial poisons. 
An animal that has been made proof against the poison 
of tetanus is not necessarily proof against the toxalbumin 
of cholera or typhoid fever. 
As stated above, the antitoxic property of the blood 
of poison-proof animals not only protects the animal it- 
self, but the blood can be drawn and used to protect and 
even cure other animals. The testimony in regard to. 
this is constantly increasing, and its practical importance 
is evident. Thus Stern10 found that freshly drawn 
blood from typhoid fever convalescents protects mice. 
G. and F. Klemperer11 found that blood-serum, and also 
sputa, from persons that have passed the crisis in croup- 
ous pneumonia, possess anti-toxic properties. They 
also made an extract from the tissues and intestinal 
juices of a pneumonia-proof animal, and used it success- 
fully on pneumonia patients. Sternberg12 found that 
blood-serum from a vaccinated calf neutralizes both bo- 
vine and human virus. It must be clear that if it is pos- 
sible to obtain blood acting as above described it is only 
necessary to make large animals poison-proof, and use 
their blood for the prevention and cure of disease. As 
pointed out by Behring, the possibility of this " blood- 
serum therapeutics" is now clearly demonstrated, it only 
remains to obtain large animals in sufficient numbers tn 
put the method into general use ; it would also require 
considerable time to make the animals poison-proof, and 
a certain percentage of loss would also have to be reck- 
oned upon. In view of any eventual practical utility of 
* Vaillard produced immunity from tetanus in rabbits with cultures 
heated to 60 or 65° C. 
54 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Artificial Immunity. 
Artificial Immunity. 
(SUPPLEMENT.) 
the blood-serum therapeutics the selection of the animals 
from which the serum is to be obtained is a matter of 
great importance. It would be practicable to use only 
large animals, so as to get sufficient quantities of serum. 
It is also necessary that the animals be susceptible at the 
start. It is true that claims have been made for the in- 
herent protective value of blood-serum from non-suscep- 
tible animals, but these claims have not been substan- 
tiated. Kitasato has shown that the blood of chickens 
ordinarily has no protective value against tetanus when 
injected into other animals, although chickens have nat- 
ural immunity from tetanus. Still Vaillard13 has shown 
that even such animals can be made to furnish protective 
serum by inoculating them with very large amounts of 
a virulent culture. Chickens injected with 15 to 20 c.c. 
of a filtered but not heated culture furnish blood of high 
protective worth. But it is only blood-serum from ani- 
mals naturally susceptible, but rendered poison-proof, 
that attains the highest protective value. So in the 
different diseases it would be necessary to use different 
animals. Thus for tetanus horses are the best suited, 
they can supply a large amount of blood, and are natu- 
rally very susceptible. In fact, horses have been used 
for this very purpose.14 Tissoni and Catanni, and others, 
have also reported a ,number of cases of tetanus in the 
human being cured with blood-serum of tetanus-proof 
dogs. The most suitable animals to use for diphtheria 
are sheep, and they have also been used for this pur- 
pose.15 The more susceptible an animal is by nature the 
higher the degree of curative value obtainable ; and the 
higher the degree of resisting power produced in the ani- 
mal the stronger the power of its blood. The value of 
the blood-serum depends, in other "words, upon the extent 
to which the animal from which it has been obtained has 
been made poison-proof. The degree to which an ani- 
mal has been rendered poison-proof is expressed by the 
number resulting from dividing the minimal fatal dose 
into the largest amount which the animal can bear with- 
out serious symptoms. In animals of the same kind the 
size of the fatal dose increases with the weight of the 
animal. The minimum fatal dose is that which is just 
able to kill an animal of a given kind and size. Thus if 
two guinea-pigs of approximately the same weight are in- 
oculated, one with .01 c.c. of a diphtheria culture, and the 
other with .005 c.c. of the same culture, and the animal 
inoculated with the larger amount dies, while the latter 
shows very slight symptoms or none at all, the minimum 
dose of this culture for guinea-pigs of such weight is .01 
c.c. If a guinea-pig of equal weight with the two in the 
example above withstands an inoculation of .01 c.c. of 
the same culture, this animal is said to have one degree 
of immunity ; if it withstands .02 c.c. it has two degrees ; 
if it withstands 1 c.c. it has one hundred degrees of im- 
munity, and so on. This is Ehrlich's method of express- 
ing the degree of immunity in poison-proof animals. 
The protective value of the blood-serum of such animals 
may be expressed numerically, as suggested by Behring 
and Wernicke, as follows: The smallest amount of 
blood-serum necessary to protect an animal is taken as a 
unit and compared with the weight of the animal, and 
this proportion is used to express the protective power of 
the serum. Suppose three guinea-pigs are used to test the 
value of the serum of a diphtheria-proof animal, and sup- 
pose one of them receives .5 c.c. of serum to every one 
hundred grammes of its weight, a second 1 c.c. of serum 
to every one hundred grammes of weight; the third 2 c.c. 
to every one hundred grammes of weight, the protective 
value of the serum would depend upon which of the ani- 
mals showed marked symptoms of diphtheria poison 
upon inoculation of a fatal dose. If the animals which 
received .5 c.c. and 1 c.c., respectively, should die, and 
the other one showed no marked symptoms, the blood- 
serum would have a protective value of 1 to 50. If the 
animal inoculated with.5 c.c. alone was affected the pro- 
tective value would be 1 to 100-the animal receiving the 
blood-serum in this proportion not having been affected 
by subsequent inoculation with a certainly fatal dose. 
Animals which show marked local or general symp- 
toms on inoculation with a fatal dose are not regarded 
as having been protected, even if they eventually re- 
cover. 
The transmission of immunity by poison-proof animals 
to their offspring has been thoroughly studied by Ehrlich 
for animals made proof against the toxalbumins of some 
of the higher plants, those already mentioned, and also 
in animals rendered proof against bacterial toxalbumins. 
The observations in the latter case were few in number, 
but they tally precisely with the observations made in 
the former as far as they w'ent. 
It is conceivable that immunity may be transmitted by 
the father and the mother both. Such, however, has 
been found not to be the case. Immunity is transmitted 
by the mother alone. It is immaterial in any case whether 
the father enjoys immunity or not. Immunity in the 
father does not even increase the immunity transmitted 
by a poison-proof mother. 
Immunity in the offspring might be either a purely 
maternal gift, or it might be brought about by rendering 
the mother poison-proof during gestation. These are 
evidently two different things. In the one case, mothers 
which have attained a fixed degree of immunity would 
transmit a part of this to the children ; in the other, the 
same process which renders the tissues of the mother 
poison-proof would act upon those of the foetus as well. 
These two means of acquiring immunity must be con- 
sidered apart. 
Ehrlich distinguishes two kinds of immunity, active 
and passive. In active immunity there is a peculiar 
adaptation of the animal organism to resist toxalbumins, 
i.e., the production in the body of antitoxins, and it is 
characterized by extraordinary stability. In passive im- 
munity there is an introduction of a certain amount of 
the ready formed antitoxin ; as soon as this is eliminated 
from the body the animal is no longer poison-proof. 
Thus by the introduction of antitoxic serum into an ani- 
mal it is possible to produce often astoundingly high 
degrees of resisting power, but, from the nature of the 
case, the resistance is limited in time. The ready-formed 
antitoxin is eliminated in from thirty to sixty days, and 
as the animal is not given the power in this way to ac- 
tively renew it, the latter is no longer poison-proof. 
Now, the immunity transmitted by the mother is of 
this kind ; she does not transmit the power of actively 
forming the antitoxins, but merely gives a part of that 
which is formed in her body. The offspring of a poison- 
proof mother are poison-proof to a high degree about 
four weeks after birth, but at the beginning of the third 
month, or more certainly by the end of the third month, 
all traces of immunity are gone. By this time the anti- 
toxin derived from the mother has been eliminated, and 
neither these animals nor their offspring, i.e., the grand- 
children of the poison-proof animals, have any resisting 
power. 
The second possible way of producing resisting power 
in the foetus, viz., by rendering the mother poison-proof 
during pregnancy, has not yet been sufficiently tested by 
actual experiment to be decided upon. It cannot be de- 
cided on general principles, for the embryonic tissues 
may not react as the adult tissues do. The probabilities 
are that they are not as susceptible to the action of the 
toxalbumins as the adult tissues, and the production of 
immunity depends upon this susceptibility. One obser- 
vation of Ehrlich's seems to show, however, that the 
foetus can be given active immunity along with the 
mother. A pregnant mouse was fed continuously with 
risin, and the young were risin-proof to a high degree 
four months after they were born ; but the experiment 
was not beyond the suspicion of error, according to Ehr- 
lich's own statement. Experiments of others in this 
direction are not convincing, because in all cases the test 
was made at a time when the young may have still had 
some of the maternal antitoxin remaining, or, as will be 
seen below, they may have been deriving it from the 
milk. 
That the offspring of a poison-proof female derive anti- 
toxin from the mother's milk is shown very strikingly 
by Ehrlich's experiments. Ehrlich found in many cases 
that the young showed resistance to toxalbumins for a 
55 Artificial Immunity, 
Asiatic Cholera. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
longer time than could be accounted for by a maternal 
gift of antitoxin at birth. They are protected after the 
antitoxin derived from this source is eliminated ; so they 
must derive additional protection from some other source, 
and this proved to be the milk. Indeed, this in suck- 
lings could be the only source. This is proven beyond 
question experimentally by the results of " swapping off- 
spring, or the wret-nurse experiment." If the litters of 
the same age from a poison-proof mother and of an ordi- 
nary non-poison-proof mother are swapped around at 
birth, it is possible to observe, in the first place, just how 
long the immunity derived from the mother as a gift 
before birth lasts, and in the second place the degree of 
immunity acquired by normally susceptible offspring 
from the milk alone. Whatever resistance is shown by 
the offspring of a poison-proof mother in this experiment 
must be due alone to the antitoxin acquired in utero ; the 
milk of the susceptible foster-mother contains no anti- 
toxic properties. Whatever resistance is show'n by the 
offspring of the normally susceptibly mother must be de- 
rived from the milk of the poison-proof foster-mother. 
The immunity derived in this way alone from the milk 
of a poison-proof foster-mother is higher in degree than 
that derived in utero alone. Offspring of an ordinary 
non-poison-proof mother derive eight times the resisting 
power from the milk of a poison-proof foster-mother 
than the latter is able to confer upon her own children, 
unless these are allowed to suckle her. An illustration 
will serve to make this clear. A normal, non-poison- 
proof female was given four offspring of a highly abrin- 
and risin-proof mother to suckle ; this highly poison- 
proof female was given the five offspring of the normal 
mother to suckle. The highest degree of immunity ob- 
served in the former case was scarcely 5, the highest 
degree in the latter fully 40, i.e., one of the offspring of 
the poison-proof mother that suckled the normal female, 
barely withstood five times the fatal dose at twenty-one 
days old ; one of the offspring of the normal mother 
which suckled the highly poison-proof foster-mother 
withstood forty times the fatal dose at about thirty days 
old. Another experiment of Brieger and Ehrlich16 which 
also gave striking results, was made with tetanus upon a 
pregnant goat and her kid. The goat was treated by the 
Brieger-Kitasato-Wassermann method, viz., by inocula- 
tions of cultures in beef-tea, with the addition of thymus 
extract. Inoculations were begun six days before partu- 
rition, and continued for twenty-seven days after. The 
kid was found to be highly poison-proof. The protective 
value of the milk inoculated into mice was shown to be 
astoundingly great, 1,600 to 2,400 degrees. The serum of 
the milk was equally potent, and the evaporated serum 
had 5,000 degrees potency. 
It is evident that in inherited artificial immunity, 
where the poison-proof mother is allowed to nourish 
her own young, there are two factors : the antitoxin de- 
rived by the foetus, and, still more important, that ob- 
tained from the milk. Now, it is evident that this 
power of the milk must lie in the antitoxin which the 
latter contains, and the question arises whether this 
antitoxin is formed by the milk-glands or whether it 
is formed elsewhere, and is merely eliminated by these 
glands. It has been found that the latter is the case. 
If a normal animal is dosed during lactation with blood- 
serum from a poison-proof animal, the sucklings acquire 
typical protection from the milk. Experiments with 
tetanus on mice showed that great immunity up to forty 
degrees can be produced in this way in the sucklings. 
Immunity produced in this way is passive, as would be 
naturally supposed ; but it makes its appearance very 
quickly, within twenty-four hours after the mother has 
received the protective serum. 
Even normal sucklings which are inoculated with a 
splinter of wood with tetanus organisms on it, and then 
allowed to suck a highly tetanus-proof foster-mother, re- 
cover even if tetanus symptoms appear. 
Meade Bolton. 
(SUPPLEMENT.) 
schritte d. Med., iii., 1884. etc. Compare Ernst Ziegler : Historisches 
und Kritisches u. d. Entziindung, p. 198 et seq. Abdruck aus Beitrage 
zur path. Anat., etc., vol. xii., Jena. 
2 Stahl and Pfeffer, Leber. Buchner. Massart and Bordet, Gabritsch- 
ewsky, Steinhaus et al. See Ziegler, loc. cit., page 180. 
3 Eber A. : fiber Rotz lymphe (Mallein). [A Review.] Centralblatt fiir 
Bact., etc., vol. xi., No. 1, p. 20. 
4 Zeitschrift fiir Hygiene, vol. xii.. No. 1. 
6 Die Blutsernmtherapie, etc. Leipzig. 1892. 
" fiber Immunitat und Giftfestigung, Zeitschrift fiir Hygiene, vol. 
xii., No. 2. 
7 Ehrlich. Paul: Deutsche Med. Wochenschrift, Nos. 32 and 44, 1891. 
8 Transactions of the Seventh International Congress for Hygiene, 
etc., London, August. 1891. 
9 Ehrlich, Paul: fiber Immunitat durch Vererbung und Siiugung, 
Zeitschrift fiir Hygiene, etc., vol. xii.. No. 2. 
10 Deutsche Med. Wochenschr., No. 37, 1892. 
11 Berlin klin. Wochenschr., August, 1892. 
12 Trans, of Assn, of Am. Phys., vol. vii., 1892. 
13 Vaillard : La Semaine M6d., No. 31. 1891. 
14 Behring : fiber Immunisirung und Heilung von Versuchsthieren 
beim Tetanus, Zeitschrift fiir Hygiene, vol. xii., No. 1. Also Schiits, 
ibid. 
15 Behring und Wernicke : Ibid. 
16 Brieger und Ehrlich: Deutsch, med. Wochenschr., No. 18, 1892. 
ASEPTOL (Sulpho-carbolic acid ; Sozolic acid) is pre- 
pared by mixing sulphuric acid and phenol in chemically 
equivalent parts. It is a sirupy, reddish-brown fluid. 
Specific gravity, 1.400. Miscible in all proportions in 
water, alcohol, and glycerine. It is less poisonous than 
carbolic acid and has a more agreeable odor. The asep- 
tol of commerce is a solution of varying strength, about 
thirty-three per cent.; specific gravity, 1.168. It pos- 
sesses antiseptic properties and is used externally for the 
same purpose as carbolic acid. It is devoid of caustic 
properties and is less irritating and not so powerful an 
antiseptic. A solution of ten per cent, may be generally 
employed as an antiseptic wash. In diphtheria it is 
recommended as a local application. It may be given 
internally, but the official salt, sulpho-carbolate ofsodi- 
um, is to be preferred. Beaumont Small. 
ASIATIC, OR EPIDEMIC CHOLERA is an acute in- 
fectious disease that is endemic in certain parts of India, 
and that has during this century advanced out of that 
country to other parts of the world, where, in its epi- 
demic form, it has produced great loss of life. It is char- 
acterized by its great fatality among the communities to 
which it may be transported, by the apparent ease with 
which it has been carried from place to place, and by its 
invariably following the lines of travel in its march from 
one place to another. It is distinctly a disease of the 
gastro-intestinal tract, produced, primarily by a micro- 
organism, and attended with secondary symptoms, due 
to the absorption of toxic principles elaborated during 
the development of this micro-organism. 
A study of the history of the epidemics that have oc- 
curred outside of India will easily demonstrate the facts 
in regard to the ways by which the disease is transported 
from place to place. 
There is only a difference of degree between cholera, 
choleraic diarrhoea, and cholerine-the disease is the 
same in all these forms provided that they are accom- 
panied by the activity of the spirillum of Koch. So far 
as true cholera and cholera nostras are concerned, there 
is a very great similarity, or rather there may be, be- 
tween the clinical symptoms of the two diseases, but the 
differentiation may be easily made by the isolation of 
the specific spirillum of the former. The same thing is 
true in regard to the differentiation of true cholera from 
an attack of indigestion, which, if severe enough, may take 
on many of the characteristics of true cholera. Cholera 
nostras is a seasonal disease and is not transportable, and 
it has been known for ages. True cholera made its first 
advance out of India in 1817, and since that time has 
been seen periodically in Europe. In all cases it has fol- 
lowed the line of travel, and has never been seen to be 
distributed in any other way. Therefore true cholera 
never makes its appearance except after other cases have 
been seen that might excite suspicion, while cholera nos- 
tras appears only in hot weather, in sporadic cases, and 
dies out if the weather becomes cooler. 
The period of cyanotic chills, although one of the most 
1 Metchnikoff : Arb. aus d. Zoolog. Inst, zu Wien, vol. v., 1883 ; Bio- 
log. Centralbl., iii., 1883-84 : Virchow's Archiv., vols., 96, 97, 107, 109, 
etc. Also various articles in the Ann. de 1'Inst. Pasteur. Also Fort- 
56 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Artificial Immunity. 
Asiatic Cholera. 
striking in both diseases, gives no special indications for 
differential diagnosis, for the same thing is seen as an 
accompaniment of many other diseases, as acute catarrhal 
diarrhoeas, acute poisonings, etc. The prodromic period 
exists in cholera nostras practically always, but not near- 
ly always in true cholera. 
* The period of reaction is of importance in differential 
diagnosis. In cholera nostras it is usually benign-if the 
patient escapes the violence of the first attack, convales- 
cence is as a rule easy and rapid ; with true cholera, on 
the contrary, convalescence is exceedingly dangerous- 
full of pitfalls, and may terminate fatally at any time. 
History of Epidemics of Cholera and Their Les- 
sons.-The dispute is active as to whether true cholera 
existed in India before its appearance outside of its limits 
in 1817, but the probabilities are all in favor of its having 
done so ; the especial point that seems to be changed in 
its nature being that it then seemed to take on the prop- 
erty of migration. Whether this ■was in reality a new 
property, or whether it was simply brought to the notice 
■of Europeans by their being first attacked by it, is an un- 
settled question. There is no doubt, however, of the 
very great influence exerted upon its spread by the great 
pilgrimages to the various shrines of India ; nor is there 
any doubt that the sole home of true cholera-the one 
place where it is present all the year in an endemic form 
-is the delta of the Ganges. There are also certain 
places in India, Indo-China, China, and Japan in which 
it seems to be present nearly all the time, but it certainly 
is not endemic in Persia, on the borders of the Caspian 
Sea, nor in Mecca. 
From this one place in which it is endemic, cholera 
has always been transported to Europe in the steps of 
the traveller and along the routes of commerce ;-neither 
wind, moisture, electricity, nor any of the forces of nat- 
ure have taken any active part in the actual transporta- 
tion of the disease, although unfavorable climatic and 
hygienic conditions, of course, may play a favoring part 
in the development of the disease, after the arrival of its 
■cause. 
Epidemics of Cholera.-Cholera has made five ap- 
pearances in Europe-in 1830, in 1846, in 1865, in 1884, 
and in 1892. Each one of these appearances was a great 
•epidemic. 
There had been also, in 1823, in Astrachan, a small 
•epidemic of cholera, important, because it traced the 
route that the succeeding invasions would follow. Leav- 
ing Persia, where it prevailed in 1822, cholera invaded 
the southern provinces of Persia, forming the southern 
shore of the Caspian Sea. After some ravages, it be- 
came quiescent during the winter of 1822, to reappear 
in April, 1823, at Recht. From this city, following the 
western shore of the Caspian Sea, it crossed the Rus- 
sian frontier in June, at the little town of Astara. From 
Astara it reached Lenkoran on the 29th of June. On 
the 11th of September it was seen at Bakou, and on the 
22d at Astrachan, where it soon disappeared. 
The First Epidemic.-The epidemic of 1830 had the 
same origin. Ghilan and Mazanderan, the two Persian 
provinces before invaded, were attacked in 1829. The 
disease was quiescent during the winter, but appeared in 
the spring in Ghilan and in the little port of Enselli, sit- 
uated several hours' journey from Recht. As in 1822, the 
•cholera followed the western border of the Caspian Sea, 
and showed itself about the middle-of June, 1830, at 
■Salian. Taking here two different directions, on the one 
side, it appeared at Bakou, Kouba, and Derbent, and in- 
vaded Astrachan ; on the other, following the whole val- 
ley of the Koura, it advanced toward Tiflis, passing by 
Elizabethpol, and spreading throughout the whole of the 
Caucasus. In this way it reached successively the neigh- 
boring regions of.Astrachan, and advanced up the Volga. 
On the 4th of August it was at Saratow, thence extend- 
ing into Russia, and reached the other European States. 
This epidemic, by certain extremely interesting pecu- 
liarities, demonstrated from the very first the transporta- 
bility of cholera. 
The Second Epidemic.-In 1846, after having reached 
Salian by a course identical with the preceding, cholera 
(SUPPLEMENT.) 
was seen on November 8tli in the city of Chemacka, a 
short distance from Salian. It was in Bakou and at 
Derbent in December. Forgotten during the winter, it 
appeared in April, 1847, in the districts of Derbent and 
of Kouba, and at Tamir-Khan-Choury. From thence 
it was transported by sick soldiers to the mineral waters 
of Kisliar. The disease was disseminated among the 
Calm neks scattered over the steppes near the Volga. 
On July 15th it appeared at Astrachan, and advanced 
at the same time toward Tiflis. From Tillis it reached 
Koutais, and was soon carried to Trebizond. 
North of Titi is, the cholera followed the great military 
road that crosses the Caucasus at the height of 7,000 feet, 
and toward the end of July it existed at Stavaropol, on 
the other slope. (It is to be observed that before reaching 
Tiflis, the cholera entered Persia by the great routes of 
travel that pass from Bakou, by Erivan, Natchichievan, 
Djoufa, Ordoubaz, and on toward Tauris. On the one 
side it attacked the region of the Black Sea, and invaded 
all its ports ; on the other, it passed through Russia, Ger- 
many, France, and Italy.) 
A striking thing about these epidemics, aside from the 
exact places that they attack, is their progress by succes- 
sive stages-a form of advance that is always the same, 
and which is a trait common to all the epidemics of 
cholera that have followed the land route. This second 
epidemic persisted until 1855. 
The Third Epidemic.-The great epidemic of 1865 was 
the first one appearing by the sea route. It demonstrated 
that the danger is not localized on the Caspian Sea, but 
that it is also present on the shore of the Red Sea. Its 
appearance by this route upset all the doctrines that had 
been held until that time, and the panic that it produced 
in Europe resulted in the first conference at Constanti- 
nople. It is interesting to follow in some of its phases 
the course of this epidemic, because its influence has 
been great. It started from Mecca, having been brought 
into that city by ships coming from India filled with pil- 
grims. Toward the end of April it broke out in Mecca 
and at Medina. The mortality increased very greatly 
during the three feast days at Arafat. More than thirty 
thousand of the pilgrims died of cholera, and the prog- 
ress of the disease showed that everywhere it accom- 
panied these pilgrims. Egypt, by reason of its proxim- 
ity to Mecca, was the first country attacked. 
From May 19th to June 10th ten steamers landed from 
twelve to fifteen thousand pilgrims at Suez. By false 
declarations from the captains they were passed at Suez, 
although the Sydney, an English steamer, had lost a 
number of cases during the voyage. The first steamer, 
landing May 19th at Suez, had thrown its dead into the 
sea. On the 21st, cases appeared at Suez, and among 
the number were the captain of the vessel and his wife. 
June 2d, the first case appeared at Alexandria, and in 
two months cholera had four thousand victims in Alex- 
andria, and in Egypt, in less than three months, it pro- 
duced the death of more than sixty thousand individuals. 
The foreign population emigrated en masse, and carried 
with them throughout the entire world the germs of the 
disease. Europeans and Levantines, to the number of 
from thirty to thirty-five thousand, started for all the 
ports of the Mediterranean, and cholera developed at 
Constantinople, at Smyrna, at Beyrout, in Mesopotamia, 
and at Odessa on the Black Sea, and was carried to New 
York and Guadaloupe by steamers, appearing in the port 
at the same time that the steamer landed its passengers. 
Its importation into Newr York was as follows : The 
Atlanta, an English ship, left London on October 10th 
with a cargo of merchandise and forty passengers. The 
sanitary condition of London was at that time excellent. 
Reaching Havre on the 11th, where it remained one day 
only, it embarked 564 new passengers, mostly Swiss, 
who had all passed through Paris, where, with certain 
exceptions, they had remained at least a short time, and 
where at the same time cholera was raging with great in- 
tensity. Two German families had stayed in Paris at 
the Hotel of La Ville de New York, and five days at the 
hotels of the Weissen-Lamm and Hultgarderhof. Some 
emigrants that had arrived several days before in these 
57 Asiatic Cholera. 
Asiatic Cholera. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
last hotels had fallen suddenly ill. The steamer sailed 
on the 12th, and on the next day there was a death from 
cholera of a child in the family coming from the Weis- 
sen-Lamm Hotel. Five other deaths followed on the 14th, 
the 16th, the 18th, the 19th, and the 22d, in the family 
that had stayed at the Hultgarderhof. 
On the arrival of the Atlanta the surgeon declared 60 
cases of cholera, and 15 deaths during the voyage. Two 
deaths occurred in port, and of the 142 patients sent to 
the Marine Hospital from November 6th to 19th, 6 died, 
which makes a total of 23 deaths. The Atlanta was im- 
mediately isolated in the lower bay, and after ten days 
of quarantine all the sick were removed, and, thanks to 
these measures, New York was preserved. 
There were also importations in 1866 by the steamers 
Virginia and England. 
The epidemic of 1865 ceased in 1874, and there was no 
other case seen in Europe until 1884, although there were 
interesting manifestations in other countries and on the 
sea-interesting from the point of view of the transporta- 
bility of the disease. 
The Fourth, Epidemic.-The epidemic in Egypt in 1883 
was no surprise to those who knew the sanitary condition 
of the country. Cholera appeared at Damietta toward 
June 19th or 20th, possibly a little earlier, and its explosion 
at this time is ascribed, certainly by the French, to the 
suppression of all sanitary precautions, including quar- 
antine, by authority of the British government. This 
epidemic at Damietta, increased for about fifteen days, 
remained stationary for about five or six days, and then 
diminished just as speedily. It was almost extinct a 
month after its appearance, having claimed from two 
thousand to twenty-five hundred victims. The spread of 
the disease throughout Egypt was manifest and rapid. 
(An interesting account of how this epidemic reached 
Damietta is given in Proust's work on the "Defence of 
Europe against Cholera," Paris, 1892, p. 7.) 
Cholera had not yet died out in Egypt, before the 
news came that it had broken out among the pilgrims to 
Mecca, and there has been much discussion as to the ori- 
gin of this epidemic. 
In 1884 a number of vessels left the extreme East, and 
had cases of cholera on board during their voyage ; but, 
by reason of the precautions taken, Egypt and Europe 
escaped the danger at this time. 
The first case of cholera seen at Toulon occurred on 
June 13th, on the ship Montebello ; a second case on 
June 14th ; a third on the 18th, on the Jupiter, near the 
Montebello ; a fourth, also on the 18th, on the Monte- 
bello ; a fifth, June 20th, on the Alexander, which was 
also placed near the Jupiter and the Montebello. After 
the 21st the disease spread through different quarters of 
the city, and it is thus shown that it did not make its ap- 
pearance at Toulon in the city, but just outside. 
Its importation into Marseilles occurred by the appear- 
ance of the first case on June 27th, in a young man, who 
had three days before come from Toulon. The next 
case, which occurred on June 28th, was that of a man 
who lived in the same neighborhood ; and from this time 
onward the disease continued to spread. 
In Paris there appeared two cases on the 13th or 14th 
of July, but the epidemic did not really begin until the 
4th of November. 
In Brittany the first case was not observed until Sep- 
tember 20th, at Concarneau. Other ports were succes- 
sively invaded. 
Algeria was attacked in 1884, and there was a slight re- 
currence in Algeria and in Tunis in 1885. 
Cholera was brought to Italy in 1884 by the Italian 
workmen, who, to the number of more than eight thou- 
sand, returned to their country after the extension of the 
cholera to Toulon and Marseilles. The Province of Cu- 
neo, in Piedmont, was the first one attacked, on June 
27th, and the disease spread successively to different 
parts of Italy, to Genoa, Naples, Venice, Sicily, and so 
on. 
It appeared in Spain, in the month of August, in the 
Province of Alicante, and ceased toward the middle of 
October, reappearing in the middle of February, in the 
(SUPPLEMENT.) 
District of Gandia, raging through the month of June 
to the month of December, 1885, and producing a consid- 
erable mortality. It is remarkable that it attacked espe- 
cially the small towns more than the large cities. The 
Commune of Aldea de San Miguel, with only five hun- 
dred inhabitants, lost more than half of them in thirty- 
six days. 
Cholera also appeared on the Adriatic shores of Croa- 
tia, at the end of 1885, and in 1886 on many points of 
the Austro-Hungarian shore in Istria and in Dalmatia. 
The comparison of the mortality in France, Italy, and 
Spain is interesting. In France and Algeria together 
there were 13,000 deaths in a population of 39,000,000- 
1 in 3,000 inhabitants. In Italy there were 35,000 deaths 
in 26,000,000, that is to say, 1 death in 600 inhabitants. 
In Spain there were 180,000 deaths, among 17,000,000 in- 
habitants, that is to say, 1 death in 100 inhabitants. So 
it appears that Italy was attacked five times more se- 
verely by the epidemic than France, and Spain six times 
more severely than Italy, and thirty to forty times more 
severely than France. 
Much has been said about the immunity of Portugal 
during the epidemic of 1884 and 1885 in Spain. Many 
reasons can be brought forward for this, viz., the slight 
tendency of the Spaniards to take refuge in Portugal, 
the geographical conditions, and finally, the prophylactic 
measures taken at the frontier. 
In spite of the imperfect quarantine and incoherent 
measures prescribed by the governments of South Amer- 
ica against the vessels coming from Europe, a ship from 
Genoa, the Perseo, carried cholera to Buenos Ayres, and 
the disease spread into the Argentine Republic, Uruguay, 
and Chili. 
From 1884 to 1886, a period'of three years, more than 
twenty vessels coming from the extreme Orient to Eu- 
rope, on passing through the Red Sea and the Suez Canal, 
had, either at the moment of their departure, or during 
the voyage, cases of cholera. 
The Cholera of 1889, 1890, 1891, and 1892 (the fifth epi- 
demic}.-In 1890 cholera appeared in Irak-Arabi, in Meso- 
potamia, in Persia, and in Syria, where it had not been 
seen for almost twenty years. It had been imported into 
the region bordering on the Red Sea and into Mecca, 
where it had not been since 1883, and it was observed in 
Spain, where it had been extinct since 1835. 
In summing up what we know of the origin of cholera 
in Irak-Arabi and in Mesopotamia in 1889 and 1890, the 
following must be our conclusions: 
It is very difficult to admit that the cholera of Irak- 
Arabi can be attributed to the revival of the old epi- 
demic of 1871, and if this hypothesis be excluded, we 
are obliged to accept the idea of importation, and it is 
only possible to think of one portal of entrance, the Per- 
sian Gulf, and one source in India, notably Bombay and 
its environs. 
We know from other sources that during and before 
the appearance of cholera in Irak-Arabi the mortality of 
this disease in Bombay and its environs reached the enor- 
mous number of more than six hundred deaths a week. 
The condition of the vessels of the British India Com- 
pany, that alone regularly frequent the Persian Gulf, 
bring passengers there, and frequently bring pilgrims 
from India, has been, to say the least, suspicious. Every- 
thing points, therefore, to the conclusion, which bears 
every appearance of truth, that the cholera penetrated 
into Irak-Arabi through Chat-el-Arab. The importation 
was performed in this way much more probably than by 
any other means. 
In regard to the epidemic of 1890-91 in Hedjaz, Proust 
offered the following conclusions to the Committee of 
Hygiene, which were accepted : 1, The cholera of Came- 
ran was imported by an English vessel coming from 
India ; 2, the cholera of Hedjaz appears to have been 
brought by the sea route ; 3, the pilgrimage to Mecca is 
a constant menace to the health of Europe ; 4, the meas- 
ures prescribed for the government of the pilgrims to 
Mecca have not prevented the cholera from developing, 
and it is therefore necessary to perfect these measures ; 5, 
the prophylactic measures prescribed by the Alexandrian 
58 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Asiatic Cholera. 
Asiatic Cholera. 
Conference, at the time of the return of the pilgrims, have 
this year prevented the disease from gaining a foothold in 
Egypt and in Europe. There is reason, therefore, for con- 
tinuing this Conference and for giving it more authority 
and making it in reality international. There is also rea- 
son for increasing the means for isolation and disinfec- 
tion on the Red Sea. 
The epidemic which appeared in Spain in the month of 
May, 1890, and lasted until the end of November, gave 
rise to much discussion in regard to its origin that is 
not yet terminated. 
The epidemic of 1892, appearing first in Southern Rus- 
sia, and thence extending in isolated instances to ports in 
the north of Europe, appears to be quiescent at the time 
of present writing, but nearly all sanitary authorities look 
for a further outbreak during the coming year (1893). 
Thus far no cases of cholera, beyond a few isolated ones 
in New York {Amer. Jour, of the Med. Sci., June, 1892), 
have appeared in the United States for nearly twenty years. 
Transportability and Means by which the Dis- 
ease is Transported.-The transportability of the dis- 
ease is demonstrated by, first, the facts in regard to its 
propagation after it has been imported ; second, by the 
efficacy of certain measures of prevention ; third, by the 
general march of epidemics of cholera ; and fourth, by 
the development of epidemics in the infected localities. 
1. Propagation.-Brochard, in " Du Mode de Propaga- 
tion du Cholera,'' Paris, 1861, reports a very large num- 
ber of observations favoring the idea of the transportabil- 
ity of cholera, and the number of instances proving this 
is so great that they need only to be spoken of to be ac- 
cepted. 
An illustration may be taken from the article by Huette, 
in the Arch. Gen. de Med., 5th series, vol. vi., p. 571. 
In speaking of cholera in Chatillon, he says that the 
first case was observed in the Faubourg du Puirault, in 
a workman, thirty-five years old, who was attacked im- 
mediately after his return from Oussoi, where he had 
gone to take care of his parents who were sick with the 
disease. His neighbors were very soon attacked, and the 
epidemic invaded the entire Faubourg du Puirault, where 
it remained concentrated for some little time. Finally, 
the inhabitants, frightened by the disease, scattered 
through Chatillon, and the cholera appeared indiscrim- 
inately throughout the city. The instance is interesting, 
because while the inhabitants remained in the Faubourg 
du Puirault, the disease stayed there, whereas, as soon as 
they scattered, it spread with them throughout Chatillon. 
Another instance, interesting as an example of the 
transmission of the disease by clothing, is given by the 
same authority, in speaking of the Commune of Oussoi. 
Madame Bresson, of the hamlet of Moulineuf, near Ous- 
soi, a precinct free from cholera, received a boarder from 
Paris June 27th, who on the next day showed the first 
symptoms of cholera, and died on July 3d. Some days 
after, a child of this woman was attacked and died on 
July 13th. On the same day Madame Bresson her- 
self was taken sick, and died on the 17th, after having 
been taken care of by two neighbors named Sahan and 
Moret, who died, one on the 16th and the other on the 
24th. The husband of Madame Bresson died on July 
26th. Madame Burette, who lived in the extreme end of 
the hamlet, washed the linen of the two women, Sahan 
and Moret, and was attacked with cholera. In this way, 
an epidemic was started that carried off eighteen per- 
sons in a very short time. Before the arrival of the per- 
son from Paris no case had been observed in this hamlet, 
that had been spared by the cholera both in 1852 and in 
1849. Dr. Huette calls attention to the distribution of 
this hamlet of Moulineuf, which is composed of ten little 
collections of houses, separated by great distances. No 
cases of cholera were observed excepting in three of these 
collections of houses-first, that occupied by the Bres- 
son and Sahan families; second, that occupied by the 
Moret family ; and third, that occupied by the Burette 
family. The third collection of houses was situated at 
the extremity of the hamlet. No case of the disease was 
observed in the other houses, of which the inhabitants 
had had no connection with these three families. 
(SUPPLEMENT.) 
Proust (loc. cit., p. 165) quotes an occurrence illus- 
trating another series of facts. 
In 1854 the French army was collected at Varna, a 
short distance from the English army, Some detach- 
ments remained at Gallipoli, the original place of de- 
barkation. There was, besides, a small Anglo-French 
force of occupation in the Piraeus, and also some detach- 
ments at Constantinople. The armies were reinforced 
practically every day by new arrivals. The sanitary 
condition was satisfactory in all respects. On July 5th, 
the packet Alexandre arrived at Constantinople, having- 
left Marseilles on June 26th with five hundred men of 
the Fifth Regiment of Light Infantry, coming from 
Montpellier, and having passed through Avignon, where 
cholera was raging. It appeared on board, and three 
men died during the voyage to the Dardanelles. Four 
cholera patients were landed at the Piraeus, where the 
cholera broke out immediately, and made great ravages. 
The troops were disembarked at Gallipoli, where two 
new cases of cholera were immediately sent to the hos- 
pital, and the ship, having only a few passengers on 
board, sailed for Constantinople, where a quarantine was- 
imposed on it. On the other hand, it appeared that 
previous vessels sailing from Marseilles had already suf- 
fered from cholera, and that one of them had landed a 
patient in the military hospital at Constantinople. On 
July 15th, after new arrivals of cholera patients, the dis- 
ease spread at Gallipoli, and there appeared in the mili- 
tary hospital of Constantinople a choleraic focus. Fauvel, 
struck by the danger, proposed, and had adopted by the 
Council of Health at Constantinople, a momentary in- 
terruption of the communication between Gallipoli and 
Varna. The measures prescribed were not executed, 
and in spite of the insistence of Fauvel before the Mar- 
shal de Saint Arnaud, many ships sailing from Gallipoli 
passed the Bosphorus, and went directly to Varna, where 
free pratique was accorded them. Cholera then broke 
out in the army among the newly arrived soldiers and in 
the hospital. On August 5th the epidemic was violent at 
Varna, especially among the troops sent into the Do- 
brudscha. The English army was invaded, having the 
epidemic on board the fleet. In the Crimea, the epi- 
demic, helped on by the arrival of the fresh troops, con- 
tinued until 1856. 
The importation of cholera into Constantinople in 1865 
equally deserves to be spoken of. Constantinople was 
in an excellent sanitary condition when the frigate 
Moukbiri-Sourour arrived from Alexandria, on June 28, 
1865. She had passed more than five days on the voy- 
age, and therefore, in accordance with the rule that then 
held, free pratique was granted her, the surgeon having 
declared that there had been no illness during the voyage ; 
but this declaration was false. The evening of June 
28th there were landed from this frigate tw'elve sick per- 
sons, of whom one was attacked with cholera, who died 
during the night, and eleven w ere affected with cholerine. 
It was learned on the next day that during the journey 
from the Dardanelles to Constantinople two choleraic 
bodies had been thrown into the sea. On June 30th nine 
other cases were landed. The ship was sent into quaran- 
tine at the mouth of the Black Sea. The patients were 
transported to the Marine Hospital, near the arsenal, and 
here one special circumstance should be noted. The 
road that went from the landing to the hospital being 
opposite, it was necessary to carry the sick past the bar- 
racks occupied by military workmen in the arsenal, and 
the first indigenous cases of cholera occurred among 
these workmen, and on board a corvette that was near 
their barracks. On July 3d one of these military workers 
was received at the hospital with a choleraic diarrhoea, 
and on the 5th presented all the symptoms of cholera. 
That same day a new case was furnished by the work- 
men, and another on the corvette spoken of above. The 
barracks were then vacated, and the workmen were 
placed in tents on the heights of Okmeidan ; neverthe- 
less, the disease continued to rage among them, and 
among the ships collected before the arsenal, and it 
attacked on the one hand the guard in the interior of 
this establishment, and on the other the w'orkmen at the 
59 Asiatic Cholera. 
Asiatic Cholera. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Ministry of Marine, situated very near the barracks of 
the military workmen. On July 8th two cases occurred 
outside the arsenal, and from July 10th the epidemic com- 
menced to invade the quarter of Kassin-Pacha, near the 
arsenal, and inhabited by the workmen of whom we have 
spoken. It then propagated itself throughout the city. 
One more instance of the importation of cholera may 
be given, as illustrating that a single case, carried a great 
distance by rail, may give rise to an epidemic. 
Toward the end of the month of August, in 1865, 
cholera suddenly broke out at Altenburg, in Saxony, in 
the centre of Germany. The first case was that of Lady 
E , who had left Odessa on August 16th, and had 
arrived at Altenburg on the 24th, without having 
stopped on the journey. She travelled with a child of 
twenty-one months old, who was affected with diarrhoea. 
She went to her brother's, and sent for a physician to 
see her child, whose diarrhoea had become very severe. 
This woman, who was meanwhile well, said that at her 
departure from Odessa there had not been in that city 
any disease ; but this was an error, for some cases of 
cholera imported from Constantinople were already in 
the hospital in the lazaret, and, the day after the depart- 
ure of this lady, cholera appeared at Odessa. She said 
also, that having embarked to go up the Danube, every- 
body appeared to her to be well on board, although the 
vessel had passed by certain localities where cholera was 
raging; however that may be, three days after her ar- 
rival at Altenburg, on August 27th, and the very same 
day that the physician had visited her child, this lady 
fell ill; and the next day the physician recognized all the 
symptoms of Asiatic cholera. She died on the 29th. 
On the same day, in the same house, her sister-in-law 
was attacked, and died on the 30th. The child died on 
the 31st. From this house the cholera spread into the 
city and suburbs. The family of a workman, who died 
on September 13th at Altenburg, carried the disease to 
Werdeau, and the house occupied by this family was the 
point of departure of another epidemic that carried off 
two per cent, of the entire population of the city. 
2. The Transportability of Cholera is Confirmed by the 
liesalts of Restrictive Measures.-We see always that a 
rigorous sequestration and a rigorous interruption of 
communication by land or sea, if that be possible, results 
in preserving certain places or certain countries, and in 
these facts is a powerful argument against any idea of 
the transmission of cholera through the air. 
In 1867 Messina and the whole of Sicily were entirely 
free from cholera, and yet vessels coming from infected 
countries daily passed through the narrow Strait of 
Messina. And again, during the epidemic of 1856 at 
Constantinople, the scholars of the Military School, to 
the number of five hundred, were rigorously sequestrated 
in the establishment, and escaped the cholera that was 
raging in the neighborhood ; and events that occurred 
at the lazaret of Fort Genoa, in Algeria, in 1884, demon- 
strated also the efficacy of isolation in order to prevent 
the transportation of the disease to the neighboring cities. 
3. Transportability as Shown by the General Progress of 
Epidemics of Cholera.-If we look at epidemics as a whole, 
we see that they always follow the course of human cur- 
rents of travel. It is in the East, or in the countries 
bordering upon Europe, that we can best follow the 
development of this law, because in such places the 
routes are less frequented, and the demonstration is more 
striking. In order to pass from Persia into Russia in 
any way except by the great line of travel passing 
through Erzeroum, Tauris, and Natchischevan, there 
are only two ways-that over the Caspian Sea, and the 
land route that follows the western shore of this sea. 
Both of these routes pass by Recht, Astara, and Len- 
koran, and end both of them at Bakou, and in the same 
way cholera, in the epidemics of 1823, 1830, and 1846, 
always and invariably passed through Recht, Astara, 
Lenkoran, and Bakou. At the latter city the land route 
splits on the north. It continues to follow the western 
border of the Caspian Sea, and passes by Derbent, and 
reaches Astrachan exactly as does the sea route, and we 
have seen cholera at every one of its appearances, in 
(SUPPLEMENT.) 
1823, 1830, and 1846, pass over this same line, passing by 
Bakou, Derbent, and Astrachan. In 1823 it stopped at 
Astrachan, while during 1830 and 1846 Astrachan was 
only one of the steps of its invading inarch. 
The second line of travel passes over the Caucasus. It 
leaves Bakou, passes by Tiflis, and follows the Caspian 
Sea to the Black Sea. The point of departure from the 
Caspian Sea is Bakou. The point of arrival on the 
Black Sea is Poti, or Trebizond. The epidemics of 1830 
and 1846 divided, following both of the two routes that 
have been spoken of. One current followed the border 
of the Caspian Sea, another crossed the Caucasus. 
This progress of cholera, always following the same 
lines, is a striking illustration of the law formulated. It 
always follows the human currents, in the steps of the 
traveller. It is imported by man alone, and precisely the 
same point is shown if we follow the successive steps of 
the epidemics that have travelled by the sea route. 
As an illustration, the epidemic of 1854 in the Crimea 
was due to vessels coming from Marseilles, and carrying 
troops from an infected country. Cholera appeared suc- 
cessively at. every one of the points where these vessels 
touched. They landed at Messina, and Sicily was in- 
vaded. They touched at the Piraeus, and Greece was 
attacked. They stopped at Gallipoli, and cholera ap- 
peared at Gallipoli. Constant communication was being 
held between Gallipoli and the Dardanelles, Constanti- 
nople, and Varna. Cholera developed at all three places. 
The same was shown in the progress of the epidemic of 
1865. It must not be supposed, however, that the asser- 
tion is made that cholera took the special direction from 
east to west; on the contrary, it radiated from India in 
all directions-north, south, east and west-according to 
the ease and number of the means of communication. 
4. Transportability as Indicated by the Evolution of 
Epidemics in Infected Localities.-Many examples of this 
may be quoted, among which are the following : 
In Constantinople it is possible to trace out the suc- 
cessive extension of the disease up to the time of its 
general diffusion. At Constantinople it manifested itself 
first at the arsenal, where it had been carried by the sick 
who were landed from the ship Moukbiri-Sourour. From 
the arsenal it reached the neighboring quarter of Kassin- 
Pacha, and then a few cases appeared in different parts of 
the city, for the most part of persons who had fled from 
the quarter first attacked. Up to July 16th the total of 
the deaths from cholera in the entire city, except those at 
the Marine Hospital, reached 130, when suddenly it was 
learned that the disease had broken out with violence at 
Eini-Keni, a village situated on the Bosphorus, twelve or 
fifteen kilometres from the quarter where the epidemic 
had begun. It was established that the first case of cholera 
had appeared on July 11th, in a Turkish cafe, in a work- 
man coming from Kassin-Pacha ; that the next day many 
of the individuals who frequented this cafe fell ill, and 
two died ; that during the following days the disease 
was propagated in the quarter until the 16th, when, after 
the occurrence of several deaths among prominent 
families, a panic seized the whole population of the vil- 
lage, who tied in all directions. Mussulmans, Greeks, 
Armenians, and Jews fled into other villages and quarters 
of the city which were then unaffected, where they trans- 
ported the disease. The Jews in particular, who had 
been the most seriously attacked, and who carried with 
them their soiled clothing and their dead, became the 
especial propagating agents of the disease. At Kous- 
toundjouc, at Kas-Keni, and at Balata, the epidemic 
broke out immediately after the arrival of these fugitives. 
From this moment dates the generalization of the epi- 
demic. It is not necessary to add other examples. The 
same thing is shown in the history of every local epidemic 
that has been intelligently traced. 
It has been opposed to this idea of the transportability 
of cholera that sometimes a restrictive intercourse failed 
to arrest the progress of the disease ; but in all these 
cases the measures were either tardily employed, or ap- 
plied without scientific rule. Others have spoken of the 
immunity of countries which had not protected them- 
selves by any sanitary measures. The answer to this is 
60 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Asiatic Cholera. 
Asiatic Cholera. 
the question, whether cholera, although it is a disease 
capable of spreading by infection, must, therefore, be 
possessed of a method of forcing this infection. And, 
in conclusion, no matter what the differences of opinion 
are, the law of transportability remains absolutely estab- 
lished by all the facts yet obtained in regard to cholera. 
Methods of Transportation of Cholera.-In a considera- 
tion of the question of the method of transportation of 
cholera, we are to look at two principal points, the agent 
of cholera, that is, the organism of the disease, and sec- 
ond, the medium. 
The agent of cholera is unquestionably a bacterium, 
having India for its origin. It extends itself, and 
reproduces itself indefinitely, and many media serve as 
vehicles for its transportation throughout the entire 
■world, but this choleraic agent would be wholly power- 
less if it did not encounter favorable conditions for its 
development. The medium, therefore, is indispensable 
to its power, and this favorable medium is made up of 
certain telluric conditions, the surroundings, and so on. 
So far as the methods of transportation of cholera are 
concerned, therefore, we have to consider more the me- 
dium in which it appears than the cause of the disease 
itself. Fauvel has expressed this truth as follows : " That 
a fire is not proportionate to the spark which gives it birth, 
but to the combustibility and mass of the material that it 
encounters." So, frequently, a few cases, or one only, as 
at Altenburg, are sufficient to produce the explosion of 
an epidemic. 
The clinical consideration of the means of transporta- 
tion of cholera is to be made under the following 
headings: 
First, the transportation by men attacked by cholera, 
and the role played by the closets that have received chol- 
eraic excreta. A person arriving from an infected place 
is always necessary for the beginning of an epidemic. 
In other words, man himself is the most powerful agent 
for the spread of cholera, the specific micro-organism 
being found, as has been demonstrated by innumerable 
experiments, in the excreta. Washerwomen have been 
attacked by the disease after washing linen soiled by 
evacuations, while others, who had simply touched this 
linen, also contracted the malady. Budd relates (quoted 
by Hirsch in Schmidt's Jahrbucher, vol. xcii., p. 255) 
that in 1854 a person affected with cholera arrived in an 
English factory of 645 workpeople. There followed 
144 deaths from cholera in five weeks. The disease de- 
veloped solely among those who made use of the closets 
where choleraic dejecta were deposited. Instances of 
this kind can be multiplied almost indefinitely. 
Second, the transportation by means of choleraic diar- 
rhoea. As illustrations of this, innumerable instances 
might be quoted, especially that mentioned by Budd in 
the reference given above. A person sick of diarrhoea 
came into the midst of a perfectly healthy population in 
a colliery, and died. Diarrhoea became general, and 
seventeen persons contracted cholera. The case of Dr. 
Alexander, in the Gazette Medical for 1849, is also an il- 
lustration of this point. There was not at Hamel, a vil- 
lage twenty-five kilometres from Amiens, any indication 
of cholera, when, on April 4th, from Paris, where chol- 
era existed, there arrived a soldier sick with diarrhoea. 
He was received into his parents' house where he re- 
mained three days. On the 14th he went to the Hotel- 
Dieu, and the same day his brother, who had come a 
number of times to see him, was attacked by foudroyant 
cholera, and died in twelve hours. His wife died three 
days afterward. The father, who had shown some symp- 
toms of cholerine, was attacked with cholera on the 11th, 
and died on the 15th. Another son of this man, seven- 
teen years old, and a child of four years, his grandson, 
were attacked with cholera, and got well. The father- 
in-law of the brother who had taken care of him and his 
daughter were attacked by cholera, but recovered. A 
child of eleven years, who was often at the house, and 
whose parents had taken care of the same brother and 
his wife, was attacked on the 14th, and died the follow- 
ing day. 
Third, can the bodies of persons dead of cholera 
communicate the disease ? Although the evidence seems 
to point toward this being a possible danger, it is not a 
serious one in civilized countries. 
Fourth, can cholera be transported by healthy indi- 
viduals ? This must be answered in the negative. The 
facts quoted that seem to show that this can be so, must be 
explained by supposing that the individuals who were 
believed to be entirely well were in reality sick of a 
choleraic diarrhoea, or else that they carried clothing or 
linen soiled with choleraic material. 
Fifth, can cholera be transported by living animals ? 
Animals are not susceptible to the disease. A certain 
number of experiments have succeeded in producing 
cholera in animals, but with great difficulty. There is no 
fact to support the supposition that animals can carry the 
disease, either on the skin or hair. 
Sixth, the transportation of cholera by means of cloth- 
ing, personal effects, and so on. The-disease cannot be so- 
transported unless these materials have been contami- 
nated by cholera dejecta. This, of course, is an exceed- 
ingly important point, for if soiled, the material may be 
dangerous ; if not soiled, there is no danger at all, even 
if it comes from cholera centres. It is of equal impor- 
tance to know whether contaminated objects have been 
packed up, or exposed to the air. A contaminated ob- 
ject exposed to free air for a definite time loses its power 
of transporting the virus. The Conference of Constan- 
tinople considered that a very short time was sufficient 
to do away with all danger, and recent bacteriological 
research has wholly confirmed this opinion. On the 
other hand, contaminated objects that have been packed 
up and kept closed from air retain their virulence for a 
greater or less time, as may be shown by many instances. 
Seventh, can cholera be transported by merchandise ? 
Although merchandise imported from India, whether to 
Suez, or directly to Europe, has never been known to- 
transmit cholera, this method of transportation is not ab- 
solutely impossible, and many of the materials brought 
from India-cloths, and so on-retain in their interstices 
a confined air that certainly might preserve and transport 
for a great distance the contagion with which they may 
be impregnated ; but although this is a possibility, it is 
not probable, and the Conference of Constantinople 
unanimously accepted the absence of proofs of the 
transportation of cholera by merchandise, while it ad- 
mitted the possibility of its being done, under certain 
conditions. Since that time, Zehnder, the Swiss del- 
egate to the Vienna Conference, in 1874, cited facts in 
favor of the danger of rags in transporting contagion 
(see the report of the International Sanitary Conference- 
of 1874, page 272). But at the Conference in Rome, in 
1885, Koch disputed the interpretation that had been put 
upon these facts. 
Eighth, water is perhaps the most important agent in 
the spread of cholera, and evidence to this effect was ob- 
tained long before the discovery of the cholera spirilla. 
J. Simon brought out some facts in England showing 
it. At London thirteen deaths out of a thousand inhabi- 
tants occurred among those whose houses were supplied 
with river water in the neighborhood of the sewer. 
Tested at this point, the water yielded forty-six grains 
of solid residue to the gallon. In other houses in the city 
that were in the same hygienic condition, but not supplied 
with this water, the mortality was only three and seven- 
tenths in a thousand, but the water which they used had 
been taken from outside the city,and yielded only thirteen 
grains of solid residue to the gallon. 
At Halle, Delbruck noticed that in prison, where the 
epidemic had developed very largely, the wells commu- 
nicated with the drains. At Brachsted the epidemic 
arrested itself just as soon as a suspected well was closed. 
Delbruck explained the less intensity of the epidemic of 
1867, compared with that of 1866, by the fact that the 
carrying of the water had been modified. Water was 
furnished almost pure in 1867, while up to the autumn of 
1866 the conduits carried the water from the Saale 
through a region where all the discharges of the city 
were scattered. Ballot also spoke of the influence of 
impure water on the spread of cholera in Holland. 
61 Asiatic Cholera. 
Asiatic Cholera. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Snow, in England, and innumerable other writers in 
Europe, India, and America, lay the greatest possible 
stress upon impure water as the special means for the 
conveyance of the infective agent of cholera. 
The contamination of water played an extremely im- 
portant part in the extension of cholera in Egypt in the 
epidemic of 1883. The Mussulman population of Egypt 
bathe very frequently, but they are not careful about the 
water that they use for drinking. At Damietta the water 
is exceedingly foul upon the points of the Nile from which 
the water-carriers fill their water-casks, and just at these 
places are the special spots selected for bathing. The 
houses along the bank discharge their foul material di- 
rectly into the river, and drains carry to it discharges 
from other houses, and from the mosques. According 
to Koch, these mosques play an extremely important 
role in the spread of cholera. The German cholera 
commission was able at Damietta to examine a number 
of mosques, the description of the arrangement of which 
is as follows : Only that part of the mosque that is di- 
rected toward Mecca is used for prayers. At the other 
end is an open space, in the centre of which is a tank for 
bathing, and sometimes this water remains several weeks 
without being changed, and surrounding the basin are a 
series of urinals and closets. The discharges from the 
whole are passed into the Nile, so that it is not strange 
that the infected material should be transported by such 
a water-supply. 
The epidemic of 1884 furnished new proofs in favor of 
the spread of cholera through the agency of water. 
Messrs. Marey, Brouardel, and Thoinot especially insisted 
upon this point. Marey, at the sitting of the Academy of 
Medicine, October 14,1884, said : " Among the influences 
that can cause the spread of typhoid fever or cholera there 
is one that by its intensity dominates all the others-that is 
the contamination of public water-supplies." If a number 
of epidemics of cholera be studied, it can be determined, 
in effect, that cholera easily follows watercourses ; that 
it is especially along small watercourses that it is prop- 
agated, is most frequent and striking. In order to explain 
this, there are but two hypotheses that are possible. 
First, brooks, torrents, or rivers flow in valleys that 
are often narrow and shut in, and the villages found 
there often can have no communication except with each 
other. When one is attacked, it is a perfectly simple 
matter that the others should be also in their turn. This 
explanation is very plausible ; for certain cases, and some 
epidemics, can be explained in no other way. The great 
rivers, the large watercourses, along which are scattered 
regions attacked by cholera, serve for the propagation of 
this disease, like the great roads of travel, in this way 
only, that they are lines of communication frequented 
by travellers. 
Second, water is certainly a propagating agent of 
cholera. It is the water of a torrent, a brook, or a small 
river, contaminated in one part of its course, that trans- 
ports the disease to the inhabitants on its borders that 
drink of the water, and innumerable instances can be 
brought forward to illustrate this point also. 
Proust (loc. cit., p. 216) speaks of the choleraic agent 
having for its vehicle of transportation either the air or the 
water, but the evidence in favor of the air as one of the 
transporting agents of cholera is nothing, and the weight 
of scientific evidence of late years militates against such 
a means of transportation. Altitude seems to have but 
slight influence upon the development of the disease up 
to a certain point, although Farr (in the Registrar-Gen- 
eral's Report on the Mortality of Cholera in England, 
London, 1852) has attempted to demonstrate that the 
mortality from cholera was in inverse proportion to the 
elevation. The objection to this is, that the less frequent 
occurrence of cholera on the most elevated points may 
be due to the fact that the less accessible points are 
more thinly inhabited. 
Moisture, taken in connection with the subsoil water, 
is a favoring cause of the greatest importance, and ob- 
servations in this direction have furnished the basis for 
Pettenkofer's theory of the connection of subsoil mois- 
ture with cholera. 
(SUPPLEMENT.) 
The development of the epidemics of 1836 and of 1854 
seemed to coincide with the period of greatest diminu- 
tion of the subsoil moisture in Munich, and therefore 
the choleraic contagion with which the soil is impreg- 
nated appears to disengage itself more easily. Hirsch 
reached a similar conclusion. Kreuzer, in 1855, at Vien- 
na, and again Pettenkofer, at Munich, observed the same 
facts. Pettenkofer's theory differs from others, in that, 
putting aside the chemical composition of the earth, he 
attaches a special importance to its physical character- 
istics, its density, its porousness, etc. He considers that 
the condition of the subsoil of localities and of houses 
plays a role of special importance in the propagation of 
cholera, and upon this special cause he places the de- 
velopment of an epidemic, after an importation from 
without; and, studying almost exclusively the physical 
condition of the region, the compact or porous condition 
of the subsoil, he considers that not only the primitive 
earth, and the soils of the transition period, but also the 
secondary formations, produce immunity when they are 
exposed to air in the condition of rocks. On the other 
hand, every porous soil that is susceptible of imbibition 
can become easily impregnated with fluid, or with gas, 
and vegetable earths as well as silicious earths, may form 
"fat," always moist, lands, throwing out continual 
moisture about them, favoring the diffusion of the germs 
of cholera. Where the soil is made up of a compact cal- 
careous rock, cholera never becomes epidemic, and a 
few cases observed in such situations as the result of 
importation, do not propagate the disease. 
Pettenkofer's theory has two points that must be dis- 
tinguished from each other. 
First, the nature of the soil. The soil must be porous, 
easily permeable, and also easily impregnated by liquids 
and gas. This condition is a permanent one. 
Second, the level of the subsoil moisture. This level 
being movable, the effect is variable ; when subterranean 
waters have reached the maximum of their elevation, 
there is neither decomposition of organic materials, nor 
throwing off of miasms. If the subsoil moisture descends 
to a lower level, putrefaction begins, the miasmatic va- 
pors are thrown off more intensely, and just at this time 
the epidemic reaches its greatest development. This 
second point of his theory, certainly an ingenious ex- 
planation of certain cases, appears to be much more 
hypothetical than the first, the question of the porosity 
of the earth. 
To sum up, Pettenkofer's theory, while it scarcely has 
the value ascribed to it by him, certainly seems to be 
a partial explanation of the propagation of cholera by 
means of the porosity and moisture of the earth. 
Ninth, atmospheric conditions play a not very im- 
portant role, although the influence of season is manifest, 
and apparently storms sometimes seem to aggravate con- 
siderably an epidemic. 
Somatic Conditions.-Race or nationality has no in- 
fluence upon the development of cholera. * The special 
influences favoring it are those of misery, fatigue, cold, 
and depressing mental conditions, which, by diminishing 
the resisting power of the body, render it more suscepti- 
ble to the influence of the epidemic. Collections of hu- 
man beings, in other words, agglomeration, plays a very 
considerable role in the propagation of epidemics; so 
also do methods of transportation. Railroads are often 
the means of propagation, as was the case in the in- 
stance of Altenburg, quoted above. The epidemic of 
1865, in Paris, was started by a woman who left Mar- 
seilles, with a choleraic diarrhoea, and was attacked with 
cholera upon her arrival in Paris. Transportation by 
caravans does not give much chance for the spread 
of the disease, when the distance passed over is of great 
extent ; in fact, a great desert is the best of all obstacles 
to the propagation of cholera. In ships is most often 
found united the conditions of crowding and confine- 
ment favorable for the development of the choleraic 
agent. 
Proust appears to believe that these elements do not 
have much potency if the entire ship's company come 
from the same infected region-in other words, have 
62 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Asiatic Cholera. 
Asiatic Cholera. 
acquired an immunity in a choleraic focus ; but if the 
ship's company has received a partial renewal, if new 
persons have come on board among the acclimated pas- 
sengers, cholera finds a new favorable medium for attack, 
and, if aiding circumstances appear, the ship may be- 
come the centre of an intense epidemic. He goes on to 
speak of this " law of accustoming," in what takes place 
in armies, the great fairs, and the pilgrimages, for when 
cholera is carried into these great collections, if the 
mass of people have not undergone the " choleraic accli- 
mating," the explosion of the disease is rapid, and the 
mortality considerable, but only continues for a few days, 
and ceases soon. The Crimean War furnishes an example 
of the rapidity of development and intensity of the dis- 
ease among vessels free from the choleraic influence. 
At the commencement of April, 1855, there reached 
Constantinople from France, fifteen to twenty thousand 
troops, made up in part of the Imperial Guard. These 
troops had not, during their voyage, a single case of 
cholera among them. They camped on the heights of 
Masslak, in an extremely healthy situation, and at that 
time there were in the city of Constantinople but very few 
traces of cholera. The rolls of the French military hos- 
pitals gave only fifty-three cases during March, and the 
roll of April 11th showed none. In the Crimea the 
cases of cholera were also very few, and nevertheless 
the troops were hardly settled at Masslak, when, on the 
night of April 14th and 15th, cholera broke out among 
them, and a severe epidemic followed. 
Fauvel (" Meinoire lu a l'Acad. des Sciences," Paris, 
1883) sums up this question of immunity in the following 
propositions : 
" 1. The ports of India that are the seat of endemic 
cholera are never the scene of a great epidemic. 
"2. This fact relates to the general, but not absolute, 
immunity enjoyed by the native population of these 
parts. 
" 3. This immunity does not exist in the endemic 
localities for strangers who are in a condition favorable 
for contracting the disease. These are especially the 
Mussulman pilgrims who come to Bombay to embark for 
Mecca. 
"4. The epidemics of cholera that develop in India, in 
the regions where the disease is not endemic, come from 
the places where it is endemic, and are favorable for 
attacking the Hindu pilgrimages. 
"5. The epidemics observed among the pilgrims to 
Mecca can also be traced to the localities where cholera 
is endemic. 
"6. A severe epidemic of cholera confers upon the 
country or upon the locality which it has attacked a more 
or less complete immunity, which is more or less durable, 
and of which it is impossible to formulate the law for 
Europe, but which in India appears to last for a num- 
ber of years, 
"7. In the Hedjaz, and in the sparsely populated parts 
of Arabia, cholera has but a feeble tendency to propagate 
itself among the native population. 
" 8. The fact of the existence of a great epidemic of 
cholera in any country whatever is a proof that cholera 
is not there endemic.' 
To sum up, new scientific facts bear upon the question 
of immunity and make them clear upon a side hitherto 
unknown. The etiology and prophylaxis, in especial, of 
cholera receive from these facts new indications, and 
these facts also appear to be the expression of a law' that 
includes an entirely different category of infectious dis- 
eases, w'hich leave after them an immunity of a greater 
or less extent." 
Period of Incubation.-The question of the period of 
incubation of cholera gives rise to a great deal of discus- 
sion. It appears, however, that in the immense majority 
of cases a period of a few days is sufficient for the incu- 
bation, and that sometimes this may require only a few 
hours. This fact is easy to observe if the beginning of 
the disease in a city or upon a ship be studied. 
The Cholera Conference at Constantinople concluded as 
follows : " That all the facts cited in regard to a period 
of incubation longer than a few days are based upon 
cases that are not conclusive, either because the premon- 
itory diarrhoea was comprised in the period of incubation, 
or because the infection could have occurred after the 
departure from the infected locality. The following is 
an instance: 
On November 3, 1848, upon the ship Swanton there 
were two hundred and eighty-nine emigrants for New 
Orleans, and the cholera did not break out on board until 
November 25th,-that is to say, the twenty-third day of 
the voyage,-and occasioned tliirteen deaths. A certain 
number of these emigrants came from points in Germany 
where the cholera existed. This long period of incuba- 
tion can be explained upon two hypotheses: either the 
passengers had with them clothing soiled with choleraic 
materials, which, placed in a confined air, could transmit 
cholera; or certain of the individuals embarked might 
have been affected at the time of their embarkation with 
a diarrhoea that might later have developed into true 
cholera. The duration of this premonitory diarrhoea has 
been much discussed, and in general it has been concluded 
that it does not last more than three days, and when it 
does pass this period, it is rarely prolonged beyond a 
week, and that therefore an individual isolated from all 
sources of contamination, and in whom the diarrhoea 
should be prolonged more than eight days after this iso- 
lation without presenting any characteristics of cholera, 
could be considered non-choleraic. But Griesinger among 
others dissents from this opinion, and declares that the 
period of incubation of cholera may be much longer. 
Bacteriological examination is the only method of set- 
tling the question. 
Description of the Disease.-Asiatic cholera, in 
individual cases, has no marked characteristics distin- 
guishing it from similarly violent attacks of "cholera 
nostras ; " the only absolute method of making a diagnosis 
in single cases is by the discovery of the spirillum of the 
disease and its identification. In general, an attack may 
suddenly develop, its onset being marked by great uneasi- 
ness, repeated discharges from the bowels, followed by 
syncope. This attack may overtake the victim while 
walking on the street in apparently good health. It is 
often preceded by a state of vague suffering, rapid pros- 
tration, deep colicky pains, anorexia, sometimes a diar- 
rhoea, profuse sweats, disturbance of the senses, and more 
or less of retardation of the pulse. After the development 
of the disease the symptoms follow each other in such a 
way as to allow of a division into two distinct periods. 
First Period.-This is marked by an increase in the 
number of dejections and acts of vomiting ; a flux is 
established which is at first serous or slightly bilious, 
and afterward becomes " choleraic." This term is used 
to designate those characteristic discharges of cholera 
which are liquid, whitish, grumous, sometimes resem- 
bling unclarified whey, sometimes a decoction of rice or 
oatmeal, and sometimes thickened meal, and nearly clear, 
which emit an insipid spermatic odor, and sometimes 
present traces of blood or bile. These evacuations are 
rarely absent, often continuing to the termination of the 
disease. Burning thirst, pain in the epigastrium, and 
prolonged hiccough are usual accompaniments. Intense 
cramps of the limbs occur, particularly in the calves of 
the legs ; the muscles are often in a state of tonic con- 
traction. Spasmodic movements, as involuntary flexion 
and extension of the fingers and toes, may often be seen. 
The pulse is very feeble, often imperceptible. The feat- 
ures are altered, trembling and great agitation come on, 
the pulse becomes suppressed : bluish spots appear, first 
upon the extremities ; the skin becomes blue or black 
almost everywhere ; the nails are livid and almost black, 
the fingers wrinkled, and the genital organs retracted. 
The volume of the body diminishes rapidly and percep- 
tibly ; the eyes sink in and are dull, with a bluish circle 
surrounding them ; the conjunctiva fades, respiration is 
slow and feeble, the breath cold, and the pulse is reduced 
to a mere oscillation. The secretions are arrested, espe- 
cially the urine, the voice is reduced to a whisper, the 
nose is cold and-rarely-gangrenous, the cornea is flat- 
tened and puckered ; spots of blood appear on the scle- 
rotic, viscid sweat on the face and limbs ; the intellect 
63 Asiatic Cholera. 
Asiatic Cholera. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
becomes obscured, respiration is embarrassed, hiccough 
commences, and death follows, in the midst of an ap- 
parent calm. This is called the cold, livid, or asphyxic 
period. When patients escape death in this stage they 
enter upon the 
Second Period.-In this the coldness ceases to increase, 
warmth returns, the pulse improves and gradually be- 
comes febrile, the face regains color, the eye becomes 
animated, and a general reaction occurs. 
If recovery is to be easy and rapid, vomiting becomes 
less frequent, the diarrhoea remains, but the discharges 
no longer present the appearance peculiar to the disease ; 
the secretion of urine returns, nausea, thirst, and pains 
in the stomach cease to be felt, the pulse becomes regu- 
lar, and convalescence begins. 
If reaction is incomplete, the cold stage returns with 
renewed severity, or, on the other hand, if reaction be 
too severe, such accidents may occur as apoplexies, 
spasms, convulsions, local congestions and inflamma- 
tions, and occasionally latent pneumonia. Stupor is 
sometimes present, with some of the signs of the last 
stage of typhoid fever. Swelling of the parotid glands 
and various skin affections, as roseola, urticaria, ery- 
thema. erysipelas, etc., may appear toward the close of 
the disease. 
The average duration is from one to three days, but 
sometimes death occurs in less than six hours, and is 
occasionally delayed a long time-in one case for fifty 
days. 
Complications and Secondary Affections. - Complica- 
tions are rare, and apparently accidental ; among them 
peritonitis, jaundice, gangrene, oedema of the lungs, ery- 
sipelas of the face, abscesses, ulcerations of the eyelids, 
and aphthae may be mentioned as of occasional occurrence. 
Secondary affections are, however, very common. They 
may consist of gastro-intestinal inflammations-immedi- 
ate or occurring after some days of convalescence-or of 
affections of the respiratory organs. In other cases, per- 
sons who have apparently escaped the accidents of cholera 
have a secondary fever, described as of a typhoidal type 
-dry skin, tension and tenderness in the epigastrium, 
jactitation, dry tongue, bilious stools, and chills. Vari- 
ous skin eruptions occur, and temporary albuminuria has 
been observed following an attack of cholera. The most 
grave of the secondary affections, however, are those 
which affect the nervous system. The cerebral conges- 
tions during reaction are, in some cases, followed by a 
typical meningitis with trismus. Rayer's "Etat Cerebral 
cholerique " includes a group of phenomena distinct from 
those of meningitis, which supervene upon the cold 
stage ; the skin is cold, the pulse feeble, the head heavy, 
the countenance stupid, and sometimes the cholera tint 
remains. Another affection is a sort of non-febrile de- 
lirium, lasting for two or three days, and the spasmodic 
contraction of the forearm which occurs during conva- 
lescence. True intermittent febrile attacks, with initial 
chills, occurring every day during reaction, have also 
been observed. All these affections are, for the most 
part, more rapid than when occurring in an individual 
previously healthy. 
Course, Duration, and Termination.-If death does 
not occur during the algid stage, a peculiar transforma- 
tion in the disease takes place and reaction sets in. This 
reaction varies in different cases, being slow and tedious 
in some, and abrupt and rapid in others ; its course is 
not essentially modified by any antecedent disease, even 
those occurring as complications. 
In the vast majority of cases cholera runs its course 
with great rapidity, the greater number of attacks last- 
ing from eighteen to twenty-four hours, the shortest from 
one to six hours, and the longest from fifteen to twenty 
days. Its duration is the shortest at the height of an 
epidemic. 
The termination of epidemic cholera may be favor- 
able, the progress of recovery varying widely in different 
cases ; it may be complete in a few hours even, and the 
patient may return to his ordinary occupation ; on the 
other hand, it may be delayed until after a long and peri- 
lous struggle against complications and secondary affec- 
(SUPPLEMENT.) 
tions. There may remain a general debility such as is 
not often seen after any other disease ; the emaciated 
features, languishing expression, capricious appetite, ob- 
stinate gastralgia, colic, wakefulness, tendency to cold- 
ness, partial or general, and intellectual and moral dejec- 
tion persist for a long time. An attack has been known 
to change the whole constitution and temperament of a 
patient. One attack appears to furnish no immunity 
against another, and relapses are always to be feared. 
Forms.-The forms spoken of-the common or grave, 
such as has just been described, "cholerine,''' foudroyant 
cholera, and paralytic cholera, described by the Russians 
and Germans-are all merely the same disease, occurring 
in varying forms of intensity. 
Pathological Anatomy.-The alterations of the internal 
organs in a case of death from cholera bear little rela- 
tion to the violence of the disease. The appearances are 
about as follows : Emaciation is general, and there is 
marked lividity of the lips and nostrils. Rigor mortis is 
not rare before the warmth of the body has wholly de- 
parted. The peritoneal surface is sticky and covered 
with a viscid exudation ; the vessels of the mesentery are 
engorged with blood. The calibre of the intestinal canal 
is more often increased than diminished, and always con- 
tains some fluid choleraic matter. The fluid is blood- 
serum, and the thicker material found in it is made up 
of intestinal epithelial cells and mucus. The intestinal 
mucous membrane is usually normal in thickness, but is 
generally denuded of epithelium. The villi are swollen, 
giving the surface a velvety appearance, and Peyer's 
patches and the solitary follicles are much enlarged. 
The glands of the stomach and of the duodenum are 
enlarged, and the surface is largely denuded of epithe- 
lium. There are no special lesions of the other organs. 
The liver is rarely enlarged, but is usually congested with 
dark, thick blood. The gall-bladder is also generally 
distended with bile, which is thicker than normal. The 
biliary duct is not obstructed. The pancreas presents no 
marked alteration. The spleen, in rapid cases, is small, 
hard, and wrinkled upon its surface, of a deep red color 
on section, and sometimes dotted with ecchymoses; in 
slow cases it may be slightly enlarged and less deep red 
in color. The blood is thicker than normal, coagulates 
slowly, and the separation into clot and serum is very 
incomplete. The corpuscles are not altered in shape, but 
there is a remarkable diminution in the proportion of 
water and neutral salts, and a decrease in the amount of 
fibrin and albumin. The heart is usually soft and flabby, 
with ecchymoses in the pericardium. The left side is 
apt to be empty and contracted, the right distended with 
dark, thick blood. The arteries are, in general, nearly 
empty, the veins distended with blood. The pleunv are 
very frequently coated with a glutinous, stringy sub- 
stance, and ecchymoses often appear in the sub-pleural 
cellular tissue. The lungs are usually healthy, but pre- 
senting engorgements at the posterior portions. The 
bronchi are much congested, and may contain a white, 
stringy mucus, analogous to that found lining the intes- 
tinal canal. The condition of the brain and spinal cord, 
together with their appendages, is merely that of conges- 
tion without special lesion, although it has been declared 
that there is a sensible increase in their consistency. The 
ganglionic system presents no change worthy of notice. 
The muscles are often engorged with blood, and a very 
marked reddish-brown discoloration of the bones and of 
the teeth has been noticed in those dying of asphyxia. 
Renal congestion is the marked symptom in connection 
with the genito-urinary tract, and the straight tubules are 
often completely stripped of their epithelium. In those 
dying in the cold stage the bladder is empty and firmly 
contracted. 
Description of the Spirillum of Cholera and 
of Certain Organisms Allied to It. - The Nature 
of the Contagium Vivum of Cholera (see Sternberg's 
" Manual of Bacteriology,'' New York, 1892.).-Asiatic 
cholera is without doubt "due to a special organism-the 
so-called "comma bacillus" of Koch-this name being 
a misnomer, for the bacterium is not a bacillus, but a 
spirillum. 
64 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Asiatic Cholera. 
Asiatic Cholera. 
The parasitic nature of the disease was suspected for a 
long time. A number of observers had noted the pres- 
ence,'in the cells, of bacteria answering the description 
of this special one, but it was not until the advance in 
methods of observation had progressed a long way that 
it was possible to isolate the organism, and study it under 
artificial conditions in such a manner as to obtain the evi- 
dence necessary to connect it with the process as a causal 
(SUPPLEMENT.) 
thicker than the bacillus of tuberculosis. It usually 
occurs in this situation singly, but not infrequently it is 
arranged in pairs, with the curves opposed to each other, 
and thus recalling the shape of the letter " S ". Under 
cultivation in bouillon it appears longer and thinner, and 
there are many true spirilla to be seen in the prepara- 
tions made from such a culture. 
A characteristic that is of especial interest, is its 
Fig. 17.-Cholera Vibrio. Intestinal Contents of a Man Dead of Chol- 
era. Cover-glass Preparation Stained with Fuchsine. (Fraenkel.) 
X 1000. 
Fig. 19.-Cholera Vibrio. Agar Culture, Twenty Hours Old. Cilia 
Bearing Cells. Cover-glass Preparation, Stained with Fuchsine. 
(Fraenkel.) X 1000. 
factor. It was in the year 1883 that Koch first dis- 
covered and described the spirillum of Asiatic cholera, 
which he first found during his investigation in Egypt 
during the epidemic there, and studied further during 
the following winter in India. 
The organism occurs especially in the small intestine, is 
generally wholly confined to the contents of the intestine 
and the glandular cul-de-sacs, but is occasionally found 
in the intestinal walls. It is exceptional to find it in any 
other part of the body, and it is not strange that investi- 
extreme motility, which has been demonstrated by Loff- 
ler to be due to a fine cilium placed at one end of the 
organism. 
Shape and motility are not, however, sufficient to dif- 
ferentiate this bacterium from others with similar char- 
acteristics-and there are many that possess such,-but 
the method of development upon the various culture- 
media is entirely characteristic, and, as shown by Koch, 
is all that is necessary for separating this one in particu- 
lar from the others that resemble it. It liquefies gelatine, 
Fig. 18,-Cholera Vibrio. - Bouillon Culture, Two Days Old. Cover- 
glass Preparation Stained with Fuchsine. (Fraenkel.) X 1000. 
Fig. 20. - Cholera Vibrio. Colonies on Gelatine Plate, Twenty-four 
Hours Old. (Fraenkel.) X 100. 
gations undertaken with the idea that cholera was a gen- 
eralized disease were not productive of results. The 
bacterium is found in large quantities in the dejecta, and 
sometimes-in fact not infrequently-in almost a pure 
culture. 
In the intestines and in the dejecta it presents the 
appearance of a short, thick rod, slightly curved in the 
long diameter, hardly half as long, but considerably 
but it does this slowly, and at the same time a certain 
part of this liquefied portion evaporates, and as a result 
there is a special appearance that can hardly be con- 
founded with anything else. At the upper portion of 
the gelatine, there is a round cavity full of air, and as 
the surrounding gelatine has remained solid, the appear- 
ance is that of a bubble of air in the midst of the upper 
part of the gelatine and above the liquefied part. The 
65 Asiatic Cholera. 
Asiatic Cholera. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
appearance is wholly different when the organism found 
by Finkler is put under the same conditions, and equally 
so with the cheese-spirillum of Deneke. 
Description of the Cholera Spirillum.-Discovered by 
Koch, in 1884, in the excreta of cholera patients, and in 
the contents of the intestine of recent cadavers. The 
etiological relation of this organism to Asiatic cholera is 
now generally admitted by bacteriologists. 
(SUPPLEMENT.) 
By Lbfiler's method of staining, the rods may be seen 
to have a single terminal flagellum. In old cultures the 
bacilli frequently lose their characteristic form, and be- 
come variously swollen and distorted. Hueppe has de- 
scribed the appearance of spherical bodies in the course of 
the spiral filaments which he believes to be reproductive 
elements, the so-called arthrospores. The cholera bacil- 
lus stains with the usual aniline colors, but not as quickly 
Fig. 21.-Cholera Vibrio. Colony on Gelatine Plate, Forty-eight Hours 
Old. (Fraenkel.) X 150. 
Fig. 23.-Cholera Vibrio. Needle Culture in Gelatine, Six Days Old. 
Natural Size. (Fraenkel.) 
Morphology.-Slightly curved rods, with rounded 
ends, from 0.8 p to 2 long, and about 0.3 to 0.4 p, 
broad. They are usually but slightly curved, like a 
comma, but are occasionally in the form of a half-circle, 
or two united rods curved in opposite directions, form- 
ing an S-shaped figure. Under certain circumstances 
these curved rods may develop into long spiral filaments, 
and in hanging-drop cultures the S-shaped figures may 
also be seen to form the commencement of a spiral. In 
stained preparations the spiral character of the long flla- 
as many other bacteria. It is best stained by a watery 
solution of fuchsin. It will not stain by Gram's meth- 
od. Sections may be stained by Lbfiler's methylene blue. 
Biological Characters.-It is an aerobic, facultative 
anaerobic, liquefying, motile spirillum, grows in the 
usual culture-media at the room temperature, more 
rapidly in the incubator, does not develop above 42° C. 
or below 14° C., does not form endogenous spores. It 
forms arthrospores, according to Hueppe. In gelatine 
plate cultures, at 22° C., at the end of twenty-four hours 
Fig. 22.- Cholera Vibrio. Needle Culture in Gelatine, Forty-eight 
Hours Old. Natural Size. (Fraenkel.) 
Fig. 24.-Cholera Vibrio. Needle Culture in Gelatine, Three Days Old. 
Natural Size. (Fraenkel.) 
ments is often obliterated, or nearly so. When develop- 
ment is very rapid, the short curved rods, or S-shaped 
spirals, only are seen, but in hanging-drop cultures, or 
in media in which the development is retarded by an 
unfavorable temperature, the presence of a little alcohol, 
and so on, the long spiral filaments are quite numerous, 
and it is quite generally agreed that the so-called comma 
bacillus is really only a fragment of a true spirillum. 
small white colonies may be perceived in the depth of 
the gelatine. These grow toward the surface, and 
cause liquefaction of the gelatine in the form of a fun- 
nel that gradually increases in depth, and at the bottom 
of -which is seen the colony, in the form of a small white 
mass. As a result of this, the plates on the second or 
third day appear to be perforated with numerous small 
holes ; later, the gelatine is entirely liquefied. Under a 
66 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Asiatic Cholera. 
Asiatic Cholera. 
low power, the young colonies, before liquefaction has 
commenced, present a somewhat characteristic appear- 
ance. They are of a white, or pale yellow color, with a 
more or less irregular outline, the margins being rough 
and uneven ; the texture is closely granular, and the sur- 
face looks as if it was covered with little fragments of 
broken glass, while the colony has a shining appearance. 
When liquefaction commences, an ill-defined halo is first 
seen to surround the granular colony, which by trans- 
mitted light has a peculiar roseate hue. 
In gelatine needle cultures development occurs all 
along the line of inoculation, but liquefaction of the gel- 
atine occurs at first only near the surface. On the sec- 
ond day, at 20° C., a short funnel is formed that has a 
comparatively narrow mouth, the upper portion contain- 
ing air ; just below this is the whitish viscid mass. At 
the end of from four to six days, the funnel, having 
increased in depth and diameter, may reach the walls of 
the test-tube In from eight to fourteen days the up- 
per two-thirds of the gelatine is completely liquefied. 
Owing to the slight liquefaction occurring along the 
line of growth the first three or four days, the central 
mass that has formed along the line of inoculation set- 
tles down as a curved or irregularly bent yellowish- 
white thread, in the lower part of a slender tube filled 
with liquefied gelatine, the upper part of which widens 
out, and is continuous with the funnel above. 
On the surface of nutrient agar a moist, shining, white 
layer is formed along the line of inoculation. Blood- 
serum is slowly liquefied. On potato in the incubator, a 
rather thin semi-transparent brown, or grayish-brown 
layer is developed. 
In nutrient bouillon, the development is abundant and 
rapid, especially in the incubator. The fluid is only 
slightly clouded, but the spirilla accumulate at the sur- 
face, forming a wrinkled membranous layer. 
Sterilized milk is also a favorable culture-medium. 
In general this organism grows in any fluid contain- 
ing a small quantity of organic material and having a 
slightly alkaline reaction. An acid reaction of the cult- 
ure-medium prevents its development as a rule, but it 
has the power of gradually accommodating itself to the 
presence of vegetable acids, and grows upon potatoes (in 
the incubator only) which have a slightly acid reaction. 
Abundant development occurs in bouillon which has 
been diluted with eight or ten parts of water, and the 
experiments of Wolifhugel and Riedel show that it also 
multiplies to some extent in sterilized river- or well- 
water, and that it preserves its vitality in such water for 
several months, but in milk or water containing other 
bacteria it dies out in a few days. This organism is de- 
stroyed, in recent cultures, in nutrient gelatine at 52° C., 
as determined by Sternberg, the time of exposure being 
four minutes. A few colonies only develop after expos- 
ure to a temperature of 50° C. for ten minutes. In 
Kitasato's experiments ten or even fifteen minutes' expos- 
ure to a temperature of 55° C. was not always success- 
ful in destroying the vitality of the spirilla, although in 
certain cultures exposure to 50°C. for fifteen minutes 
was successful. The low resisting power to heat, desic- 
cation, and chemical agents, indicates that this organism 
does not form spores, and many bacteriologists agree 
that this is the case. 
Hueppe has described a mode of spore formation 
which is different from that occurring among the bacilli, 
that is, the formation of so-called arthrospores. These 
are said to be developed in the course of the spiral 
threads, not as endogenous, refractive spores, but as 
spherical bodies with a somewhat greater diameter, and 
somewhat more refractive; but this method of spore 
formation has not been observed by others who have 
investigated the question, and cannot be considered as 
established. 
The test for the presence of the cholera spirilla origi- 
nated by Bujwid and by Dunham consists in the reddish 
violet color produced in the bouillon cultures containing 
peptone, or in cultures in nutrient gelatine, when a 
small quantity (five to ten per cent.) of sulphuric acid 
is added to the cultures. According to Fraenkel this test 
(SUPPLEMENT.) 
serves to distinguish it from the ordinary bacteria of the 
intestine, and from the Finkel-Prior spirillum, but not 
from Metschnikoff's spirillum. The reaction is shown 
by bouillon cultures which have been in the incubator 
for ten or twelve hours, and by gelatine cultures in 
which liquefaction has occurred. The sulphuric acid 
should be quite pure. The color quickly appears, and 
is reddish violet or purplish red. According to Sal- 
kowski, the red color is due to the well-known indol 
reaction, which in cultures of the cholera spirillum is ex- 
ceptionally intense and rapid in its development. 
The most satisfactory method for obtaining the " chol- 
era-red " reaction,-as we have had lately abundant oppor- 
tunity to verify,-is that of Beyerinck (Cat. f. Bact. ii. 
Parasit. Bd. xii. S. 715) in which cultures are made in 
filtered neutralized one-half per cent, solution of com- 
mercial peptone, at 37° C. After twelve to twenty-four 
hours the cultures are cooled, and from two to five drops 
of C. P. Sulphuric Acid are added. If the spirillum be 
present, a very marked and beautiful rose-violet color is 
produced in the course of a few moments. 
A test which is said to distinguish cultures of the 
cholera spirillum from the spirillum of Deneke and 
that of Finkler-Prior has been suggested by Cahen. 
This consists in adding a solution of litmus to the bouil- 
lon, and in making the cultures at 37° C. The cholera 
Fig. 25.-Cholera Vibrio. Bouillon Culture, Three Weeks Old. Invo- 
lution Forms. Cover-glass Preparation, Stained with Fuchsine. 
(Fraenkel.) 
cultures show on the following day a decoloration which 
does not occur at this temperature with the other spiril- 
lum named. For determining as promptly as possible 
whether certain suspected excreta contain the cholera 
spirilla, a little of the material may be used to inoculate 
greatly diluted bouillon, gelatine plates being made at 
the same time. At the end of ten or twelve hours the 
cholera spirilla, if present, will already have formed a 
characteristic wrinkled film upon the surface of the 
bouillon. A little of this should be used to start a new 
culture in bouillon, and a series of gelatine plates made 
from it, after which the cholera test may be applied. The 
result of this, in connection with the morphology of the 
micro-organisms forming the film, and the character of 
growth in the gelatine plates, will establish the diagnosis, 
if the cholera spirillum is present in considerable num- 
bers ; if but few are present in the original material it 
may be necessary to make two or more series of plates 
and bouillon cultures before a pure culture can be ob- 
tained. and a positive diagnosis made. 
Pfeiffer has just published (in 1892) bis researches 
upon the cholera poison. He finds that recent aerobic 
cultures of the cholera spirillum contain a specific toxic 
substance fatal to guinea-pigs in extremely small doses. 
This substance stands in close relation with the bacterial 
cells, and is perhaps an integral part of the same. 
The spirilla may be killed by chloroform, thymol, or 
67 Asiatic Cholera. 
Asiatic Cholera. 
BEFEBENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
by desiccation without apparent injury to the toxic char- 
acter of this material. It is destroyed, however, by 
absolute alcohol, by concentrated solutions of neutral 
salts, and by the boiling temperature, and secondary 
products are formed which have a similar physiological 
action, but are from ten to twenty times less potent. 
Similar toxic substances were obtained by Pfeiffer 
cles of Lieberkuhn, and in some cases were seen between; 
the epithelium and the basement membrane. As a rule, 
the spirillum is not present in vomited material, but 
Koch found it in small numbers in two cases, and Nicati 
and Rietsch in three. All observers have found the or- 
ganism always present in cases of true cholera ; on the 
other hand, very numerous control experiments fail to 
show its presence in the intestinal contents of healthy 
persons, or in that of those dead from other diseases. 
Nicati and Rietsch observed a certain degree of at- 
tenuation in the pathogenic power of the spirillum, after 
it had been cultivated for a considerable time at from 
20° to 25° C., and the observation has since been made 
that cultures which have been kept up from Koch's 
original material have no longer the original pathogenic 
power. 
Cunningham in his recent publications gives the fol- 
lowing conclusions as the result of his own bacteriolog- 
ical studies : 
1. In many undoubted cases of cholera he has failed 
to find the " comma bacilli." 
2. In one case he found three different species. 
3. From sixteen cases in which he made cultures he 
obtained ten different kinds of curved bacilli, the char- 
acters of which are given in his report. 
It is possible that in India, which appears to be the 
Fig. 26.-Tooth-scraping. Curved Bacilli, Spirochaete and Leptothrix. 
Cover-glass Preparation, Stained with Gentian Violet. (Fraenkel.) 
X WOO'. 
from cultures of Finkler-Prior's spirilla, and from the 
spirilla of Metschnikoff. 
The spirillum is not found in the blood, nor in the 
various organs of individuals dead of cholera, but is al- 
ways found in the discharges during life, and in the con- 
tents of the intestines examined immediately after death, 
frequently in almost a pure culture in the colorless rice- 
water discharges. It is evident, therefore, that the mor- 
bid phenomena must be ascribed to the absorption of 
toxic substances formed during its growth in the intes- 
tine. In cases which terminated fatally after a very 
Fig. 28.-Finkler-Prior's Vibrio. Colony on Gelatine Plate, Twenty-four' 
Hours Old. (Fraenkel.) X 100. 
permanent habitat of the cholera spirillum, many varie- 
ties of this micro-organism may exist, but extended re- 
searches made in the laboratories of Europe show that 
Cunningham is mistaken in supposing that spirilla re- 
sembling " comma bacilli " are commonly present in the 
intestines of healthy persons. Sternberg says that in 
very extended researches, made in the United States and 
in Cuba, he has never found any micro-organism re- 
sembling Koch's cholera spirillum, in the dejecta of pa- 
tients with yellow fever, or of healthy individuals, or in 
the intestinal contents of yellow fever cadavers.' 
The organism most likely to be confounded with the 
cholera spirillum, and from which it must be differenti- 
ated by the methods of cultivation, as well as by the aid of 
the microscope, is the spirillum of Finkler-Prior, other- 
wise called the vibrio proteus. It was obtained by Fink- 
ler and Prior in 1884, from the faeces of patients with 
cholera nostras, after allowing the dejecta to stand for 
some days. Subsequent researches have not sustained 
the view that this spirillum is the specific cause of 
cholera nostras. 
Morphology of the spirillum of Finkler-Prior : It re- 
sembles the spirillum of Asiatic cholera, but the curved 
segments are somewhat longer and thicker, and not so 
uniform in diameter, the central portion being usually 
thicker than the somewhat pointed ends ; it forms spiral 
filaments which are not as numerous, and are usually 
Fig. 27.-Finkler-Prior's Vibrio. Gelatine Culture. Cover-glass Prep- 
aration, Stained with Fuchsine. (Fraenkel.) X 1000. 
brief sickness Koch found but very slight changes in 
the mucous membrane of the intestine, which was 
slightly sw'ollen and reddened ; but in more protracted 
cases, the follicles and Peyer's patches were reddened 
about their margins, and an invasion of the mucous 
membrane by the organisms was observed in properly 
stained sections. They penetrated especially the foili- 
68 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Asiatic Cholera. 
Asiatic Cholera. 
shorter than those formed by the cholera spirillum. In 
unfavorable media other forms are common, such as large 
oval, spherical, or spindle-shaped cells. It has a single 
flagellum at one end of the curved segments, which is 
from one to one and a half times as long as these. It 
stains with the usual aniline colors-best with a watery 
solution of fuchsin. 
Biological Characters: Is an aerobic and facultative 
anaerobic, liquefying, motile spirillum ; spore formation 
not demonstrated ; grows in the usual culture-media at 
the room temperature. 
Upon gelatine plates small, white punctiform colonies 
may develop at the end of twenty-four hours, which 
under the microscope are seen to be finely granular, and 
yellowish, or yellowish-brown in color. Liquefaction of 
the gelatine around these colonies progresses rapidly, and 
at the end of forty-eight hours is usually complete in 
plates where they are numerous. Isolated colonies on 
the second day form saucer-shaped depressions in the 
gelatine, the size of lentils, having a sharply defined 
border. 
In gelatine needle cultures, liquefaction progresses 
much more rapidly than in similar cultures of the 
cholera spirillum, and a funnel of liquefied gelatine is 
to be seen on the second day, so that by the end of a 
week the gelatine is usually completely liquefied. Upon 
the surface of the liquefied medium a whitish film is 
seen. 
Upon agar a moist, slimy layer covering the entire sur- 
face is quickly developed. 
The growth in blood-serum is rapid and causes lique- 
faction of the medium. 
Upon potato this spirillum grows at the room temper- 
ature, and produces a slimy, grayish-yellow glistening 
layer, which soon extends over the entire surface. The 
cholera spirillum does not grow upon potato at the room 
temperature. The cultures give off a fairly strong pu- 
trefactive odor, and, according to Buchner, in media con- 
taining sugar an acid reaction is produced as a result of 
their development. They have a greater resistance to 
desiccation than the cholera spirilla. 
Pathogenesis : Pathogenic for guinea-pigs when in- 
jected into the stomach by Koch's method, after previ- 
ous injections of carbonate of soda, but a smaller pro- 
portion of the animals die from such injections (Koch). 
At the autopsy the intestine is pale, and its watery con- 
tents, which contain the spirilla in great numbers, have 
a penetrating, putrefactive odor. 
Another organism resembling that of Asiatic cholera 
is the spirillum of Deneke, called the cheese, or the spi- 
rillum tyrogenum, which was obtained by Deneke in 1885 
from old cheese. 
Morphology of the spirillum of Deneke : Curved rods, 
and long spiral filaments resembling the spirilla of Asiatic 
cholera. The diameter of the curved segments is some- 
what less than that of the cholera spirillum, and the turns 
in the spiral filaments are fewer and closer together. The 
diameter of the segments is uniform throughout, so that 
this organism more closely resembles the cholera spiril- 
lum than does the preceding. It stains with the usual 
aniline colors-best with a watery solution of fuchsin. 
Biological characters : Is an aerobic and facultative 
anaerobic motile spirillum ; spore formation not de- 
monstrated ; grows in the usual culture-media at the 
room temperature, more rapidly than the cholera spi- 
rillum, and less so than that of Finkler and Prior. Upon 
gelatine plates small pin-point colonies are developed, 
which on the second day are about the size of a pin's head, 
and have a yellowish color. Under the microscope they 
are seen to be coarsely granular, of a yellowish-green 
color in the centre, and paler toward the margins. The 
outlines of the margins are sharply defined at first, but 
later, when liquefaction has commenced, the sharp con- 
tour is no longer seen. At first, liquefaction of the gel- 
atine causes funnel-shaped cavities resembling those 
formed by cholera spirilla, but liquefaction is more 
rapid. 
In gelatine needle cultures liquefaction occurs all 
along the line of puncture, and the spirilla sink to the 
bottom of the liquefied gelatine in the form of a coiled 
mass, while a thin yellowish layer forms upon the sur- 
face. Complete liquefaction usually occurs in about 
two weeks. 
Upon the surface of agar a thin yellowish layer forms 
along the needle-track. 
Upon potato, at a temperature of 37° C., a thin yellow 
Fig. 29.-Finkler-Prior's Vibrio. Needle Culture in Gelatine, Forty- 
eight Hours Old. Natural Size. (Fraenkel.) 
layer is usually developed, but not always, and it con- 
tains as a rule beautifully formed spiral filaments. 
Pathogenesis : It is pathogenic for guinea-pigs when 
introduced into the stomach by Koch's method ; three 
out of fifteen animals treated in this way died. 
Still another organism resembling the spirillum of 
Asiatic cholera is: the spirillum of Metschnikoff, ob- 
tained by Gameleia in 1888, from the intestinal contents 
of chickens dying of an infectious disease which pre- 
vails in certain parts of Russia during the summer 
months, and which in some respects resembles chicken 
Fig. 30.-Vibrio of Metschnikoff. Gelatine Culture. Cover-glass Prep- 
aration, Stained with Fuchsine. (Fraenkel.) X 1000. 
cholera. His experiments show that the spirillum under 
consideration is the cause of the disease referred to, 
which he calls gastro-enteritis cholerica. 
Morphology of the spirillum of Metschnikoff: Curved 
rods with rounded ends and spiral filaments. The curved 
segments are usually somewhat shorter, thicker, and 
more decidedly curved than is the spirillum of Asiatic 
cholera. The size differs very considerably in the blood 
of inoculated pigeons, the diameter being sometimes 
69 Asiatic Cholera. 
Asiatic Cholera. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
twice as great as that of the cholera spirillum, and at 
other times about the same. A single long undulating 
flagellum may be seen at one extremity of the spiral fila- 
ments or curved rods in properly stained preparations. 
It stains with the usual aniline colors, but not by Gram's 
method. 
Biological characters: An aerobic, facultative anae- 
robic (?), liquefying motile spirillum. According to Ga- 
maleia, endogenous spores are formed by this spirillum, 
but Pfeiffer does not confirm the observation, and it 
must be considered extremely doubtful, in view of the 
slight resistance to heat (killed in five minutes by a tem- 
perature of 50° C.). Grows in the usual culture-media at 
the room temperature. 
Upon gelatine plates small white pin-point colonies are 
developed at the end of twelve to sixteen hours. These 
rapidly increase in size, and cause liquefaction of the gela- 
tine, which takes place, however, much more rapidly with 
some than with others. At the end of three days, large 
saucer-shaped areas of liquefaction may be seen, resem- 
bling those produced by the Finkler-Prior spirillum, the 
contents of which are turbid, while other colonies have 
produced small funnel-shaped cavities filled with trans- 
parent liquefied gelatine, resembling colonies of the 
cholera spirilla of the same age. Under the microscope 
cept for very large doses. A few drops of a pure cult- 
ure inoculated subcutaneously in pigeons, or injected 
into their muscles, cause their death in eight to twelve 
hours. At the autopsy an excessive subcutaneous 
oedema is found in the vicinity of the point of inocula- 
tion, and a superficial necrosis may be observed. The 
blood and the organs generally contain the vibrio in great 
numbers, showing that the animals die from general in- 
fection-acute septicaemia. 
In spite of all that has been said since the first an- 
nouncement by Koch that he considered his spirillum 
to be the cause of cholera, and the many assertions to 
the contrary, the relationship between the two to-day is 
practically universally admitted. The opinion to this 
effect is based upon a number of reasons, some of which 
are as follows : 
1. The spirillum of Koch has never been found in any 
other situation, a point that has been established by in- 
numerable observations. 
2. This spirillum is found in all cases of Asiatic chol- 
era, without exception, provided that the case is not too 
far advanced. In such a case there has been a secondary 
infection, that has killed out the true organism and 
masked its effects. (To this class must be assigned Em- 
merich's "Naples bacillus.") Ever since the first an- 
Fig. 31.-Vibrio of Metschnikoff. Needle Culture in Gelatine, Forty- 
eight Hours Old. Natural Size. (Fraenkel.) 
Fig. 32.-Vibrio of Metschnikoff. Pigeon's Blood. Cover-glass I'repara- 
tion, Stained with Fuchsine. (Fraenkel.) X 1000. 
the larger liquefied areas are seen to contain yellowish- 
brown granular masses, which are in active movement, 
with the margins surrounded by a border of radiating 
filaments. 
In gelatine needle cultures the growth resembles that 
of the cholera spirilla, but the development is more 
rapid. Upon agar at 37° C. a yellowish layer resem- 
bling that formed by the cholera spirilla is quickly de- 
veloped. 
Upon potato no growth occurs at room temperature, 
but at 37° C. a yellowish-brown or chocolate-colored 
layer is formed, which closely resembles that produced 
by the cholera spirillum under the same circumstances. 
In bouillon at 37° C. development is extremely rapid 
and the liquid becomes clouded and opaque, having a 
grayish-white color, while a thin, wrinkled film forms 
upon the surface. When muriatic or sulphuric acid is 
added to a culture in peptonized bouillon, a red color 
is produced, similar to that in cultures of the cholera 
spirillum, and even more pronounced. In milk at 35° C. 
rapid development occurs, and the milk is coagulated at 
the end of a week. The precipitated caseine accumulates 
at the bottom of the tube in irregular masses, and is not 
redissolved. The milk acquires a strongly acid reac- 
tion, and the spirilla quickly perish. 
Pathogenesis : It is pathogenic for chickens, pigeons, 
and guinea-pigs. Rabbits and mice are refractory, ex- 
nouncement of this discovery by Koch, observers have 
carried out his assertions in all parts of the world where 
cholera has been investigated at all-in France, Italy, 
Austria, Hungary, Germany, India, China, Japan, etc. 
3. This spirillum is found in slight cases as well as in 
severe. It is present in the beginning of the attack, and it 
is located in the intestine, that is to say in the region es- 
pecially attacked by the disease, and in which occur the 
initial and essential lesions. 
The attempts to add to these arguments the more deci- 
sive one of successful inoculation experiments, were at 
the first not satisfactory in their results. Nicati and 
Bietsch were the first to secure successful results, which 
they obtained by introducing pure cultures of the or- 
ganism into the duodenum of guinea-pigs, in which 
animals they had previously tied the ductus choledochus. 
By these experiments they obtained symptoms extremely 
analogous to those of true cholera, and Koch also suc- 
ceeded in the same direction by passing the infectious- 
material (pure cultures) into the stomach by an oesopha- 
geal catheter. In his experiments the animals had been 
previously narcotized by the injection of tincture of 
opium, this to prevent peristalsis, and their stomachs- 
had been made alkaline by the introduction of carbonate 
of soda, a solution to make the stomach alkaline being 
necessary, because the spirillum of Asiatic cholera will 
not develop in an acid medium. 
70 BEFEBENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Astatic Cholera. 
Asiatic Cholera. 
Doyen has shown that by introducing alcohol into the 
stomach the alkaline solution and the tincture of opium 
may be dispensed with. But, however the experiments 
may be conducted, they all show one important thing- 
the great necessity for a healthy condition of the gastro- 
intestinal tract for the avoidance of infection with chol- 
era. Dyspeptics and alcoholics have been shown in all 
epidemics to be especially fatally attacked by the dis- 
ease. It cannot yet be affirmed that the absolute proof 
of the production of cholera by the specific spirillum 
has been obtained, because the methods employed in the 
experiments mentioned above leave too many loop-holes 
open for the occurrence of accidents, and yet the evidence 
is so nearly complete that there seems to be no reason 
for any doubt ; the more especially as the exact experi- 
mental evidence can probably never be obtained, because 
none of the lower animals, so far as is known, are sus- 
ceptible to cholera under natural conditions. The near- 
est approach to an actual experiment upon man is the 
case of one of the members of one of the cholera courses 
held in Berlin in the winter of 1884r-85. This man, 
a physician, was attacked with " cholerine,'' and after 
some suffering, but no dangerous symptoms, recovered, 
the cholera spirillum being isolated from the discharges 
at various times during his illness. There seems to be 
no doubt that this was a case of true cholera, arising 
from some carelessness upon the victim's part in hand- 
ling the cultures with which he had to deal in the labo- 
ratory, for there were no cases of cholera in Berlin at 
the time, nor had there been for a long time previous. 
The entrance of the spirilla is undoubtedly effected by 
means of the gastro-intestinal tract, and there has not 
been a particle of evidence from experimental work to 
favor the theory of Pettenkofer that it ever enters from 
the air and through the respiratory region. 
The acidity of the gastric juice is extremely unfavor- 
able to the growth of the organism, and this explains the 
liability of the persons with functional or organic disease 
of the stomach to the attacks of the disease, for in these 
instances the reaction of the gastric juice is altered or 
modified so as to allow of the spirillum living until it 
has passed this point of danger and has reached the in- 
testine, where there are more favorable conditions for its 
development. 
Nicati and Rietsch, and Van Ermengen determined 
the toxicity of cultures of this organism when they had 
been deprived of the bacteria, either by filtration or by 
heating. In 1885, Nicati and Rietsch, by treating similar 
cultures with alcohol, succeeded in extracting a substance 
that killed guinea-pigs and rabbits, with the production 
of cramps and a lowering of temperature. Brieger 
studied the various chemical bodies that appeared in the 
cultures of the cholera spirillum ; among the number 
there were convulsivants, methyl-guanidine and a base, 
C3HeAz2, a febricant poison, and compounds that pro- 
duced inflammation and necrosis. More recently, Brie- 
ger and Fraenkel have isolated a toxalbumin, and Petri 
has determined the presence of a less active substance, 
toxopeptine. 
Hueppe and Scholl have perhaps made as important 
researches as any in their work upon cultures that have 
been deprived of free access of oxygen. From such cult- 
ures they succeeded in obtaining a peptotoxine that in 
a dose of 5 c.c., killed guinea-pigs in forty minutes, the 
animal presenting paralytic symptoms after ten minutes 
and convulsions after a quarter of an hour. This is 
a more active poison than was obtained before and was 
got in larger quantities : an egg after inoculation with 
a pure culture produced at the end of eighteen days 
enough to cause the death of ten guinea-pigs. The im- 
portance of this is seen when it is remembered that the 
spirilla are deprived of the access of oxygen when they 
are developing in the human intestine, and according 
to these experiments are therefore under the most fav- 
orable conditions for the development of this peculiar 
toxine. 
A temperature of from 30" to 40° C. is the most fav- 
orable for the development of the cholera spirillum, but 
it will grow slowly at a temperature as low as 17° C. 
It ceases to grow at a temperature lower than this, but 
its vitality is not destroyed, and it grows well when the 
temperature is again raised ; at 10° C. of cold its vitality 
has been retained, but, on the other hand, a temperature 
of as low as 56° or 60° C., is sufficient to destroy its vi- 
tality in a short time. 
Inasmuch as no true spore-formation has been seen to 
occur in the development of this organism, it is not sur- 
prising that drying was shown, first by Koch, to destroy 
its vitality in a very short time-less than twenty-four 
hours. But conclusions drawn from his experiments may 
be misleading, for while this destruction of vitality by 
drying does occur in a very short time in the case of thin 
layers, it does not take place under less favorable con- 
ditions. This was shown by Kitasato, and by Berkholtz, 
who saw the vitality retained, the one for thirteen days, 
and the other for thirty-eight, in experiments in which 
silk-threads were used for holding the organism during 
their subjection to desiccation. It should be said, how- 
ever, that these experiments were conducted in a desic- 
cator, which did not permit the free access of oxygen to 
the bacteria, and it is undoubtedly the case that this 
agent is as important as any in the production of the re- 
sult that it was desired to obtain. 
The organism has been found in ordinary drinking- 
water by Koch in one of the tanks in India, in the neigh- 
borhood of which an epidemic of cholera had broken 
out. It does not live long in distilled water, however, as 
shown by Meade Bolton, Wolfhiigel and Riedel, and 
others. Strauss and Dubarry found that it lived for 
fourteen days in one case, and Kraus, for two days only. 
Other observers have not seen it retain its vitality for 
anything like so long a time. In ordinary sterilized 
water it lives longer, according to the experiments of 
Wolfhiigel and Riedel, as well as Pfeiffer, who found 
that it existed for seven, nine, and twelve months, while 
Hochstetter lengthened this time to three hundred and 
ninety-two days. Its vitality appears to be shorter again 
in non-sterilized water. Strauss and Dubarry found it 
to be thirty days in one specimen, and thirty-nine in an- 
other ; while a mixture of other bacteria shortens the 
time still more. This latter point is one of great impor- 
tance and has been studied by many experimenters. Koch 
determined that the organism ceased to live in ordinary 
drinking-water at the end of six or seven days, and that 
after twenty-four hours' contact with sewer-water they 
appeared to be dead ; while Schiller, on the other hand, 
found that they retained their vitality in the same me- 
dium for fourteen days. Petri, in an effort to find out 
how long they lived in the intestine after burial, was able 
to demonstrate them in cultures at the end of nineteen 
days. Certain foods may be of great importance in 
transmitting the organism, as in the case of milk, in 
which it grows with great energy and without producing 
the least visible alteration ; it has been shown that it will 
live for at least four days in milk, and forty-eight in 
butter. 
Most of these experiments were conducted with the 
idea that this organism is an aerobic one, but Hueppe has 
shown that it is also an anaerobic, and that grown under 
these conditions the spirillum is possessed of a greater 
virulence, but it is also easier of destruction. As sug- 
gested by Proust, this may explain the comparative 
rarity of immediate infection. The bacterium coming 
from the intestine as an anaerobic organism is possessed of 
feeble resisting powers and is therefore easily destroyed, 
and it is only after it has taken on the conditions of aero- 
bic growth that are furnished it in the medium in which 
it develops outside of the body that, it finds itself pos- 
sessed of the power of resistance sufficient to enable it to 
again enter the human body. Such observations are of 
especial interest in connection with the theory of Petten- 
kofer (vide supra), as seeming to show that his idea of 
the influence of locality is exact, in so far as this influ- 
ence is extended in changing the anaerobic to an aerobic 
organism. 
According to Koch, solutions of 1 to 400 of carbolic 
acid, 1 to 2,500 of sulphate of copper, and 1 to 10,000 of 
corrosive sublimate are sufficient for the arrest of the de- 
71 Asiatic Cholera. 
Asiatic Cholera. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
velopment of the spirillum of Asiatic cholera. Esmarch 
and Eisenberg show that creolin will destroy it more 
quickly than carbolic acid in solutions of the strength of 
from 1 to 1,000, or 1 to 2,000. Liborius, Kitasato, and 
Pfuhl have shown the active effect of freshly prepared 
milk of lime, while Hueppe and Loewenthal seem to 
have established the important prophylactic and thera- 
peutic value of salol in the management of cholera. 
Treatment.-Inoculation Against Cholera.-Haffkine, 
whose first article upon the protective inoculation of ani- 
mals against cholera appeared in the spring (La Semaine 
Med., No. 36, 1892), tried the virus upon himself (Munch. 
Med. Woch., August 9, 1892). He injected subcutane- 
ously in his left side a somewhat larger dose than that 
used in animals, of the so-called first kind of anti-cholera 
vaccine, prepared after Pfeiffer's method (Ueber das 
Choleragift, Zeit. f. Hyg., xi., 393). An illness fol- 
lowed, lasting for twenty-four hours, made up of a rise 
of 1° C. in temperature, headache, dryness of the mouth, 
and clouding of the urine, with no disturbance of the 
digestive tract. There was pain, slight swelling, and 
glandular enlargement at the seat of the inoculation, the 
pain lasting five days, and the swelling diminishing 
gradually until the ninth day. Six days after the first 
inoculation the other side was inoculated with the 
strengthened cholera virus (Vaccine No. 2), and there 
was a second rise of temperature and local pain, but no 
swelling. The pain disappeared in three days, and the 
condition became normal in twenty-eight hours, with no 
digestive disturbances. Similar inoculations were tried 
in three other persons with like results. In one of these 
cases a slight diarrhoea which had lasted for several days 
stopped the day after the injection (first). The inocula- 
tion of both kinds of anti-cholera vaccine, the protec- 
tive power of which in animals has been experimentally 
proved, is harmless to men, and Haffkine has the hope 
that six days after inoculation with this vaccine the hu- 
man organism will have obtained complete immunity 
against every cholera infection (Boston Med. and Burg. 
Journ., cxxvii., 227). 
Salol in Cholera (Deut. Med. Woch., August 11, 1892). 
-The treatment first proposed by Loewenthal (first dose 
of two grammes of salol, followed by hourly or half- 
hourly doses of one-half to one gramme [Ibid., 1889, Nos. 
25 and 26]) has been reported by several authors as pro- 
ducing remarkable results when employed in man. Dr. 
Gonzales, of Salvador, has used it in fifty-three cases 
of cholera in one of the Philippine islands with only 
three deaths (and these were already in the last stages of 
the disease when they came under observation) ; the mor- 
tality under other methods of treatment being about forty- 
five per cent. 
As a contrast to these results may be quoted those next 
following, and the paper upon this subject in the Prac- 
titioner (for November, 1892) will be of interest. It is 
by Dr. Hehir, of India, who was the first to recommend 
the use of the drug in India several years ago. After a 
careful experimentation with it in a large number of cases 
he concludes that it, like many other drugs, must be con- 
sidered as having failed to justify the expectations raised 
in regard to it, and that it should be relegated, like its 
predecessors, to the limbo of oblivion as far as its special 
usefulness in cholera is concerned. 
The following treatment of cholera was suggested by 
Nothnagel and Kahler (Munch. Med. Woch., August 16, 
1892, and quoted in the Boston Med. and Surg. Journ., 
September 8, 1892), at the request of the Austrian Gov- 
ernment : The use of dilute hydrochloric acid, eight or 
ten drops to a quarter of a glass of water after meals, the 
relief of constipation by enemata of boiled water, and 
the careful treatment of already existing gastric or in- 
testinal catarrh are advised. Colds must be guarded 
against and attention given to the general hygiene of 
the body (baths, exercise, sleep). Every diarrhoea must 
be treated as if it were a choleraic diarrhoea. The pa- 
tient must be put to bed, if possible after a warm bath, 
or a hot sitz-bath, with warm compresses on the abdo- 
men, the nourishment limited to barley-broth, and tinct- 
ure of opium, with tea, rum, or cognac given. If nau- 
sea or vomiting appear, carbonated, not alkaline, water 
is recommended. All drinking-water must be first 
boiled. Before the patient is put to bed an energetic 
cold rubbing down is recommended, but this must be 
superintended by the physician. Calomel comes into 
consideration only in the very beginning of the disease. 
For the treatment of a well-developed cholera attack the 
tannin enemata recommended by Cantani are best suited, 
one-half to two litres (quarts) of water boiled, and at a 
temperature of 39° to 40° C. (102.2° to 104° F.), in which 
15 to 20 grammes (3f to 5 drachms) of tannin are dis- 
solved, are discharged by high irrigation. This proced- 
ure is best suited to the premonitory stage, but can be of 
use in the fully developed algid stage. The tannin has a 
limiting action on the development of the cholera spiril- 
lum, but is also supposed to counteract and favor the 
quick elimination of the cholera poison from the blood. 
In the stage of asphyxia, in order to counteract the 
thickness of the blood, hypodermatic injections or intra- 
venous injections may be used to advantage. For the 
first, two litres (quarts) of distilled water are boiled for 
half an hour in a vessel, the mouth covered with cotton, 
6 grammes (1| drachm) of carbonate of soda and 8 
grammes (2 drachms) of sodium chloride dissolved in it, 
and cooled to 40° C. (104° F.). This fluid is injected by 
means of a large, hollow needle, through a fold of skin 
of the abdominal wall into the cellular tissue. The skin 
is first to be made thoroughly aseptic. 
Instead of a syringe a burette is connected with the 
needle with a rubber tube. The whole apparatus should 
be previously disinfected. In the course of a half-hour, 
li litre (quart) of the fluid can be injected. The skin 
of the thigh or interscapular region can also be chosen 
for the injection, and the resulting swelling can be re- 
duced by massage. If after the third injection the re- 
lief is only transitory, intravenous injection is to be 
tried. For this the same solution can be used, or a 
solution of 5 grammes (1| drachm) sodium chloride, 
with 10 grammes (2| drachms) sodium sulphate to 1,000 
grammes (one quart) of water, previously boiled and 
thoroughly filtered as the other. In a quarter of an 
hour, from 2 to 2| litres (quarts) can be injected into a 
vein in the arm. The first appearance of the algid stage 
is the indication for these procedures. For stimulants, 
champagne, fermented mixtures, heavy wines with the 
addition of ten to twenty drops of ether, tea with brandy, 
subcutaneous injections of camphor in olive-oil, in the 
proportion of 1 to 9, warm baths, energetic and long- 
continued rubbing with alcohol, or with cloths dipped 
in ice-water, and warmth to the extremities are useful. 
In case of muscular cramps injections of morphine are 
useful. The treatment of the typhoidal condition, often 
observed, must depend upon the individual case. It is 
important to watch for and treat renal complications, 
and especially to bear in mind the necessity of maintain- 
ing the general nutrition. 
During the time of cholera, it is well known, ac- 
cording to Sansom (The Practitioner, November, 1892), 
that there are many cases of simple diarrhoea, and the 
question often comes up as to whether these are to be 
treated by castor-oil or by opiates and astringents. The 
author quoted recommends most emphatically the use 
of castor-oil in moderate doses, offering the following 
prescription as a good one, viz. : B. Ol. ricini, Muci- 
laginis acaciae, aa | ss. ; Aquae menth. pip., § ss. ; Elixir 
saccharini, Tf[v. Mix carefully and make an emulsion. 
In addition to this, and during times of cholera, he rec- 
ommends also a mixture containing either the sulphite or 
the sulpho-carbolate of sodium. He thinks he has seen 
evidence that the sulpho-carbolate acts certainly as an in- 
testinal antiseptic, but if it be employed at all it must be 
used in much larger doses than are usually given-in 
children 15 to 20 grains, and in adults half-drachm doses 
in peppermint-water or cinnamon-water, and repeated 
every three or four hours. If there be much pain or 
griping, small doses of compound tincture of camphor 
(ten-minim doses for children or half-draclnn doses for 
adults) may be added. He thinks that opium in most of 
its forms does harm. In the acute stages he has never 
72 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Asiatic Cholera. 
Asiatic Cholera. 
seen any real good from the use of astringents, but in the 
later periods, if much looseness continues, astringents, 
especially in the form of logwood, were useful. He pre- 
fers the sodium sulphite to the sodium sulpho-carbolate. 
These he considers to be the chief principles of medical 
treatment of cholera until, or unless, the signs of collapse 
make their appearance. He does not place much reliance 
upon the statistics in regard to the various methods of 
treating true cholera, because in the first place cases of 
simple diarrhoea are likely to be returned as true cholera, 
and in the second, the variations in the intensity of the 
disease at various periods of the outbreak must of neces- 
sity result in many false deductions. It is an established 
fact that the mortality of epidemics of cholera is much 
greater in the beginning of the outbreak, being as much 
as 60 per cent, and more, and that this very high rate re- 
cedes to 25 per cent, or less after the first outbreak. 
It appears as if there was a sudden maximum of poten- 
tial energy in the cholera bacteria that fails as the epi- 
demic goes on, a condition of things that is ascribed by 
the more recent writers to the development of an ac- 
quired immunity among the population, and by others 
to the change in atmospheric and telluric conditions that 
become more unfavorable to the development of the 
organisms. Certain authorities assert that there is no 
medical treatment that is of avail in the maximum of the 
epidemic, that a patient in collapse must die, but it is not 
the part of the practitioner to adopt an attitude of help- 
lessness in such a case. 
Upon the approach of collapse it is recommended to 
place the patient at once either in a hot bath and keep 
him there, allowing the dejecta to be passed in the tub, 
or-much more convenient-the hot pack at 100° F. may 
be usefully employed, reapplications of the hot flannel 
being made at short intervals. The evacuations are 
the fnost difficult to deal with and the most important, 
because in them lies practically all the danger of the 
spread of the disease. If they be passed into a bed- 
pan they should be at once covered with a solution of 
corrosive sublimate 1 to 1,000, or of carbolic acid 1 to 20, 
or with a saturated solution of sulphate of iron ; and they 
should be allowed to remain in contact with these solu- 
tions for at least six hours before they are allowed to pass 
into the sewers. But the best method of all is to destroy 
them by fire, and in this respect the suggestions of Sansom 
(loc. cit.) are of so much value that we shall quote them 
entire : " In hospitals receiving cholera patients a special 
furnace should be provided. In private houses, if pos- 
sible, a scullery or a room having a fireplace should be 
appropriated for the purpose and the chimney swept clear. 
The evacuation should be received upon a large piece of 
oiled paper (e.g., newspaper), on which layers of tow 
have been spread. To absorb further the liquid matters, 
sawdust or peat should be added. On removal from the 
patient more sawdust or peat should be thrown over the 
surface, and then a sprinkling of a mixture of powdered 
nitre and sulphur (proportions of 3 to 1). The whole 
should be then rolled up in the oiled paper and an outer 
•cover of paper, brushed with carbolized oil, applied. 
The package is then ready to be taken to the furnace. 
If no fireplace can be used for the sole purpose, the burn- 
ing might take place in the open air, care being taken 
that no nuisance is created. The addition of the nitre 
and sulphur (to which charcoal or coal-dust may be 
added if the matters are to be consumed in the open) is 
not only to promote combustion, but concurrently to 
disinfect by the sulphurous oxidation products. 
"After any attention to the patient whereby it is pos- 
sible that there may be contact with the evacuated 
matters, the nurse should plunge her hands into a watery 
solution of corrosive sublimate, 1 to 1,000, or one of 
thymol of equal strength, or, preferably, into a solution 
of thymol in methylated spirit, 1 to 1,000. Experience 
has abundantly shown that the attendants on cholera pa- 
tients run scarcely any risks of infection if only contam- 
ination by the excreta be avoided." 
If there be much pain, inhalations of chloroform may 
be used, and also, between these, the vapor of nitrite of 
amyl from the crushed capsules. 
(SUPPLEMENT.) 
If the condition of collapse does not soon show signs 
of amending, the methods of Cantani, termed by him 
"enteroclysis" and " hypodermoclysis," may be em- 
ployed. By enteroclysis is meant a copious enema of 
hot water, medicated by various drugs, by means of 
which not only may the irritating contents of the intestine 
be cleared away, and, perhaps, in some degree disinfected, 
but fluid may be absorbed from the surface of the in- 
testine to replenish the empty blood-vessels. Long be- 
fore the epidemic of 1866 Dr. Murray, in India, bad 
recommended the half-hourly injection of a pint of a 
weak solution of common salt and carbonate of sodium 
into the rectum at a temperature of 120° F., and is said 
to have obtained very striking results. Similar means 
were employed by Sansom (loc. cit., p. 325), in 1866. 
Cantani advises the addition of tannin to the hot water. 
From 80 to 320 grains are dissolved in 3 pints or a quart 
of water or chamomile-infusion at a temperature of 102° 
to 105° F., and twenty drops of laudanum and an ounce 
or an ounce and a half of gum acacia are added. Instead 
of tannin, thymol in solution of hot water (1 to 1,000) 
has been recommended by other authorities. In the rec- 
ommendations of the Royal College of Physicians re- 
cently (1892), benzoate of sodium, two drachms to a quart 
of water, has been suggested as an alternative to the 
tannic acid. In every case the injection should be made 
with much gentleness. The best position of the patient 
is that on the back with the hips well raised and the legs 
well drawn up as for lithotomy. The reservoir douche 
enema should be used and not the ordinary pump. There 
is much room for doubt as to whether the addition of any 
medicament to the hot water is of any special value, the 
favorable results being due probably to the clearing away 
of irritant and offensive debris, to the absorption of fluid 
from the intestinal surface, and to the relaxation of the 
arterial spasm by the hot and moist application. As 
shown by Cantani, the hot saline solution may pass 
through the ileo-caecal valve into the small intestine. 
If signs of improvement do not soon follow the pro- 
cedure described above, recourse should be had to the 
second method, that specially introduced by Cantani and 
called by him "hypodermoclysis," and consistingin the 
injection of a hot saline solution into the subcutaneous 
tissue. About one drachm of common salt is dissolved 
in a quart of distilled water at a temperature of 100° 
to 105° F. The apparatus for this should consist of a 
glass funnel with a long rubber tube attached to a hypo- 
dermic needle of fairly large calibre. The needle is in- 
troduced in the gluteal, interscapular, lumbar, or ileo- 
costal region, the funnel being held at about the level of 
the patient, and the needle pushed so far in that it may 
be moved freely in the subcutaneous tissue. The reser- 
voir is then elevated slowly so that the fluid runs into the 
tissue by the force of gravity and its distribution is aided 
by the manipulation of the fingers. When about half of 
the fluid has been introduced the needle is removed and 
the remainder is injected in another place. The method 
seems to be rational and is supported by strong evidence 
by Cantani, who has made extensive use of it. It is easier 
of application than the older method of intravenous injec- 
tion that has been employed for many years, and it seems 
to be attended with better permanent results. Either or 
both of these methods must be employed earlier than is 
usually the case, and before the actual symptoms of death 
have made their appearance ; to wait too long is to throw 
away all chances of success. It must be remembered 
that even if the dangers of the period of collapse have 
been safely passed, an ever-watchful care must be exer- 
cised. for even after the vaso-motor spasm has passed off 
there is in some cases the condition of paresis to be reck- 
oned with, and the resulting typhoid state, the tendency 
to congestions of the viscera, and especially to pneumonia, 
must be most carefully watched for and guarded against. 
General and Special Hygiene.-Measures of pre- 
caution in nursing cholera patients (Brit. Med. Journ., 
September 3, 1892) are thus given by Mr. Ernest Hart, the 
editor of the journal from which the extract is made. 
He states that in the epidemic of 1885 the following rules 
were used and enforced at the London Hospital: The 
73 Asiatic Cholera. 
Asiatic Cholera. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
following disinfectants were employed-the first two or 
three days Condy's fluid diluted and chloride of lime, 
subsequently carbolic disinfecting powder and carbolic 
acid largely diluted (1 to 40), mixed with sawdust in 
quantities sufficient to wet the sawdust, and sprinkled 
about the passages, wards, closets, etc. 
None of the excreta from the patients were allowed to 
be emptied into the sewers ; instead of this a portion of 
dilute carbolic acid - about half a pint - was put into 
each chamber-pail and the contents were buried in the 
garden. The pails had water-tight lids. Burnett's fluid 
was sprinkled in the cabs that brought the patients. The 
straw from the beds was burned in each case of death, or 
where they had been much soiled by excreta. The linen 
from the cholera wards was washed separately in the 
laundry of the hospital with McDougall's disinfecting 
soap. Hot coffee, beef-tea, etc., were recommended to 
be taken by the nurses at early dawn, and everyone was 
advised to avoid going on duty on an empty stomach, or 
in a depressed condition. An extra allowance of wine 
and of pay was made to the nurses. 
Again, although cholera raged so severely in Chili in 
1886-87, the doctors and nurses in a number of small hos- 
pitals were enabled to protect themselves entirely. Each 
of the hospitals (Russell) contained from fifty to sixty 
beds, and had a staff of six doctors, six students, and 
thirty attendants. All wore long aprons, reaching from 
the chin to the feet, and caps. For washing the hands 
and face a solution of corrosive sublimate (1 to 1,000) was 
exclusively used. In the dining-room all dishes before 
use were strongly heated by the flame of burning alcohol. 
The bread was sterilized by toasting. It is stated that 
no one of the staff sickened who adhered strictly to these 
precautions. The convalescents before their discharge 
were bathed in the corrosive-sublimate solution and their 
clothing was washed in a similar disinfecting solution. 
The floors of the hospital were made of a kind of pine par- 
quet soaked in tar, and were washed daily with a solution 
either of copper sulphate or potassic permanganate (1 to 
1,000). On emptying a ward it was fumigated, according 
to rule, by sulphurous acid gas for twenty-four hours. 
Instructions of the French Committee on Hygiene as 
against Cholera, prepared in 1889.-The germ of cholera 
is contained in the dejecta and vomited matters of patients. 
It is transported especially by water, linen, and clothing. 
1. Personal prophylaxis. Follow out a careful hy- 
giene ; avoid all causes of fatigue, especially cold, when 
the body is in a perspiration ; excess of all kinds, of wine 
or of alcoholic liquors, and the excessive use of ice-water ; 
abstain from green fruit. Special attention should be 
paid to drinking-water ; it should be boiled if its origin is 
suspicious. Natural mineral waters, called table waters, 
are recommended. 
2. Isolation of the sick. The person attacked with 
cholera should be isolated. The patient should be under 
constant supervision, and those who have charge of him 
should be the only ones to have access to him, and these at- 
tendants should be governed by the following rules: Take 
no drink or fluid in the sick chamber, never eat without 
having washed the hands with soap and a disinfecting 
solution, bathe the body frequently with a disinfecting 
solution, and wash the mouth from time to time, and par- 
ticularly before eating, with a disinfecting solution. 
3. The sick chamber. The chamber should be aired 
many times a day, and curtains, shades, rugs, and all 
furniture that is not indispensable, removed ; the bed 
should be placed in the middle of the room. 
4. Disinfection. The principal disinfectants that are 
recommended are sulphate of copper, freshly prepared 
chloride of lime, freshly prepared milk of lime,* corrosive 
sublimate. 
(SUPPLEMENT.) 
The two following solutions should be used according; 
to the circumstances indicated : First, the strong-sul- 
phate of copper or chloride of lime, 5 per cent, solution 
(that is to say, 50 grammes of the sulphate of copper or the 
chloride of lime in a litre of water, milk of lime 20 per 
cent.). The other, the weak-sulphate of copper or chlo- 
ride of lime 2 per cent, (that is, 20 grammes of these 
substances in a litre of water, milk of lime 7 per cent.). 
Solutions of corrosive sublimate are to be employed, one 
to a thousand, the strong ; or one to two thousand, the 
weak, according to the case. The solutions of sublimate 
should be colored with fuchsine or eosine, which has. 
been added to a litre of water containing 10 grammes of 
hydrochloric acid. 
Wash the body and hands. For washing the hands- 
use the weak solution. 
Rinsing the mouth. For rinsing the mouth use a so- 
lution of hydrochloric acid, 4 to 1,000 (that is, 4 grammes- 
of hydrochloric acid to a litre of water). 
Dejections. All the dejections of the patient, the vom- 
itus and fecal matters, are immediately disinfected with 
one of the strong solutions ; milk of lime is especially 
recommended. A tumblerful of one of these solutions- 
should be previously turned into the vessel destined to 
receive the dejecta. The dejecta are immediately turned 
into the cabinets, which are also disinfected twice a day 
with one of the strong solutions. 
The cabinets. These are washed twice a day with one 
of the strong solutions. 
Body linen. Soiled body linen is immediately col- 
lected, and placed for two hours in one of the strong so- 
lutions. It is then sent to the wash, where it is kept for 
half an hour in boiling water before being cleansed. 
The unsoiled linen is plunged into one of the weak dis- 
infecting solutions. The same precautions are taken at 
the laundry. Neither of these classes of linen should be 
washed in a watercourse, for such water being likely to 
be drunk later may start a new epidemic. 
Clothing. The clothing of the sick and the nurses- 
should be placed for half an hour in a disinfecting oven, 
in steam under pressure, or in boiling water for half an 
hour. If these two procedures cannot be carried out, the 
clothing should be disinfected by sulphurous acid, after 
the manner indicated below in the disinfection of the 
infected lodging. Clothing soiled by dejecta should be 
placed for an hour in one of the strong solutions. 
The furniture. Spots or soiled places on the furniture 
or walls of the room should be immediately washed with 
one of the strong solutions., 
The mattresses and bed furniture. These should be 
placed in a disinfecting oven, or, when this is not accessi- 
ble, should be disinfected by sulphurous acid. 
Corpses. The corpses should be placed as soon as- 
possible in a tight coffin, that is to say, one with good 
joints, and well closed and containing a layer of five to 
six centimetres of charcoal, in order to prevent filtration 
of fluids, and should be immediately buried. 
Disinfection of infected lodgings. A room occupied 
by a person affected with cholera should not be inhabited 
until there is complete disinfection. 
(a) Disinfection by sulphurous acid. The procedure is- 
by the combustion of 40 grammes of sulphur to the cubic 
metre of space to be disinfected, in the following manner : 
Bands of paper are pasted over the cracks or joints that 
might let the sulphurous vapors escape. For half an 
hour water should be boiled in the room in a way to fill 
it with vapor. Sulphur is broken into very small pieces 
and placed in pottery vessels, or vessels of cast-iron, with 
large openings, and holding each about a litre. If of 
iron, they should be of a single piece, or riveted without 
solder. To avoid the danger of fire, the vessels containing 
the sulphur are placed in the centre of basins of iron, 
holding a layer of five or six centimetres of water. To 
burn the sulphur, a little alcohol is poured out on it, or 
it is covered with a little cotton soaked in alcohol, and a 
match is put to this fluid. The sulphur being lighted, 
the doors are closed, and paper is pasted over the joints. 
The room is not opened for twenty-four hours. 
(b) Disinfection by sublimate. The disinfection of 
* In order to obtain very active milk of lime, one should take good 
quality lime, and slack it little by little with a small portion of its weight 
of water. When the deliquescence is completed the powder should be 
placed in a carefully closed receptacle, and a dry situation. As a kilo- 
gramme of lime which has absorbed 500 grammes of water for slacking 
requires a volume of 2.200 c.c., it is enough to add double this volume of 
water, that is to say. 4.400 c.c., in order to have a milk of lime of about 
20 per cent. To disinfect cholera dejecta, it is enough to use a quantity 
of this milk of lime equal to 2 per cent, of the materials to be disinfected. 
74 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Asiatic Cholera* 
Asiatic Cholera* 
plastered walls, or those covered with colored papers, 
should be methodically carried out over the entire sur- 
face of the chamber walls with the aid of a spray of 
a strong solution of sublimate. The atomizing of this 
solution should begin at the upper portion of the wall, 
should follow a horizontal line, and descend successively 
in such a way that the whole surface will be covered with 
a fluid layer in very line drops. All the woodwork 
should be washed with boiling water, dried, and gone 
over with the same solution. The municipal adminis- 
tration will inspect the disinfection, and if the inhabi- 
tants do not carry it out, will proceed officially. It is 
part of its duty to see that the inhabitants of a lodging 
proceed to a serious purification. The room is not rein- 
habited until at least twenty-four hours have elapsed. 
5. Private Hygiene. Drinking-water. Great care should 
be exercised in regard to the purity of the drinking-water. 
In case of an epidemic drink boiled water. Water com- 
ing from sources which possibly are contaminated should 
be prohibited, and bakers should never, in making bread, 
utilize such water. The washing of contaminated linen 
in watercourses is forbidden, as well as throwing into 
them any material from the dejecta. 
Prodromic diarrhoea. It is proper to give special at- 
tention to the general condition of the public health, in 
order to prevent maladies, accidental and only slightly 
grave in themselves, and notably those of the digestive 
organs, from producing individual indispositions favor- 
able to the development of cholera. It is therefore nec- 
essary to establish preventive medical visits. Physicians 
appointed for this purpose should exercise a surveillance 
over the health of the inhabitants of their quarter, and 
should insist upon the necessity for immediate treatment 
of intestinal derangement in all cases. 
Obligatory information. Every case of cholera, or sus- 
pected case of cholera, must be at once declared at the 
Health Office. 
Isolation. The sick person should be immediately iso- 
lated. 
Inspection. In every house where a case of cholera 
occurs an immediate inspection is made by a physician 
delegated by the municipal administration, who should 
take at once all the necessary measures for isolation and 
disinfection. 
Transportation to the hospital in a special ambulance. 
When a case of cholera appears in a room containing 
many inhabitants, the sick person is transported to the 
hospital in a special ambulance. The chances of cure in 
such case are greater, and the transmission is not to be 
feared. 
Carriages. The carriages in which persons sick of 
cholera have beep transported must be disinfected. They 
should be washed with one of the strong solutions. 
6. Public Hygiene. All causes of unhealthfulness that 
prepare the region for an invasion of epidemics should be 
removed when cholera approaches ; also, the general 
rules of hygiene applicable at all times should be more 
rigorously observed in time of cholera, especially what 
is concerned with the purity of drinking-water ; with 
crowds of individuals, such as fetes, fairs, and pilgrim- 
ages ; with the watching over and feeding of armies ; 
with the proper condition of the soil; with the minute 
control of closets, and search for possible causes of in- 
fection ; with the regular removal of filth. 
The proper condition of houses, and the particular sur- 
veillance over localities, flats, concert-rooms, and all such 
places meant for the working or industrial population ; 
the condition and regular disinfection of public and pri- 
vate closets ; the inspection and disinfection of outhouses ; 
the cleansing of sewers ; special inspection of the quarters 
and houses where cholera prevailed in previous epi- 
demics - all these things are the special duties of the 
municipal authorities. 
• The following extracts from the " Report of the Medi- 
cal Advisory Committee of the Chamber of Commerce of 
New York, on Certain Points Relating to Quarantine De- 
tention of Passengers and the Disinfection of Passengers' 
Baggage, Merchandise, and Infected Ships " (Abstract of 
Sanitary Reports, September 23, 1892, No. 39, Washing- 
ton) are of great interest, and express the general consen- 
sus of medical opinion at the present time. ". . . It 
should be distinctly understood that in formulating the 
opinions contained in this report we have limited the 
scope of our consultation entirely to Asiatic cholera, and 
to the circumstances of the present epidemic. We re- 
port here only the circumstances under which the germs 
of this disease are liable to enter our country in transat- 
lantic ships, and certain of the measures which seem to 
us necessary to prevent their access. The control of 
other infectious diseases offers distinct problems in each 
case. The opinions which we have formed rest prima- 
rily upon this consideration : That under ordinary con- 
ditions there is little liability to the introduction of the- 
germs of Asiatic cholera, either through the mails or 
through ships' cargoes. It is, on the other hand, through 
the ship's inhabitants and their personal effects that the- 
contagium of this disease is most liable to enter. 
" Merchandise and Mails.-In view of the facts just 
stated, we concur in the general conclusion adopted by 
the International Sanitary Conference at Home, in 1885, 
namely, that disinfection of merchandise and of the- 
mails is unnecessary. This general statement, however, 
must, we believe, be qualified when the merchandise is 
known to have been prepared for shipment in infected 
places, has been shipped from infected ports, or has been 
brought on ships in which cholera has occurred during 
the voyage. Under either of these conditions it is our 
opinion that measures of disinfection should be practised. 
The nature of these measures will depend upon the 
nature of the cargo, its form of packing, and the cir- 
cumstances under which it has been placed before or 
during the voyage. We do not think that general mer- 
chandise prepared and packed in uninfected places, in 
boxes or barrels, or close packages, and which has been 
shipped at infected ports or brought on infected ships, 
would need other than such an exterior disinfection as 
could be practised on the ship or during the unloading 
without injury to the goods. . . . We believe that 
merchandise in bales presents greater possibility of con- 
tamination from its handling by infected dock-hands, 
stevedores, or ships' crews at infected ports, or on an in- 
fected vessel, than when packed in boxes, and should 
therefore be subjected to more rigorous inspection and: 
disinfection processes than if it were entirely closed. 
We are assured by our advisers that hides can be disin- 
fected without injury. A thorough, prolonged, intelli- 
gent exposure of rags to live steam or prolonged boiling 
are the only means known to us by which they may be- 
rendered absolutely safe. . . . We are furthermore 
of the opinion that, at present, edibles which have either 
been prepared or packed in infected places should be re- 
fused entry altogether. . . . 
" The Inhabitants of Infected Shipsand their Effects.- 
We have in this report limited the term ' infected ship * 
to such ships as may have had a case or cases of Asiatic 
cholera on board during the voyage. . . . We believe 
that on arrival in port of an infected ship, its passengers 
should be at once removed to a safe and comfortable 
place of detention, where they should be isolated in 
groups as small as practicable and held under observa- 
tion. We believe that under ordinary conditions the 
period of quarantine detention of healthy persons when 
removed, as they should be at once on their arrival in 
port, from all known or possible sources of inf ection, and 
properly placed, should be five days, in case no cholera 
occurs among them. We believe that the baggage of 
cabin passengers arriving on infected ships should be the 
subject of most careful investigation as to its point of 
shipment, its degree of protection from the possibility of 
contamination while on board, and as to its condition on 
arrival, and that such manner of disinfection should be 
practised as may seem necessary to the health officer in 
view of the facts in each particular case, special attention 
being paid to the baggage of those who may have taken 
ship at infected ports, or who have been recently staying 
in infected towns. We believe that the personal clothing 
and baggage of the steerage passengers, among whom 
cholera has occurred during the voyage, should be sub- 
75 Asiatic Cholera. 
Bacteriological. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
jected during their detention to reliable processes of dis- 
infection ; and furthermore, that the persons of such 
steerage passengers should be freed as fully as may be 
from all possibly infected clothing and effects before 
they are taken from the infected ships to the place of 
•detention. We hold the opinion that the detention of 
passengers of any class on infected ships for a moment 
longer than is absolutely necessary is unjustifiable. . . . 
We believe that the disinfection of a ship, in which, 
■during a voyage, a case of Asiatic cholera has occurred, 
cannot be, with certainty, accomplished while its passen- 
gers are on board. ... We have, in this report, not 
attempted to lay down rules which will govern all cases, 
nor have we felt called upon to specify particular modes 
of disinfection. . . . Stephen Smith, M.D., Chairman ; 
A. Jacobi, M.D. ; E. G. Janeway, M.D. ; T. Mitchell 
Prudden, M.D. ; R. H. Derby. M.D. ; Herman Biggs, 
M.I).; Allan McLane Hamilton, M.D., Secretary." 
Harold C. Ernst. 
ASPARAGIN. An alkaloid obtained from asparagus 
■officinalis. It also may be obtained from marshmallow', 
lily-of-the-valley , and many other plants. It occurs in 
hard, brilliant, colorless crystals, with a faintly saline, 
■cooling taste, soluble in water, one part in twelve. 
The use of asparagus is being revived, and this alkaloid 
is recommended as the best means of obtaining its thera- 
peutic properties. It is administered in doses of one to 
one and a half grain three times a day. 
Asparagus has long been known to possess therapeutic 
properties, but it has not received much attention. The 
roots and shoots are official in the French Codex, and at 
many European watering-placesit occupies an important 
"position in the articles of diet in lithiasis and in the treat- 
ment of gouty patients. It increases the flow of urine 
and imparts a peculiar strong odor. It may cause vesical 
irritation, and should be used with caution when the 
renal tissue is diseased. In cardiac dropsy it is recom- 
mended, as its action is said to resemble that of conval- 
laria. Beaumont Small. 
ASTRINGENTS, VEGETABLE, IN CHRONIC IN- 
TESTINAL CATARRH. There are three drugs which, 
in the course of years, I have used, singly or combined, 
in a considerable number of chronic cases of intestinal 
catarrh. Each of these drugs contains more or less 
tannic acid and bitter extracts, but their therapeutic 
value I have found to be greater than that of tannic 
acid by itself, and they are apt to disturb the gastric 
functions either very little or not at all, and can conse- 
quently be given for an indefinite period, and without 
harm. 
1. Extractum Monesiae is derived from the bark of 
Chrysophyilum glyciphlaeum, a Brazilian tree. It was 
known and used to a great extent some forty or fifty 
years ago, but has now been almost forgotten. Heyden- 
reich (1839) found it to contain fifty-two per cent, of tan- 
nin and thirty-six per cent, of a sweetish substance, prob- 
ably glycyrrhicin. It is sold in the shape of irregularly 
shaped, dark brown pieces, is soluble in water, and has 
a sweetish, astringent, and later rather acrid taste. In 
doses of five to ten grains it improves the stomachic func- 
tions, in larger doses of fifteen grains to half a drachm 
it is apt to disturb digestion and produce constipation. 
2. The well-known Ratanhia root comes from a bush 
growing in Bolivia and Peru. Wittstein (1854) found in 
it eighteen per cent, of tannin, some resin, wax, and 
sugary substances. This extract has a more acrid taste 
than the former, has similar effects, but is not as well 
borne by the stomach. 
3. The Colombo root derives its name from the Afri- 
can " Kolumb," and belongs to a large species of creeper 
encountered in the forests of Mozambique and Southeast 
Africa. Boedeker and Buchner found in it the alkaloids 
columbin, berberin, and a peculiar acid, some resin and 
wax, and much starchy substance. For many years 
the extract and tincture have been in medicinal use as 
stomachic stimulants, but the natives, and also the Hin- 
(SUPPLEMENT.) 
doos, use the drug, in the form of infusion or decoction, 
for diarrhoeal and dysenteric diseases. 
For a number of years I prescribed extr. monesiae in 
the form of a jelly-paste, thus : Extr. monesiae, § ss.; extr. 
columb., 3 ij.; conserv. rosarum, mellis, aa § iij. M. Ft. 
electuarium. S. : Keep in cool place, and take a tea- 
spoonful three or four times a day. In many cases of 
otherwise uncomplicated chronic diarrhoea in adults 
there is often considerable pain and purging, and small 
doses of morphine or opium may have to be given be- 
tween the doses of the extract for a week or so, when 
they may be left off and the remedy continued by itself. 
Later on, and up to the present time, I have discontinued 
the use of the paste in all cases that could take pills 
instead, and I prescribe them as follows : Extr. monesiae, 
extr. columb., aa § ss.; extr. gentian, et glycerin., q. s. 
F. pil. 120 ; two, three, or four of such pills to be taken 
three times a day, and to be continued until a cure is es- 
tablished. If it be preferred, the pills may be put up in 
gelatine capsules. I have the accurate record of at least 
twelve cases of chronic catarrh of the ileum in adults, 
and some among them of two or three years' duration, 
with intervening periods of relative well-being and exac- 
erbation, all of which were cured by the above remedies. 
At least twenty cases more I have lost sight of, but I 
may safely say that a cure was effected in every case 
that was not complicated by organic disease. In chil- 
dren's practice these remedies have not been used by me, 
but in the form and combination mentioned they have 
been prescribed for adults alone. Monesia and columbo 
together act well and produce no dyspeptic symptoms, 
giving off their tannic acid as they proceed to absorption 
in the gastro-intestinal tract. And this is a point of im- 
portance, that, in the treatment of many chronic func- 
tional or simple catarrhal disorders, a positive result may 
be hoped for, if we are able to continue long enough the 
use of properly acting remedies, without disturbing by 
them the functions of the stomach or other organs. I 
have now used these remedies in so many cases, and have 
observed their effects for so long a time, that I feel war- 
ranted in recommending their more general use. 
Leonard Weber. 
AUDINAC. A watering-place in the department of 
Ariege, in the South of France. 
Location.-Audinac is situated five miles to the south 
of Saint-Giron, amid attractive surroundings. Mild 
climate. Season, June to September. There are two 
springs yielding an abundance of water having a harsh, 
styptic taste. Temperature of water, 70° F. 
Analysis.-One quart of the water contains : 
Grains. 
Sulphate of lime 10.976 
Sulphate df magnesia 9.739 
Chloride of magnesium 5.391 
Carbonate of lime 8.074 
Carbonate of iron 1.096 
Bitumen 0.972 
Total 36.248 
Indications.-These purgative and diuretic waters 
are employed in abdominal plethora, dyspepsia, genito- 
urinary disorders. They are supposed also to be rather 
tonic, on account of the iron which they contain. 
Accommodation.-Audinac has not kept pace with 
modern improvements. It is a sleepy French village and 
no longer a fashionable resort. Still the thermal estab- 
lishments are not altogether devoid of comforts for 
invalids, and of the power of the springs there is no 
doubt. Edmund C. Wendt. 
AUSSEE. A climatic and bathing resort in Steier- 
mark, Austria. (See also Vol. I. of this Handbook.) 
Location.-Aussee is charmingly situated among the 
hills of the so-called " Salzkammergut." It is over 2,000 
feet above sea-level. The saline waters are used for brine 
baths and hydrotherapy in all its forms. The place is 
also popular with mere tourists on account of its fine 
76 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Asiatic Cholera.. 
Bacteriological. 
surroundings and the facilities it offers for excursions. 
Season, July to September. 
Access.-Aussee is now a station on the Austrian 
State Railroad. 
Indications.-The baths are employed with benefit in 
scrofula and neurasthenia. Some phthisical cases and 
" run-down" people generally do remarkably well there. 
Diseases of women are largely treated in various pri- 
vate medical establishments, which constitute a special 
feature at Aussee. 
Accommodation.-Many large and small hotels, sana- 
toria, institutions, etc. The Kaiser Franz Joseph's Bad 
is a new thermal establishment with excellent arrange- 
ments. There are concerts and other amusements, read- 
ing-rooms, bowling-alleys, etc. Among the hotels may 
be mentioned Hackl, Erzherzog Johann, Erzherzog 
Franz Karl, Sonne, Wilder Mann. Owing to its growing 
popularity the prices are now relatively high. 
Edmund C. Wendt. 
AXENFELS. A climatic station on the southern arm 
of the Lake of Lucerne-that part which is known as the 
Bay of Uri, about two and one-half miles from the town 
of Brunnen. The latter place may be reached either by 
steamboat or by railroad from Lucerne, at the eastern 
end of the lake, or from Fluelen, at the southern end of 
the Bay of Uri. From Brunnen Axenfels is reached by 
the old St. Gothard diligence road, which zigzags up the 
side of the mountain to an elevation of about two thou- 
sand five hundred feet, affording an almost constantly re- 
curring series of magnificent lake and mountain views, 
such as can be seen in only a few parts of Switzerland. 
The hotel (Hotel et Pension Axenfels) is a well-built 
stone structure, with large and airy rooms, all modern 
conveniences, and pleasant surroundings. While every- 
thing is on a more modest scale than at the Hotel Axen- 
stein, which is scarcely a mile distant, in all that relates 
to the comfort and well-being of its guests, the Axenfels 
house is in no respect behind its more pretentious neigh- 
bor. Edmund C. Wendt. 
AXENSTEIN. A climatic station on the Lake of Lu- 
cerne, Switzerland. 
Location.-One of the most beautiful spots on the 
Lake of Lucerne, Axenstein affords a pleasant sojourn 
to those in need of rest, or " after-cures." It is 2,400 feet 
above the level of the sea, in a fairly well-sheltered po- 
sition, and of easy access. The air is " Alpine" in quality. 
The Axenstein establishment is situated in a picturesque 
country, near the small village of Morschach. An ex- 
tensive park surrounds it, planted with pine and fir 
trees. The excursions are varied arid interesting. Two 
villas situated in the park contain billiard-rooms, baths, 
etc. There is a telegraph and post-office. English church 
in one of the villas. 
Access.-By the St. Gothard Railroad from Lucerne to 
Brunnen, thence by omnibus or carriage in one hour to 
Axenstein. 
Indications.-Milk- and whey-cures are about the 
only special therapeutic measures made use of here, the 
place being a popular resort for invalids without serious 
affections. 
Accommodation -The Grand Hotel Axenstein is a first 
class Swiss hotel, with all modern comforts, and prices 
are not yet inconveniently high. Edmund C. Wendt. 
BACILLUS PYOGENES SOLI.1 I isolated this organ- 
ism from an abscess which formed at the seat of inocula- 
tion in a rat inoculated with an impure smear-culture 
from an animal dead of tetanus. The smear-culture was 
one of those made in the manner described for isolating 
the bacillus of tetanus by Kitasato's method (see this 
organism under heading Tetanus). It was found im- 
possible to isolate the pyogenic bacillus by plating the 
pus in the usual way. This was only possible by inoc- 
ulating from abscesses in animals to culture-media, and 
from culture-media back to animals a number of times. 
In this way the contaminating organisms gradually dis- 
appeared, and the pus organisms became relatively more 
(SUPPLEMENT'.) 
and more numerous, until finally all contaminations were 
got rid of. 
The organism resembles in many respects the bacillus 
of diphtheria. It presents the same irregularities of 
shape ; the swollen, club-shaped extremities ; the trans- 
verse, unstained, clear spaces in stained preparations ; the 
deeply stained, often perfectly round spots, as are seen 
in the diphtheria organism. They stain readily with all 
the ordinary staining solutions, but best with Loeffler's 
methylene blue. With this stain the older cultures often 
present a very remarkable appearance, in that there ap- 
pear bright-red spots in the otherwise blue rods. In 
some preparations the organisms look as if they had 
been double stained. The red color is especially evident 
in the swollen knobs. They have no independent motion, 
and do not stain by Gram's method. 
The growth of the organism is slow on all media. 
When first obtained it could only be got to grow on 
gelatine and in beef-tea, but cultures which I have kept 
reinoculating now for about a year grow equally well on 
agar. The growth in all cases 
is scanty. Colonies in gelatine 
are very small, and appear as 
round yellowish spots under 
the lower power of the micro- 
scope. Stab-cultures resemble 
stabs of streptococcus pyo- 
genes ; along the bottom of the 
line of inoculation are discrete, 
round colonies. Growth on 
potatoes and on blood-serum is 
weak, and presents nothing 
characteristic. In the hydro- 
gen tubes as described for teta- 
nus (see under this heading) the 
growth is comparatively good. The bacillus is. there- 
fore, a facultative anaerobe , indeed, it seems to grow 
best where there is paucity of oxygen deep in the stab. 
The effects upon animals differ with the mode of in- 
oculation. In rats, gray mice, rabbits, and usually white 
mice, subcutaneous inoculation of small or large amounts 
produces an abscess strictly confined to the seat of inocu- 
lation. These abscesses form in twenty-four hours, and 
run a shorter or longer course, depending upon the 
amount of the culture inoculated. Animals do not suffer 
from any general symptoms, as a rule, from subcutaneous 
inoculation, but white mice do sometimes have abscesses 
in the joints and internal organs. Injections of from 
one-half to three-fourths cubic centimetre of a liquid 
culture into the ear-vein of a rabbit produce, in some 
cases, multiple abscesses in the joints, kidneys, and in 
other internal organs ; sometimes also ulceration of the 
intestines. 
The organism is found aggregated in small and large 
irregular clumps, seldom separate bacilli, in and among 
the pus-corpuscles. Meade Bolton. 
1 Meade Bolton : The Am. Jour, of the Med. Sciences, June, 1892. 
BACTERIOLOGICAL TECHNOLOGY. This article is 
supplementary to that under the title " Micro-organisms " 
in the Reference Handbook. The same order in the 
arrangement of subjects has been followed, to facilitate 
reference, and the principles of bacteriology there ex- 
pounded are in this article amplified by such selections 
from the literature of the subject as seem applicable to a 
work of this nature 
Staining Reagents.-Ziehl's Carbolic Fuchsin Solu- 
tion : Fuchsin (crystals), 1 gm.; carbolic acid, five per 
cent, aqueous solution, 100 c.c., and add slowly absolute 
alcohol, 10 c.c. A permanent solution. When used cold 
this solution stains in a few minutes most forms of bac- 
teria. Wurtz recommends that it should be filtered after 
forty-eight hours. He advises against its use for stain- 
ing pathological tissues, as it stains all granular and 
coagulated matter, and in this way disfigures the prep- 
aration. 
Kuehne's Carbolic Methyl-blue Solution : Methyl-blue 
(crystals), 1.5 gm.; absolute alcohol, 10 c.c.; add grad- 
ually while mixing, carbolic acid, five per cent, aqueous 
Fig. 33. - Bacillus Pyogenes 
Soli (schematic), showing 
some of the various shapes 
often met with. X 1,000. 
77 Bacteriological 
Technology. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(Supplement.) 
solution, 100 c.c. Action is similar to that of Ziehl's 
solution. 
Lithion-Carmine Solution : Carmine, 2.5 gm. to 5 gm.; 
saturated aqueous solution of lithion carbonate, 100 c.c. 
Stain for two to three minutes ; wash for one-half to one 
minute in the following: Concentrated hydric nitrate, 
1 part; seventy per cent, alcohol, 100 parts. Wash in 
■distilled water, then transfer to alcohol, then to oil, and 
mount in balsam. Over-staining is impossible, as the 
color can be removed to any extent by the action of the 
hydric nitrate alcohol. 
Fraenkel's Solution for Decolorizing and Double Stain- 
ing : Hydric nitrate, 20 c.c.; distilled water, 30 c.c.; 
ninety per cent, alcohol, 50 c.c.; saturated alcoholic 
solution of methyl-blue, 66 c.c. 
Czenzynski's Solution : Concentrated aqueous solution 
■of methyl-blue,40 c.c.; one-half per cent, eosine solution 
(in seventy per cent, alcohol), 20 c.c.; distilled water, 
40 c.c. For contrast staining of blood cover-glass prepa- 
rations. 
Fixative for Dry Substances in Making Cover-glass 
Preparations, v. Sehlen recommends a mixture of equal 
parts of egg albumen and a cold saturated solution of 
boric acid. The dry substances are mixed with a drop 
of this mixture on the cover-glass, and coagulation is 
effected by passing three times through the flame. It 
filters clear, and remains unchanged for a considerable 
time. 
Staining of Sections and Cover-Glass Prepara- 
tions.-Gram's Method, Modifications : Guenther rec- 
ommends the use of a three per cent, hydric chloride 
solution in alcohol instead of absolute alcohol, after the 
section has been removed from the iodine solution ; also, 
the use of xylol, instead of the oil of cloves, for clearing 
sections. 
Weigert suggests washing the section in water or a 0.6 
per cent, sodium chloride solution after its removal from 
the aniline gentian-violet stain, then placing it on a slide 
and drying it with filter-paper. Gram's iodine solution 
is applied on the slide and removed with paper. The 
section is then moistened with aniline oil, which removes 
the water, and, it is claimed, produces a more marked 
contrast. The aniline oil is removed and replaced by 
xylol, and the specimen mounted in balsam. 
Fibrine, hyaline matter, etc., are stained a deep blue ; 
micro-organisms are stained a dark violet. 
Botkin recommends washing the cover-glass prepara- 
tion or section in aniline water after its removal from the 
aniline gentian violet solution and before using the iodine 
solution. This, he claims, removes the excess of dye 
from the tissues, and fixes that already taken up by the 
bacteria. 
Staining the Bacillus Tuberculosis.-Ziehl: Cover-glass 
preparations of sputum or tissue-smears are rapidly and 
effectively stained by this method. Float the prepared 
cover-glass on Ziehl's carbolic fuchsin solution in a porce- 
lain capsule, and heat gradually to the boiling-point. 
After boiling has continued for a few minutes, decolorize 
without previous washing, in a five per cent, aqueous so- 
lution of hydric sulphate, then wash in two to three alco- 
hols (sixty to eighty per cent.) and rinse thoroughly in 
water. Contrast stain in a watery solution of methyl-blue. 
This method is applicable to the staining of the B. 
tuberculosis in tissues, but the section of tissue should 
not be heated above 45° C., and must remain in the stain- 
ing fluid for about one hour. 
Ahrens : Dissolve a small crystal of fuchsin in two to 
three drops of ninety-seven per cent, alcohol (or a few 
drops of a saturated alcoholic solution may be used) and 
add to this 2 to 3 c.c. of chloroform. This mixture is at 
first cloudy, but clears by precipitation, and when clear 
the prepared cover-glass is floated upon it for four to six 
minutes. Allow the chloroform adhering to the cover to 
evaporate, and decolorize with a three per cent, hydric 
chloride (ninety-seven per cent.) alcohol. Tiien wash in 
water and contrast stain with a watery solution of methyl- 
blue. 
In employing this method for tissues the acid alcohol 
is washed out with absolute alcohol. 
Gabbet recommends staining the prepared cover-glass 
for two minutes, without heating, in Ziehl's solution and 
washing in water. Then decolorize and contrast stain by 
immersing the preparation for one minute in the follow- 
ing solution : Methyl-blue (crystals), 2 gm. ; twenty-five 
per cent, hydric sulphate, 100. c.c. Wash thoroughly in 
water and mount in balsam. This is a simple method 
and gives good results. 
Czaplewski : Stain the preparation in warm Ziehl's 
solution and after draining off the surplus coloring mat- 
ter, immerse six to ten times in a solution composed of a 
saturated alcoholic solution of yellow fluorescin with an 
excess of methyl-blue and allow the stain to drain off 
slowly after each immersion. Then contrast stain in a 
concentrated solution of methyl-blue and wash quickly 
in water. 
The especial advantage claimed for this method of 
staining is said to be that mineral acids may decolorize 
many of the tubercle bacilli, while fluorescin does not. 
Fraenkel recommends that sections be stained for 
twrenty-four hours in an aniline-water-fuchsin solution, 
then immersed for one to two minutes in his decolorizing 
and double staining solution (see above), washed in 
water, etc. 
In cases where the tubercle bacilli are few in number 
a method of precipitating them in the sputum may be 
employed. 
Biedert: 15 c.c. of sputum are mixed with about 6 
c.c. of water, and with from 4 to 8 drops (never more) 
of a strong solution of sodium hydrate, according to the 
viscidity. This is then boiled, being continually stirred, 
and 12 to 18 c.c. more of water are gradually added 
until a thin fluid is produced. 
This is to be stood in a precipitating glass for two days, 
when the upper layers of fluid are poured off and the 
sediment stained and examined. 
It is well to preserve some of the original sputum, to 
cause the adherence of the sediment to the cover-glass, as 
the power of coagulation by heat is frequently lost by 
the above treatment of the sputum. 
Stroschein : 5 to 10 c.c. of sputum are mixed with one 
to three times their bulk of the following solution: Borax, 
1; boracic acid, 3 ; water to saturation, and thoroughly 
shaken for one minute. This is allowed to stand for 
twenty-four to forty-eight hours and the sediment is then 
examined. 
Centrifugal Machine.-This apparatus is employed to 
precipitate bacteria from urine, milk, and other fluids, 
with satisfactory results. Its use was first suggested by 
Litten. (See Fig. 34.) 
The apparatus consists of a perpendicular shaft, which 
supports a metal disk. At the periphery of the disk four 
test-tube holders are swung, and the disk is made to re- 
volve very rapidly, through the agency of a series of 
multiplying cogs by turning a crank. One is enabled 
to accomplish in minutes what formerly required hours, 
as Professor Litten states. 
Staining the Diplococcus Pneumonia.-This lancet- 
shaped bacillus stains easily by the usual methods, but 
the capsule by which it is encompassed, when found in 
the tissues, remains unstained. 
Staining in Ehrlich's aniline water gentian-violet solu- 
tion and decolorizing by Gram's method leaves the coccus 
stained. The capsule is unstained, but remains visible. 
v. Kahlden recommends, for demonstrating the capsule, 
staining for some hours in a one per cent, solution of 
fuchsin in five per cent, carbolic acid water. This gives 
a deep red color to the coccus, and the capsule has a 
pale reddish tint. 
Staining the Gonococcus.-In cover-glass preparations 
made from the suspected secretions, the coccus is easily 
stained by watery solutions of the aniline dyes, prefer- 
ably methyl-blue. It is decolorized by Gram's method. 
The cocci lie for the most part within the pus-cell, 
and are mostly grouped about the nucleus. Kratter 
states that this grouping is more characteristic than the 
" semmel " shape. 
Schutz recommends staining cover-glass preparations 
for five to ten minutes in a saturated solution of methyl- 
78 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Bacteriological 
Technology. 
blue in five per cent, carbolic acid water. Then immers- 
ing for three seconds in dilute hydric acetate, 5 parts ; 
water, 20 parts, and washing thoroughly in water. Con- 
trast stain in a very dilute solution of saffranin. 
v. Kahlden recommends staining two to three minutes 
in an alcoholic solution of eosin and warming. The ex- 
cess of eosin is absorbed with paper, and the film is then 
stained for half a minute in an alcoholic solution of 
methyl-blue. Wash in water, dry, and mount in balsam. 
Touton recommends that sections be stained in Ziehl's 
solution and washed in alcohol. 
Staining Actinomyces.-In examining pus for actino- 
myces the characteristic whitish granules must be sought 
for. This is best done on a glass plate, upon a dark 
background. The granules are carefully crushed be- 
tween two cover-glasses, which are then drawn apart; 
the film is dried in the air, and the cover passed three 
times through a flame. 
A number of methods of staining have been suggested, 
but the results are uncertain. For diagnostic purposes 
•double staining in haematoxylin and eosin suffices, giving 
a red color to the fungus and a blue color to the tissue. 
Gram's method (staining in Ehrlich's aniline-water 
alcohol^ the following solution for double staining : 
Methyl-blue, concentrated aqueous .solution, 60 parts ; 
eosin, one-half per cent, solution in seventy-five per cent, 
alcohol, 20 parts; distilled water, 20 parts ; twenty per 
cent, potassic hydrate solution, 12 parts. Stain for five 
to six minutes and wash in water. 
Czenzynski's solution may be employed with excellent 
results for producing a contrast stain. The covers 
should be floated upon it for some hours at a tempera- 
ture of 37° C. 
Staining of Spores.-Guenther : The cover-glass, be- 
ing prepared in the usual way, is floated on a solution of 
aniline-water fuchsin or gentian-violet, in a watch-glass, 
and very carefully heated to the boiling-point, when it is 
held entirely away from the flame for one minute. This 
operation is repeated five times. The cover is then 
plunged into a three per cent, hydric acetate alcohol, 
and thoroughly rinsed in water. 
The bacilli may be contrast stained by an aqueous so- 
lution of the aniline dyes. 
Moeller : The cover-glass preparation, dried in the air, 
is fixed by passing three times through a flame, or by 
immersing for two minutes in absolute alcohol. It is 
then placed in chloroform for two minutes, to remove 
fat-globules and crystals, and washed in water. 
Chromic acid has been found so to act upon the spore- 
covering as to allow the stain to penetrate it. The time 
required to effect this change in the covering varies from 
one-half to two minutes. If the action is insufficient the 
spore does not stain ; if too great, the spore is too readily 
decolorized. To test this action for the species under ex- 
amination a five per cent, solution of chromic acid is al- 
lowed to act upon the specimen for one minute. This 
effect being noted, a second specimen is treated for a 
longer or shorter time, as may be required. 
After removal from the chromic acid the preparation 
should be thoroughly rinsed and stained by a few drops 
of Ziehl's solution being heated upon it for one minute, 
and brought but once to the boiling-point. Without 
being washed it is at once immersed in a five per cent, 
hydric sulphate solution and then thoroughly washed in 
water. 
A contrast stain is produced by immersing the cover 
for thirty seconds in an aqueous solution of methyl-blue 
or malachite-green. 
Staining of Flagella.-Neuhaus recommends boiling 
the prepared cover-glass for five minutes upon black 
logwood ink, " Kaisertinte," and then placing it in a di- 
lute neutral sodium dichromate solution for fifteen 
minutes. This process must be repeated several times. 
Trenkmann stains the flagella of motile bacteria, liv- 
ing in water, as follows: A small drop of fluid which 
contains the bacteria is spread upon a cover-glass with a 
large drop of distilled water, and dried in the air. It is 
then placed, without heating, in an aqueous solution of 
one per cent, of tannin and one-half per cent, of hydric 
chloride, for two to twelve hours, and after rinsing thor- 
oughly it is stained from one to four hours in a dilute 
solution of dahlia or fuchsin (concentrated alcoholic 
solution, 2 parts; water, 20 parts), gentian-violet, or me- 
thyl-violet (1 to 8Q parts of water), methyl-blue, etc. 
Dahlia, fuchsin, and methyl-violet give especially good 
results. 
As this method answers only for staining the flagella 
of bacteria as found in nature, and not in cultures, he 
recommends for the latter the following procedure : 
Use as culture-medium an infusion of potato, or, if 
this is not suited for propagating the species of bacte- 
rium desired, broth may be employed. In the former 
case the growth must be diluted five to ten times, in the 
latter forty to fifty times, before the cover-glass prepara- 
tions are made. Where it is necessary to make prepara- 
tions directly from plate cultures, dilute at least one hun- 
dred times. 
Dry in the air, and, without heating, the covers are 
placed in the following solution : Tannin, two per cent.; 
hydric chloride, one-half to one-fourth per cent.; dis- 
tilled water, q.s., for six to twelve hours or more. After 
thoroughly rinsing they are placed in Gram's solution, or 
Fig. 34.-Litten Centrifugal Machine. 
gentian-violet solution and decolorizing in a solution of 
iodine-potassium iodide) gives good results when the sec- 
tion is left in the staining solution for twenty-four hours, 
but isopen to the objection that the fungus is liable to 
fall out when the celloidin is dissolved by the absolute 
alcohol. 
Weigert's stain for bacteria, when preceded by the 
lithion-carmine stain, produces good results, giving an 
especially sharp outline to the edge. 
Weigert also recommends staining for one hour in 
Wedl's orseille solution, washing in alcohol, contrast 
staining in a one per cent, aqueous solution of gentian- 
violet, again washing in alcohol and mounting in balsam. 
This gives a blue color to the inner parts of the " ray 
fungus," and to the outer parts a ruby red. 
Israel stains the pear- or flask-shaped ends of the fun- 
gus a burgundy-red, by staining for several hours in a 
solution of orcein in water, rendered acid by hydric 
acetate. 
Staining the Plasmodium Malaria.-Blood obtained 
by puncture is quickly spread upon a cover-glass in the 
thinnest possible film. When dried in the air and passed 
rapidly three times through a flame the organisms may 
be stained with an aqueous solution of methyl-blue. 
The red blood-cells remain unstained. 
Plehn recommends, after fixing the film in absolute 
79 Bacteriological 
Technology. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
in a solution of tincture of iodine, 1 drop ; water, 10 c.c., 
for about an hour, then thoroughly washed and stained 
for about one-half hour in a very dilute aniline-water 
gentian-violet solution, as follows: Saturated alcoholic 
solution of gentian-violet, 1 drop ; water, 20 c.c.; aniline 
water, 80 c.c. 
Loeffler at first recommended the use of a corrosive 
solution before applying the stain, but modified the 
method by mixing the corrosive material and stain in the 
same solution, and adding an acid or an alkali as he 
found necessary. 
Add a minute amount of the culture to a small drop of 
water on a cover-glass and mix carefully so as not to 
break off the flagella. A small portion of this mixture is 
transferred to a second, and from the second to a third 
cover, and dried in the air. The covers are then passed 
three times through the flame, being held between the 
thumb and finger to prevent overheating and destruction 
of the delicate tissue, and are stained by filtering a few 
drops of the following solution upon the cover-glass : 
Tannic acid solution (acid, 20; water, 80), 10 c.c.; sat- 
urated ferrous sulphate solution, 5 c.c. ; methyl-violet, 
or preferably fuchsin, 1 c.c. This to be carefully warmed 
until vapor begins to rise. It should never come to a 
boil. 
This solution answers well for staining the flagella of 
many forms of bacteria, but for certain others it requires 
to be modified by the addition of an alkali or an acid. 
The alkali used is an exact one per cent, solution of 
sodium hydrate, and the acid a solution of hydric sul- 
phate, of such strength that 1 c.c. will exactly neutral- 
ize 1 c.c. of the one per cent, solution of sodium hydrate. 
The amount of acid or alkali required to produce the 
best results in staining the flagella is to be determined by 
experiment. For the following species it has been shown 
that to each 16 c.c. of the tannic-acid-iron solution the 
following additions are necessary : Spir. cholerae Asiati- 
cte, 1 drop of acid ; Spir. rubrum, 9 drops of acid ; B. 
typhosus, 1 c.c. of alkali ; B. subtilis, 28 to 30 drops 
of alkali ; B. of Rauschbrand, 29 drops of alkali ; B. 
oedematis maligni, 36 to 37 drops of alkali. The flagel- 
la of the B. typhosus are found to be best developed in 
five to eight hour blood-serum cultures. 
Staining Bacteria in Milk or Substances Containing 
Fat.-Ahrens : Dilute milk with an equal part of water 
(cream and substances containing a large quantity of fat 
require greater dilution), and spread in a thin layer on a 
cover-glass. The film is dried in the air and the cover 
passed three times through a flame. 
Mix 12 to 15 drops of a saturated alcoholic solution of 
methyl-blue with 3 to 4 c.c. of chloroform, and on this 
float the cover^glass prepared as directed above, for four 
to six minutes. On removing from the staining fluid, 
after allowing the chloroform adhering to the cover to 
evaporate, wash thoroughly in water and mount in bal- 
sam. This makes an exceedingly clear preparation. 
Examination of Blood for Bacteria.-For this examina- 
tion blood must be spread in the thinnest possible layer 
on the cover-glass and fixed by one of the following 
methods: 1, By passing three times through a flame; 
2, in absolute alcohol ; or, 3, and besf, by subjecting it for 
five minutes in an oven to a temperature of 125° C. 
Staining such a film for some hours in Czenzynski's 
solution and washing in water produces excellent results 
in contrast staining. 
Guenther has suggested washing the film in a one to 
five per cent, solution of hydric acetate for ten seconds, 
to remove the normal coloring matter from the red blood- 
cells, thus making the bacteria more apparent. The 
hydric acetate is removed first by blowing it off the prep- 
aration by means of a tube, and then allowing the fumes 
of strong ammonia to act upon it for a few seconds. 
Staining is accomplished by an aqueous solution of the 
aniline dyes. 
Sections of Pure Cultures.-A pure culture, either in 
agar or in gelatine, after removal from the tube may 
be hardened for four to eight days, exposed to the light 
in a one per cent, solution of potassium bichromate, then 
washed in water and treated with seventy per cent, and 
(SUPPLEMENT.) 
ninety-six per cent, alcohols. Gelatine cultures thus- 
hardened are mounted on cork, kept for twenty-four 
hours in absolute alcohol, and then cut and stained. 
Agar cultures, after being hardened are to be saturated 
with bergamot oil, then placed in a soft bergamot oil 
paraffine, and then in pure paraffine, at 37° C., for twenty- 
four hours, when sections may be made. Sections should 
be stained on the slide, cleared only with bergamot oil, 
and mounted in balsam. Loeffler's alkaline blue and 
Gram's and Weigert's methods of staining give good re- 
sults. Colonies from thin gelatine plates may be hard- 
ened in the same way, and are then to be treated as sec- 
tions. To prevent them from folding they should be 
placed between two slides before immersing in alcohol, 
and a weight should be placed upon the cover after 
mounting in balsam. 
Culture Methods.-Sterilization.-By moist heat. 
An apparatus known as the Arnold Steam Cooker was 
first applied as a steam sterilizer by Prudden. It is 
now manufactured as a steam sterilizer and is largely 
used in preparing foods for infants, sterilizing surgical 
instruments and dressings, and is of value for sterilizing 
clothing and bedding used by persons suffering from 
contagious diseases, and the clothing of their attendants. 
It also presents advantages for laboratory use. It con- 
Fig. 35.-Arnold Steam Sterilizer, Sectional View. 
sists of (A) a flat, shallow boiler, holding but a small' 
amount of water, and therefore requiring but a mini- 
mum amount of heat to produce steam ; (B) a reservoir, 
placed upon the boiler, which it constantly feeds and in- 
sures the constant formation of steam ; (D) a covered 
steam-chest or receiving-vessel, placed above the reser- 
voir and connected with the boiler by a cylindrical tube 
of large diameter (C); and (E) a hood, covering the re- 
ceiver and enclosing an air-space which is constantly sup- 
plied with escape steam. The hood and the steam-jacket 
which it encloses prevent variations in temperature in 
the receiving-vessel, so long as the heat applied to the 
boiler remains unchanged. 
By dry heat. A double sheet-iron or tin oven placed 
on a range or on a gas-stove is employed as an efficient 
sterilizer. 
By desiccation. Koch has shown that the vitality of 
the spirillum choleric Asiatics is rapidly destroyed by 
drying, and the same effect is produced upon the vege- 
tative forms of all bacteria, the time required varying- 
with the species. Spores have a much greater resisting 
power, and some forms are known to retain their vitality 
for several years. Spores of the B. anthracis, dried on 
silk threads, after five years have shown active and typi- 
cal growth and proved to be pathogenic to white mice. 
By sunlight. Numerous writers have shown that bac- 
teria are destroyed by the action of direct sunlight upon 
80 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Bacteriological 
Technology. 
them, as well as by the action of diffused light. Vegeta- 
tive forms are destroyed much more rapidly than are 
spores. That spores are eventually destroyed seems proven 
from the experiments of Arloing, Momont, and Gaillard. 
The B. tuberculosis, as stated by Koch, is killed in a 
short time by exposure to the direct rays of the sun, and 
the same effect is produced by diffused light, when the 
exposure is continued for several days. 
By electricity. Experiments in this line have been 
made by several writers, those made by Spilker and 
Gottstein seem to be the most convincing. They used an 
induction current from a dynamo machine, which was 
passed through a wire wound around a test-tube con- 
taining a culture, the tube being suspended in water. 
No growth occurred after resowing the culture, and repe- 
titions of the experiment gave similar results. 
The strength of the current seems to have a direct 
effect upon its germicidal power, but in no experiment 
were the bacteria destroyed in less than one hour. 
Pasteurization.-Freeman has experimented in this 
line and offers an apparatus (now a commercial article) 
for pasteurizing milk and infant foods. This apparatus 
consists of a covered tin pail of given size, which is filled 
to a certain marked level with water which is actually 
boiling. Into this is placed a second tin vessel filled with 
water of ordinary temperature and holding the bottles 
which contain the fluid to be pasteurized. The outer 
pail is then covered, and the apparatus left standing for 
one hour, when the bottles are removed and put in a re- 
frigerator to prevent development of any spores which 
are present. 
The apparatus described has been found to raise the 
Schultz recommends the following titration method as 
a more simple and more exact process for neutralizing 
media : 
Measure out 1 c.c. of the medium to be neutralized, 
put it in a beaker-glass, standing on white paper, and add 
one drop of a solution of phenolphtalein (1 to 300 in 
vinegar) and mix thoroughly. This forms a colorless 
solution. To this a 0.4 per cent, aqueous solution of 
sodium hydrate is cautiously added from a graduated 
pipette until the fluid assumes a pale rose tint. This pro- 
cess is performed three times, the amount of alkali used 
in each experiment carefully noted, and the arithmetical 
mean of the three results taken as the amount of alkali 
necessary to neutralize 1 c.c. of the medium. The figure 
thus obtained is multiplied by the number of cubic centi- 
metres of medium to be neutralized and divided by ten. 
The quotient represents the amount of a four per cent, 
solution of sodium hydrate required to render the whole 
medium neutral in reaction. 
Filtration of broth, gelatine, and agar has been much 
simplified by employing in the funnel several crossed 
layers of absorbent cotton, loosely packed, instead of 
filter-paper. The use of the hot funnel is not required, 
and the properly neutralized medium can be cleared by 
passing it several times through the cotton. There is but 
little likelihood of any of these media becoming too cool 
to flow during the process, as filtration is very rapid. 
v. Freudenreich recommends that agar be filtered 
through paper in the autoclave. He claims that it is 
rapidly accomplished, it is thoroughly sterilized, and the 
medium is crystal clear. He also states that if agar be 
boiled for two hours at 115° C. and allowed to stand in 
the unopened autoclare for three 
hours, it will remain fluid, all the 
impurities will settle, and a clear 
medium may be obtained by care- 
fully pouring off the upper layers. 
Neisser and Jacobi suggest filter- 
ing agar under pressure through 5 
ctm. of absorbent cotton, closely 
packed in a large titrating funnel. 
They state that filtration by this 
method requires but a few minutes. 
Schultz has suggested the follow- 
ing rapid method of preparing nu- 
trient agar: 
To 1,500 c.c. of water, placed in 
an open enamelled iron vessel, add 18 gm. of agar and 
boil vigorously over a free flame for thirty minutes. 
During the boiling 2 gm. of Liebig's meat extract are 
added, and the thick, white scum which forms is to be 
removed. The fluid is now cooled to 60° C., and 10 gm. 
of dry peptone (Witte's) and 5 gm. of sodium chloride 
are added, together with the entire contents of one or 
twro eggs, which are mixed with sufficient water to re- 
place that which has evaporated. 
The reaction, which usually is too alkaline, must be 
corrected and the mixture is again brought to the boil- 
ing point and boiling continued for ten or fifteen min- 
utes. 
Filtration is effected through a filter-paper, selected on 
account of its allowing a rapid filtration, without the use 
of the hot-water funnel, and may be repeated through the 
same paper. The process should be completed in an hour, 
and one litre of medium should be obtained. 
The agar thus prepared may be used at once for Es- 
march tube-plates, even after the addition of four per 
cent, of glycerine. 
If it is desired to prepare the medium with meat in- 
fusion, instead of with Liebig's meat extract, the pro- 
cedure is modified as follows : 
One pound of finely chopped lean meat is digested 
in 1,500 c.c. of water at 50° C. for thirty minutes, 
strained through a cloth, boiled for five minutes, and 
then filtered. To the filtrate, in an agate saucepan, 18 
gm. of agar are added, and the process is continued as 
described above. 
Potato.-Esmarch suggests cutting potato in moderately 
thin slices, placing them in covered glass dishes, measur- 
Fig. 36.-Freeman Pasteurizer. 
temperature of the fluids contained in the bottles to be- 
tween 73° C. and 76° C., and to hold them at that tem- 
perature for a sufficient time to destroy the B. tuberculo- 
sis, spir. cholerte Asiaticte, B. typhosus, etc. Milk treated 
in this manner shows no visible alteration, and if kept in 
an ice-box remains unchanged for several days. 
Culture - media.- Meat Extract Media. - Liebig's 
Beef Extract is largely used in preparing nutrient broth, 
gelatine, and agar. It is substituted in the proportion 
of one half of one per cent, for the infusion of meat, 
and makes a most efficient growing medium for most 
forms of bacteria. 
Melting Agar.-To facilitate the melting of agar, it 
may be soaked over night in water, but the water ab- 
sorbed must be measured and taken into account. 
Soaking agar in a very dilute solution of hydric ace- 
tate for some hours facilitates its melting, but this treat- 
ment causes it to lose some of its stiffness, which it does 
not regain. 
Neutralization.-For the purposes of neutralization a 
solution of potassium or sodium hydrate possesses an ad- 
vantage over the CO2 salts in not giving off carbon diox- 
ide, wffiich, when held mechanically in the viscid fluid, 
may mask its proper reaction and cause the medium to 
be made too alkaline. 
A medium, when markedly alkaline, cannot be cleared 
except by coagulating in it the white of egg. To facili- 
tate this coagulation, which sometimes requires prolonged 
boiling in an alkaline solution, a single drop of concen- 
trated hydric chloride may be dropped in while the fluid 
is boiling. This acid does not appreciably alter the re- 
action. 
81 Bacteriological 
Technology. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
ing not more than 5 ctm. in diameter, and sterilizing in 
steam for three consecutive days. This answers well for 
the purposes of culture. 
Roux first suggested 
placing potato in test-tubes 
for culture purposes. He 
cut a core out of the potato 
with a cork-borer, placed 
it in a test-tube, the lower 
end of which had been 
constricted to form a recep- 
tacle for water, and steril- 
ized in steam. 
Bolton used larger tubes. The method of preparation 
is as follows : 
A potato squared off at each end, cut out by an apple- 
corer, and the core thus obtained divided obliquely into 
two equal parts. Each half is put into a test-tube 
measuring about 3 ctm. in diameter 
and 12 ctm. in length, and steril- 
ized for three consecutive days. A 
small amount of water collects in 
the bottom of the tube and prevents 
rapid drying of the medium, while 
the oblique surface of the potato 
renders sowing upon it easy, and 
enables the culture to be readily 
observed through the tube. 
When potato has been prepared 
in this way, before placing it in 
the tubes it should be left in cold 
running water for about twenty 
minutes, to prevent the potato from 
turning dark. 
Plant states that potatoes, or 
other vegetables or fruits, cut to 
the proper size, may be sterilized in 
large storage-tubes, and fished out 
with a heavy platinum needle as 
required for use. 
Macaroni is recommended by de 
Lagerheim as a culture-medium. 
To prepare it, cut the macaroni 
in short pieces, and place in cotton- 
plugged tubes, which are nearly 
(SUPPLEMENT ) 
per cent, solution of potassium hydrate, showed an al- 
teration in the consistence of the albumen. In four days 
it becomes "fluid-gelatinous-transparent," and in from 
five to fourteen days it becomes " solid-gelatinous " and 
faintly yellow, but remains transparent. 
The broth-like medium'is made by using a ten percent, 
aqueous solution of the "fluid-gelatinous-transparent" 
albumen and sterilizing. 
The syrupy medium is a fifty per cent, aqueous solution 
of the " fluid-gelatinous-transparent" albumen. 
The solid medium may be either a, the " fluid-gelati- 
nous-transparent" albumen placed in tubes and sterilized, 
or 3, the "solid-gelatinous" albumen, cut in thin slices 
and used unsterilized, in small double dishes. 
Blood-serum.-Abbott has suggested an improvement 
in the method of securing blood-serum. He recommends 
collecting the blood in museum jars of one gallon capac- 
ity, closed by a cover which can be tightly secured upon 
a rubber joint. 
After the blood has stood in these jars for about fif- 
teen minutes, or until clotting has begun, a clean glass 
rod is passed around the edges of the surface of the clot, 
to break up adhesions which have formed, and which 
would prevent the sinking of the clot to the bottom. 
The covers are then tightly replaced, and with as little 
agitation as possible the jars are removed to an ice-chest. 
At the end of about forty-eight hours the firm clot will 
have sunk to the bottom of the jar, and above it a quan- 
tity of dark straw-colored serum is found. This serum 
should be drawn off with a sterilized pipette and placed 
in tall cylinders and the blood-corpuscles allowed to set- 
tle by standing the cylinders in an ice-chest for twenty- 
four hours. The clear serum is then pipetted off into 
tubes or flasks and sterilized by the fractional method. 
Kirchner has demonstrated that chloroform added to 
various fluids will prevent putrefaction in them. He 
recommends the use of this agent in the strength of one 
per cent, for preserving storage - flasks of unsterilized 
blood-serum and milk. Chloroform does not kill spores, 
but prevents their development, so that when fluids thus 
preserved are prepared for use the chloroform must be 
driven off by heat, and sterilization effected by the usual 
methods. 
Blood-serum thus preserved in sealed flasks for more 
than a year has been successfully used as a culture-me- 
dium. 
Loeffler mixes three parts of blood-serum with one part 
of beef-broth containing one per cent, of glucose. This 
is sterilized and used as a fluid or solid medium. It is 
recommended for growing the B. diphtherias, and Park 
has shown that within eighteen hours a sufficient growth 
may be obtained on the coagulated medium to establish 
a differential diagnosis between diphtheria and the other 
pseudo-membranous inflammations. 
Hueppe combines blood-serum with agar to make 
plates. He mixes the sterile fluid serum with equal 
parts of two per cent, nutrient agar to which 0.5 to 1 per 
cent, of glucose has been added. The following pro- 
cedure should be closely adhered to, viz., warm the 
serum to 37° C., melt the agar and cool to 42° to 45° C. 
and mix them together. The material to be studied is 
then added and the plate poured before the agar has be- 
come solid. 
Bumm suggests collecting human blood from the pla- 
cental end of the cut umbilical cord, in a sterilized vessel. 
The serum is collected and sterilized in the usual way. 
From single cases he has secured from 15 to 20 c.c. of 
clear serum. 
Human blood-serum seems to be necessary for procur- 
ing cultures of the gonococcus. 
Plate Cultures.-Petri suggested for plating gela- 
tine and agar, the use of double glass dishes measur- 
ing 10 ctm. in diameter and 1.5 ctm. in height. The 
upper dishis a cover and the lower dish, with its per- 
pendicular edges, serves to hold the medium, and ob- 
viates the necessity of using a levelling apparatus and 
cold stage. The " Petri dish " has in most cases re- 
placed the flat plate formerly used. It seems to be 
adapted to every need. 
Fig. 37.-Dish for Potato Culture. 
(Esmarch.) 
Fig. 38.-Tubes for Potato Cultures. A, for anaerobic growth; B, for 
aerobic growth. (Roux.) 
filled with water. These should be boiled in the steam 
sterilizer for fifteen minutes, then the excess of water is 
poured off, and the regular process of sterilization per- 
formed. 
Many species of bacteria do not grow upon macaroni, 
but it is useful as an additional medium. 
Urine.-Heller has suggested that urine reduced to the 
specific gravity of 1.010 be used as a culture-medium, to 
which peptone, salt, gelatine, agar, glycerine, sugar, etc., 
may be added. He also suggests the use of diabetic and 
albuminous urine. 
Ascitic and hydrocele fluids are used for the purposes 
of culture, with or without adjuvants. They are to be 
drawn off from the body by sterilized instruments and 
received in sterilized vessels. They are prepared as cult- 
ure-media by the processes employed for blood serum. 
Egg.-The white of egg is an efficient culture-medium. 
Schenck recommends using the outer, clear, and most 
fluid of the albuminous layers, mixed with equal parts of 
water. This is sterilized discontinuously at 65° to 70° C. 
Tarschanoff and Kolessnikoff make a broth-like, a 
syrupy, and a solid medium from eggs by treating them 
■with potassium hydrate. 
They found that eggs in their shells, placed in a ten 
82 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Bacteriological 
Technology, 
(SUPPLEMENT.) 
" Streak-plates " are made on gelatine and agar, after 
the medium has been poured in the plates and become 
solidified, by drawing an infected needle across them in 
four or five parallel courses. When the number of bac- 
teria on the needle is small, and the streaks are made with 
a light touch, separate colonies will be 
found growing along the line which 
the needle has travelled. This method 
of plating is especially adapted for use 
at autopsies. 
Anaerobiosis.-Various methods 
a tube containing a column of nutrient medium, 8 or 10 
ctm. in height, is an efficient method of obtaining anae- 
robic growth. The first growth appears at the lower 
part of the tube and extends slowly upward, sometimes 
reaching nearly to the surface of the medium. 
Fig. 42.-Tube for Anaerobic Culture. (Salomonsen.) 
Substituting an atmosphere of some pure gas, prefer- 
ably hydrogen, is a method long in vogue. 
Fraenkel devised the following procedure. Using a 
large test-tube, fitted with a double-bored rubber cork, 
through which two glass tubes pass, one extending 
well into the medium, the other ending at the lower 
surface of the cork. The upper parts of both tubes, 
just above the cork, are bent to right angles and the 
ends drawn out to capillary tubes. 
Through the longer tube a stream of hydrogen or 
other gas is passed to replace the air which is driven out 
through the shorter tube, and when this is accomplished 
both tubes are sealed, the shorter one first. 
After the tubes have been sealed an Esmarch tube- 
plate may be made. 
Salomonsen has devised a culture-tube in which the 
air may be replaced by hydrogen. It consists of a piece 
of glass tubing drawn out at both ends, leaving between 
them a bulb 8 or 10 ctm. in length. One of the ends is 
bent up upon the bulb, and at 
the middle of the bulb bent 
outward at a right angle. 
After the medium has been 
introduced, a stream of hy- 
drogen is passed through it from below while it is still 
fluid. Inoculation is effected by means of a platinum 
needle, and after the air has been replaced by hydrogen, 
both ends are sealed. 
Blucher has devised an ingenious and very effective 
apparatus for anaerobic plating. It consists of a glass 
dish about 8 ctm. in di- ameter (B), which is 
raised on a wire frame (Q and placed within a 
dish about 12 ctm. in diameter and 5 ctm. high 
(A). Over the smaller dish a tulip-shaped fun- 
nel (D), intermediate in size between the two 
dishes, is inverted, the neck of which has been 
1 o o s e ly plugged with cotton (E). 
This is sterilized by dry heat. 
Fig. 39.-Dish for Plating. (Petri.) 
have been suggested for obtaining bacterial cultures in 
an atmosphere from which oxygen has been excluded. 
Some forms, the obligatory anaerobes, require that this 
condition be absolutely fulfilled, while others, the facul- 
tative anaerobes, develop both in the presence and in the 
absence of oxygen. 
The methods de- 
scribed answer the 
requirements more 
or less perfectly, but the process is a dif- 
ficult one to carry out, and attention is 
required to the minute details. 
The oxygen may be removed from 
the culture by mechanical means, and 
this is the most usual procedure, or it 
may be absorbed and enter into chemi- 
cal combinations which are not broken 
up by the processes re- 
quired to obtain a growth 
of the bacteria in ques- 
tion. 
By means of the air- 
pump the air may be 
rarefied, and a large pro- 
portion of the oxygen re- 
moved, or, as was first 
suggested by Koch, the 
medium on a plate is cov- 
ered with a sheet of mica, 
beneath which the air is 
excluded and the growth 
which occurs remains un- 
der observation. 
For growth in tubes, 
Hesse has suggested pour- 
ing upon the medium a 
quantity of sterilized oil. 
Librious, after boiling 
the medium for 20 min- 
utes to drive off the oxy- 
g e n contained in it, 
cooled the medium quick- 
ly, inoculated the germ 
to be cultivated, and then 
sealed the tube. 
Roux, after boiling, 
cooling, and inoculating 
the medium, poured upon 
it a thick layer of agar, 
which, when cool, he in- 
oculated with an aerobic 
germ, to use up any oxy- 
gen which might still be 
present or which might 
gain admission. 
Deep puncture, with a 
Inno- nlatinnm needle in 
Fig. 43.-Apparatus for Anaerobic Plating. (Blucher.) 
The plates are poured into the inner or smaller dish, 
the opening which exists between the rim of the funnel 
and the outer dish is closed by a sufficient quantity of 
glycerine and water, poured into the outer dish, and the 
neck of the funnel is connected with the gas generator 
by a piece of rubber tubing, 8 or 10 ctm. in length, which 
is provided with a spring clip. The gas, passing from 
Fig. 40. -Anae- 
robic Growth 
Obtained b y 
Deep Punct- 
ure. 
Fig. 41. -Anae- 
r o b i c Tube- 
plate. (Fraen- 
kel.) 
83 Bacteriological 
Technology. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
above, drives the air out beneath the rim of the funnel, 
and when this process is completed, the rubber tubing 
is closed by the spring clip, the connection with the gas 
generator is broken and a drop of glycerine placed in the 
lumen of the rubber tubing, above the spring clip, to 
effectually seal it. It is necessary to weight the funnel 
to overcome the buoyancy of the gas contained in it (?'). 
(SUPPLEMENT.) 
growth by filling the tube with gelatine. In doing this, 
it is necessary that the tube-plate already made be held 
in ice-water, to prevent its melting, w hile the gelatine, 
which should be as cool as it is possible to have it, is- 
poured in. 
Nikiforoff has devised a bulb for cultures, from which 
the air can be absolutely excluded. It is made from a 
moderately thin glass tubing of 1.5 to 2 ctm. 
diameter, sealed at one end and drawn out to a 
long capillary tube at the other, leaving a bulb 
about 5 ctm. in length. The capillary tube is 
broken at its middle, and at a distance of about. 
10 ctm. from the bulb it is curved through 
an angle of 160°. The end of the capillary 
is then immersed in sterilized water, the air 
driven out by heating the bulb with a tiame, 
and on cooling some of the water is sucked 
up into the bulb. To fill such an apparatus 
with the nutrient medium the water in the 
bulb must be carefully boiled out, leaving 
practically a vacuum, and just before the 
emptying of the bulb the end of the capillary 
tube is immersed in the desired medium, 
which must be in a fluid condition. On cool- 
ing, the medium flows rapidly into the bulb, 
and sealing is effected by holding the curve 
of the capillary tube in a flame. 
To allow of inoculation the tube must be 
cut off where the bulb begins to narrow into 
the capillary. The process of sowing in a 
solid medium is the same 
as in ordinary tubes, after 
which the tube is sealed 
by a blow-pipe. 
To sow in broth, or in 
a melted gelatine or agar, 
he recommends the in 
g e n i o u s method of 
touching an end of a 
short, sterilized capil- 
lary tube, held in 
sterilized forceps, to 
the fluid to be ex- 
amined. The cap 
i11 a r y at once 
fi 11 s, and it is 
dropped into 
the bulb, where 
it falls to the 
bottom, its 
contents be- 
ing w s^s h 
ed out by 
the fl u i d 
medium 
Fig. 44.-Apparatus for Anaerobic Plating. (Hesse.) 
Hesse and Botkin have both devised apparatus for 
growing anaerobic plates. 
In both cases a closed chamber is formed by inverting 
a vessel of considerable cubical contents, within one of 
slightly greater diameter. A small rack to hold several 
plates, one above the other, is placed within the chamber, 
and raised from the floor of the lower vessel. 
Hesse seals the opening between the upper and lower 
vessels with mercury, and conducts the stream of hydro- 
gen through a glass tube curved at its extremity to a 
short U-shape. The air is conducted off by a similar 
glass tube placed on the other side, and when the sub- 
stitution of the hydrogen is completed both tubes are 
removed without allowing any of the gas to escape. 
Botkin uses a liquid paraffine joint, *3 ctm. in height, 
and conducts both the gas and the air through rubber 
tubes. These tubes, when bent to the desired shape, re- 
tain this shape through the agency of a fine copper wire 
Fig. 46.-Anaerobic Culture-tube, a, Method of filling- 
tube with culture medium ; b, tube inoculated and sealed. 
(Nikiforoff.) 
during its descent. The bulb is then sealed. 
Hueppe recommends the use of eggs in their 
shells for anaerobic cultures. 
After external cleansing and disinfection 
with sublimate, washing in sterilized water,, 
and drying with sterilized absorbent cotton,, 
the egg is thoroughly shaken and a fine opening made at 
its point, by a sterilized instrument, through the shell 
and membranes. Through this opening the inoculation 
is made, and it is afterward covered with sterilized paper 
and sealed with collodion. 
Buchner absorbs the oxygen present in the tubes. 
Fig. 45.-Apparatus for Anaerobic Plating. (Botkin.) 
previously passed through them. They are easily re- 
moved, after steadying the upper vessel, by simply draw- 
ing them out. 
Esmarch's roll tube-plates may be used for anaerobic 
84 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Bacterio logical 
Technology. 
and uses for the purpose an alkaline solution of pyro- 
gallol. 
A tube inoculated in the ordinary way is placed in a 
large test-tube containing 1 gm. of commercial pyrogallic 
acid. To this 10 c.c. of a 10 per cent, potassium hy- 
drate solution is added from a pipette, and the large tube 
is quickly closed with a rubber cork and 
sealed. In twenty-four hours, at 37° C., 
the contained oxygen is absorbed. At 
lower temperatures a longer time is re- 
quired. 
It is of advantage to raise the inoculated 
test-tube above the fluid in the large tube 
on a glass or metal support (p). 
Kitasato and Weil have proposed adding 
to the nutrient medium substances which 
possess the power of absorbing oxygen. 
They believed that the good effect of sugar, 
as used by Liborius, upon the growth of 
anaerobic bacteria was due to this absorb- 
ing power, and they experimented to find 
a substance which wrould act more power- 
fully in this regard. 
They found that sodium formate, used 
in the strength of 0.3 to 0.5 per cent, in 
nutrient agar, left a clear, transparent me- 
dium, and its presence was so beneficial 
upon the growth of three anaerobic species 
experimented with, that they recommend 
its use for this purpose. 
They also found very characteristic ap- 
pearances from growing anaerobes in agar, 
to which 0.1 per cent, of sodium indigo- 
sulphate had been added. 
Before inoculation and for about twelve 
hours after it, this medium is bluish-black 
and opaque. As growth progresses the 
color changes to one of a greenish tint, the 
change appearing first in the lower part of 
the tube and spreading upward. Grad- 
ually the growth in the puncture-line be- 
comes apparent, and the agar, which event- 
ually regains transparency, also regains its 
original yellow or brownish color. In all 
cases the color of the superficial layers of 
the medium, to the depth of about two 
ctm., remains an indigo-blue. 
Anaerobic Hanging-drop.-The growth 
of anaerobic bacteria in hanging-drop has 
been carried on by apparatus which al- 
lowed a stream of hydrogen to replace the 
air, or from which the air was exhausted 
by the air-pump. Two much more simple 
and very efficient methods have been sug- 
gested. 
Nikiforoff prepares the hanging-drop as usual, upon 
the hollow slide, and, by slipping the cover to one side, 
places a small drop of a saturated solution of pyrogallol 
on the edge of the hollow ; then by slipping the cover to 
the other side he inserts a small drop of ten per cent, 
potassium hydrate solution, and returns the cover-glass 
its upper surface. Over this opening a glass ring is 
sealed. The hanging-drop is made in the ordinary way, 
and sealed with vas- 
eline upon the glass 
ring. Through an- 
other opening in the 
retort the pyrogallol 
is first introduced, 
then the ten per 
cent, solution of 
potassium hydrate, 
and the opening is 
plugged and sealed. 
Inoculation of 
Animals. - Petri 
h a s recommended 
an inoculation syr- 
inge which seems to 
present advantages 
over those formerly 
used. He employs 
a graduated glass 
pipette of 1, 2, or 5 
c.c. capacity, with a 
short tube of exit, 
which is ground to 
lit accurately into 
the shoulder of a 
hypodermic needle. 
The needle and 
pipette are easily 
sterilized and are 
the only parts w hi< h 
come in contact with the fluid to be 
injected. 
The injecting power is supplied 
by a double bulb, such as is used in 
an ordinary hand-spray apparatus, 
and attached to the pipette by rub- 
ber tubing, in the course of which a 
stop-cock has been inserted. 
The pipette being filled with the 
desired fluid, the stop-cock turned to 
cut off the air, and the bulb being 
inflated, the needle is introduced into 
the tissues and by carefully turning 
the stop-cock enough force can be 
applied to drive the desired quantity 
of the inoculating fluid into the body 
of the animal. Then by turning the 
stop-cock to cut off the force and 
withdrawing the needle the oper- 
ation is completed. 
Examination of Air. - It has 
been demonstrated that the air may 
be freed from the dust and bac- 
teria which it contains by filtration 
through various substances and this 
fact has led observers to employ fil- 
tration for studies of air analysis. 
After a measured quantity of air 
has been aspirated through the filter, 
the bacteria are freed from the filter- 
ing substance and grown upon plates. 
Cotton, glass-wool, and asbestos-wool 
serve as efficient filters, but the diffi- 
culty of spreading these materials in 
the fluid medium and their opacity 
have led to a discontinuance of their 
use. 
Petri, after a series of experiments, 
suggested the use of a column of 
sand as an air-filter and has de- 
vised the following method for its 
use. 
Grains of sand, measuring between 
0.25 and 0.5 mm., are collected by 
means of a series of sieves, and thor- 
oughly burned over a flame for the 
Fig. 49. - Syringe for Animal Inoculation. 
(Petri.) 
Fig. 47. -Ap- 
paratus for 
An aer o bic 
Culture. 
(Buchner.) 
Fig. 48.-Slide for Anaerobic Hanging-drop. (Braatz.) 
to its proper place. By careful manipulation the two 
drops may be run together, and the oxygen is then ab- 
sorbed. The alkaline pyrogallol forms a dark ring 
around the hanging-drop. 
Braatz also uses the alkaline pyrogallol solution to 
absorb the oxygen, but forms a retort for it beneath the 
slide, which is connected through a hole in the slide with 
Fig. 50.-Sand Filter 
for Air Analysis. 
(Petri.) 
85 Bacteriological. 
Bagnolles. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
purpose of sterilization. This gives them a reddish 
color. 
A glass tube, 9 ctm. in length and 1.5 ctm. calibre, 
is fitted within its lumen with four disks of fine wire 
gauze to serve as supports, and between each two of 
these disks a sand-filter, 3 ctm. in length, is closely packed. 
Each end of the tube is plugged with cotton and the 
whole is sterilized in hot air. The filter is now ready 
for use. 
When the apparatus is to be used for an analysis, the 
cotton plugs are removed and placed in a sterilized cov- 
ered vessel, and the filter is attached to an exhaust-pump 
by means of rubber tubing. From 5 to 10 litres of air a 
minute are drawn through the sand, until the required 
amount has passed, when the filter is separated from its 
attachments, the cotton plugs are replaced and the filter 
preserved for plating. 
The method of plating is as follows : After removing 
the uppermost cotton plug, the upper gauze disk is 
taken out with sterilized forceps and placed in a steril- 
ized Petri dish. The sand is then poured into the same 
dish, the melted gelatine added, and the sand spread 
evenly by short, quick lateral movements of the dish. 
The lower sand-filter is then treated in the same man- 
ner and the plates preserved for observation. 
With the aid of a good hand-magnifier, the colonies of 
bacteria may be readily distinguished from the grains of 
sand. 
Opaque areas are sometimes formed in these plates, by 
a grouping of the sand-particles, which may obscure 
certain parts of the plate. To overcome this objection 
the use of soluble filters has been proposed. Sedgwick 
and Tucker have used for this purpose a filter of granu- 
lated sugar, about 8 ctm. in length and 3 mm. in diam- 
(SUPPLEMENT.) 
pies taken from the deeper parts of a stream are collected 
in sterilized weighted bottles, fitted with ap apparatus to 
withdraw and replace the stopper, and lowered to the de- 
sired depth. 
Water should be plated as soon as possible after it has 
been obtained. Should it be necessary to transport it 
before the plates can be made, the bottle containing it 
should be packed in ice. 
The quantity of water used for an analysis must depend 
upon the number of bacteria which it contains. One 
cubic centimetre is the amount usually employed, but 
less should be used if more than five hundred colo- 
nies develop from this amount. For quantitative anal- 
ysis a measured quantity must always be employed, a 
drop, being an indefinite quantity, is not to be recom- 
mended. 
The colonies should be counted on the third or fourth 
day. T. M. Cheesman. 
BAD BRONN. An Alsatian watering-place, known 
also as Kestenholz (Ger.) and Chatenois (Fr.). 
Location.-Kestenholz is prettily situated not far 
from Strasbourg, and within sight of Schlettstadt on the 
river Rhine. It is an unpretentious, quiet resort, with 
four saline and moderately alkaline springs, flowing in 
great abundance, and having a temperature of about 64°F. 
It is chiefly frequented by ladies. Although the water con- 
tains traces of sulphuretted hydrogen, it is not unpleasant 
to the taste. The baths are refreshing, and the thermal 
establishment is modern in its appliances. There are 
beautiful natural promenades through chestnut-planta- 
tions and fine forests. The walks resemble those of 
Marienbad. Mr. Wolff writes as follows concerning 
this place (" The Watering Places of the Vosges, 1891 "): 
" Apart from the use of the 
waters, for a cheap sojourn in for- 
eign mountain country it would not 
be easy to hit upon a fitter place than 
Chatenois. It is easily reached, be- 
ing situated on the branch-line from 
Schlettstadt to Markirch, at the 
junction of the valleys of the Le- 
ber (Liepvre) and of Weiler (Vai de 
Ville), both exceedingly pretty and at the same time in- 
teresting valleys, leading up to the lofty ridge which 
rises farther south to the high points of the Schlucht and 
the Hohneck." 
Analysis.-In 1,000 parts there are contained : 
Free carbonic acid traces 
Sulphuretted hydrogen traces 
Chloride of sodium 3.200 
Chloride of magnesium 0.078 
Chloride of potassium 0.010 
Sulphate of soda (anhydrous) 0.086 
Sulphate of magnesia 0.050 
Sulphate of lime 0.020 
Silicate of soda ) n 
Bicarbonate of soda j VAOU 
Silicate of lime 0.410 
Silicate of magnesia 0.270 
Silicate of iron and of manganese 0.020 
Basic salts of bromine and of iodine strong traces 
Organic matter, in combination with lithia silicic I _ - 
acid and ammonia f 0.02U 
Fluorine, arsenic, lithia strong traces 
4.214 
Indications.-These saline waters are useful in rheu- 
matic and gouty affections, hepatic plethora, catarrhal 
affections of the bowels, anaemia and chlorosis. For con- 
ditions of neurasthenia the place itself, apart from the 
springs, has undeniable advantages. Tuberculosis and 
cutaneous affections are also said to be much benefited 
by a course of these waters, but this statement must be 
taken cum grano salis. 
Accommodation.-A new hotel is in course of con- 
struction, the older ones are mediocre, though clean. 
The usual sprays, douches, pine-needle baths, inhala- 
tions, etc., are provided. But everything is on a small 
scale. It is a cheap place-Mr. Wolff stating that one 
dollar a day will about cover all necessary expenditures. 
Fig. 51.-Aerobioscope. (Sedgwick and Tucker.) 
eter, contained in a glass tune, to avoid the risk ot con- 
tamination in pouring the plates they attached to the 
tube containing the filter, a cylindrical glass bulb, ruled 
in squares, into which the sugar used for filtering is to be 
transferred and in which the plate is rolled. Both ends 
of the apparatus are plugged with cotton and sterilization 
is effected at 150° C. in hot air. 
These writers propose the use of an exhaust receiver 
of measured capacity provided with a vacuum gauge, to 
determine the amount of air used. To this receiver their 
apparatus is attached and the desired amount of air 
drawn in through it. When this is accomplished the 
sugar is transferred from the tube to the bulb by careful 
tapping, a sufficient amount of gelatine is then poured 
into the bulb, and after the sugar is dissolved a plate is 
rolled, under a stream of cold running water. 
The sand-filter for air analysis may be simplified as 
follows : In a glass tube, 9 ctm. in length, about 0.3 ctm. 
in diameter, 6 ctm. of sand, of the size recommended 
by Petri, are placed, and the column supported on a roll 
of fine wire gauze pressed into the tube. Both ends of 
the tube are plugged with cotton and the whole is steril- 
ized in dry heat. After removing the cotton plugs this 
filter is inserted in a rubber tube connected with an ex- 
haust receiver, as suggested by Sedgwick, and the re- 
quired amount of air is drawn through it. The plating 
is effected by scattering the sand used for filtering in a 
Petri dish and adding the melted gelatine. 
The amount of sand used in such a filter is less than 
that used in the method proposed by Petri, which over- 
comes an objection to the use of his method, since a sat- 
isfactory examination of the plate can be made with a 
hand-magnifier or with low powers of the microscope. 
Examination of Water.-Water for bacteriological 
examination, taken from the surface of a stream or a fau- 
cet, may be collected in a sterilized tube or flask. Sam- 
86 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Bacteriological. 
Bagnolleg. 
BADEN-BEI-ZURICH, so called to distinguish it from 
the other European Badens, is a popular watering place 
of Switzerland, only a short distance from Zurich. 
Location.-This Baden was at one time the most fash- 
ionable spa of Europe. It is prettily situated in one of the 
most picturesque spots of the Jura Mountains. The river 
Limmat pierces the mountain chain here on its way 
down from Zurich. There are beautiful promenades 
with fine views of the Alps. Richly wooded hills are 
found in all directions. The elevation of Baden above sea- 
level is less than twelve hundred feet. There are a num- 
ber of sulphurous springs, rich in chloride of sodium, and 
having a temperature of 118° F. They furnish about 
one million litres a day. It is a quiet place now. 
The climate is bracing, and the temperature on the 
whole equable. It is an all-the-year-round resort, but is 
largely frequented only during the warmer months. 
Access.-Baden is a station on the railroad from 
Zurich to Bale, thirty minutes from Zurich. 
Analysis.-One quart of Baden mineral water con- 
tains : 
Grains. 
Sulphate of soda 2.218 
Sulphate of magnesia 2.442 
Sulphate of lime 10.860 
Chloride of potassium 0.711 
Chloride of sodium 13.042 
Chloride of magnesium 0.566 
Carbonate of lime 2.599 
Carbonate of magnesium 0.152 
Carbonate of strontium 0.005 
Fluoride of calcium 0.016 
Chloride of calcium 0.719 
All other ingredients 0.013 
Total of solids 33.3-13 
Indications.-Baden was known to the Romans, and 
has a good reputation in the treatment of gouty and 
rheumatic affections, motor disturbances after fractures 
and dislocations, metallic intoxications, and all digestive 
and respiratory troubles on a lithtemic basis. It is also 
a " Terrain-Kurort " for the Oertel method of treating 
cardiac affections and obesity. 
The baths have all modern appliances and comforts. 
There are opportunities for milk-, whey-, and grape- 
cures. Inhalation-rooms, massage, etc., are not wanting 
to meet the requirements of certain cases. 
Accommodation.-There are numerous "bath-hotels," 
such as the Baren. Blume, Limmathof, Hirsch, Schwan, 
etc. There is a fairly good Kurhaus, with salons, read- 
ing-room, etc. An orchestra plays from April to Octo- 
ber, and there are two theatres. The proximity to the 
University town of Zurich is an advantage. Not many 
English and American visitors go there now. 
Edmund C. Wendt. 
BADENWEILER. A popular watering-place and cli- 
matic station in the Black Forest, known to the Romans 
as Aqua Villarum. 
Location.-Badenweiler is pleasantly situated in the 
southern part of the Black Forest, in the Duchy of 
Baden, near the university town of Freiburg. It has 
only about six hundred inhabitants, but is annually 
visited by over five thousand patients and tourists. It is 
one thousand three hundred feet above the sea-level, and 
the pure air, impregnated with the balsamic odors of the 
surrounding pine woods, is a factor which adds greatly to 
the popularity of the place as a health-resort. 
Dr. C. W. Allen, of New York, recently spent some 
time there, and has given his impressions in the St. Louis 
Courier of Medicine. There are interesting remains of 
the old Roman baths, still showing the usual atrium, 
vestibulum, frigidarium, calidarium, tepidarium, etc. 
The new baths are equipped with all the modern appli- 
ances of a complete establishment, such as douches, 
showers, sprays, inhalation-cabinets, etc. The waters 
of the springs are earthy and slightly alkaline, having a 
temperature of 80° F. and flowing at the rate of 1,140 
litres per minute. It is a peculiarly pleasant wrater to 
swim and bathe in, according to Dr. Allen's personal ex- 
periences. 
The higher peaks of the Black Forest shut in the little 
village from the northeast and partly from the south, 
while it is open toward the Vosges Mountains on the 
west. Sharp and raw wdnds are unknown, the ground 
dries quickly after rains, and even in the w'oods no un- 
pleasant dampness is felt. The temperature is even, the 
night and day variations being slight. The place is very 
healthy, the mortality (exclusive of the first year of life) 
being only about fourteen per thousand. There are ex- 
cellent facilities for many highly picturesque excursions. 
From near-by mountains fine views of the Alps, Jura, 
Vosges, and the Valley of the Rhine are obtained. Sea- 
son, May to October. 
Access.-From the station Miihlheim, on the railroad, 
between Bale and Freiburg, by omnibus or carriage. 
Indications.-Diseases of the chest, nervous and 
catarrhal affections, neuralgia, rheumatism, female dis- 
eases, neurasthenia, anaemia, protracted convalescence, 
are all treated with happy results at Badenweiler. There 
are plenty of amusements-concerts, theatre, "Italian 
nights," etc. Cows', goats', and donkeys' milk. A spe- 
cial feature is made of the grape and whey cure. Ba- 
denweiler is also a so-called " Terrain-Kurort" (Oertel) 
for cases of heart disease. 
Accommodation.-There are good hotels, chief among 
which are the Hotel Sommer, Rbmerbad, and Sonne. 
Apartments in villas are also found, and there are quite 
a number of good boarding-houses. The Kurhaus is ele- 
gantly fitted up with a ball-room, reading-rooms, etc. 
It is a commodious structure and under good manage- 
ment. There is a moderate " cure-tax " for visitors and 
patients. Edmund C. Wendt. 
BAD HEILBRUNN. A popular watering-place in 
Bavaria, Germany. 
Location.-Heilbrunn (healing spring) is prettily situ- 
ated near the Bavarian Alps. It is two thousand five 
hundred feet above sea-level. Attractive scenery and 
abundant vegetation add to the charm of the little village. 
Access.-By way of Munich to station Tolz, thence by 
omnibus. 
Analysis.-The waters of the spring called Adel- 
haid's quelle are rather rich in bromides and iodides. In 
1,000 parts of water there are contained : 
Sodium chloride 4.758 
Sodium carbonate 0.777 
Calcium carbonate 0.073 
Magnesium carbonate 0.018 
Sodium iodide 0.027 
Sodium bromide 0.046 
The spring has a temperature of 50° F. The water is 
limpid and sparkling, and something like 60,000 bottles 
are exported annually. 
Indications.-Cutaneous and syphilitic affections, 
scrofula, also amemia and catarrhal affections of the air- 
passages, are chiefly treated at this place. But obesity, 
goitre, and diseases of women are said to do well there 
also. 
Accommodation.-Rather primitive and not over 
clean. There is a Badehaus and a number of boarding- 
houses. Summer season only. Edmund C. Wendt. 
BAGNOLLES.-A watering-place in the Department 
of Orne, France. 
Location.-Bagnolles (not to be confounded with 
Bagnols-les-Bains), is situated in a picturesque valley, 
surrounded by hills, and about five hundred feet above 
the level of the sea. This region of the country is known, 
on account of its mountainous character, as the " Switzer- 
land of Normandy." The springs are mildly mineralized 
and have a temperature of 65° F. ; 10,000 parts contain 
only 1.309 of solids. There are also several cold cha- 
lybeate springs in the place. 
Access.-From Paris to Domfort, thence to the village 
of Couterne, which is about six miles from the springs. 
Analysis.-Besides chloride of sodium, small quan- 
tities of arsenical salts, sulphides, silica, lithia salts, and 
87 ISagnolles. 
Bertricli. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
baryum are contained in these waters ; also a moderate 
proportion of carbonic acid gas. 
Indications.-Chronic sores, phlebitis, skin diseases, 
scrofula, chlorosis, rheumatism, abdominal plethora, and 
gastralgia, are the diseases said to be beneficially affected 
by a course of these waters. 
Accommodation.-Modern bathing establishment, 
with the usual appliances. Moderately good lodgings at 
boarding houses. Edmund C. Wendt. 
BAGNOLS-LES-BAINS.-A watering-place in the De- 
partment of Lozere, France. 
Location.-Bagnols-les-Bains is situated in a narrow' 
valley at an elevation of about two thousand six hundred 
feet above the level of the sea. The climate is rather 
trying on account of sudden atmospheric changes. 
There are six hot sulphurous springs with temperatures 
ranging from 50° F. to 105° F. Season, June to Sep- 
tember. 
Access.-Paris to Mende, on the Paris, Lyons & Med- 
iterranean Railroad (fifteen hours). From there by stage 
to Bagnols in three hours. 
Analysis.-The springs are only slightly mineralized, 
the chief ingredients being sulphate of soda, carbonate of 
soda, and sulphides. 
Indications.-The diseases usually treated here are 
cutaneous affections, scrofula, rheumatism, chronic ulcers, 
etc. But it is at least open to question whether cardiac 
and pulmonary complaints, for which the springs are 
also recommended by French physicians, would not be 
made worse there, on account of the known uncertainties 
of the climate. 
Accommodation.-There are two thermal establish- 
ments, with the usual facilities for douches, sprays, in- 
halations, etc. Hotels moderately good and cheap. 
Edmund C. Wendt. 
BAINS-LES-BAINS, a quiet watering-place in the 
Vosges Mountain district, with springs highly prized by 
the Romans. 
Location.-Bains-les-Bains is pleasantly situated in a 
wooded district of France, near the town of Epinal. Ele- 
vation above sea-level, nine hundred feet. 
Mr. Wolff, in " The Watering-places of the Vosges " 
(London, 1891), thus speaks of it: " Thanks to the meet- 
ing of two different geological formations-the granite of 
the Vosges on one side, and the calcareous stretch of 
Champagne on the other-the climate of this intervening 
sandy belt is also said to be all that could be desired, in- 
imical to disease, and remarkably conducive to longev- 
ity. Proceeding to more minute local features, the new 
hotel seems, in respect of construction, tolerably perfect. 
There are airy, good-sized rooms. And I was surprised 
to find of all places this retired and old-fashioned oasis 
taking the lead among Vosges watering-places in the 
adoption of the electric light, which is laid on all over the 
house. The glories of Bains are now obscured, but it 
has had its halcyon days. In the Roman period it was 
in its own country, fairly rich in thermal waters, the 
' Balneum ' par excellence, of the bath-loving conquerors. 
There is a Bain Romain still in use, modern of course, 
but built upon the site of the original old Roman bal- 
neum." 
Dr. Bailly considers the waters of Bains, Plombieres, 
and Luxeuil almost identical in effect, their main con- 
stituents being sulphate of sodium and chloride of so- 
dium. 
At Bains-les-Bains there are eleven springs in all, by 
far the most productive and most important-and also 
the hottest-of which is the Grosse Source, which is the 
property of the State. The next in importance is the 
Source Tiide de la Promenade, which indicates from 82° 
to 86° F. ; and the third is the Robinet de Fer, a very 
weakly mineralized water, having but 0.35 gramme of 
solids in the litre, which is almost, if not quite, as hot as 
the Grosse Source. 
Access.-From Paris, via Mulhouse to Epinal, thence 
by omnibus or carriage. 
(SUPPLEMENT.) 
Analysis.-In one thousand parts : 
Grosse 
Source de la 
Source de 
Source 
Source. 
Promenade. 
la Vache. 
Savonneuse. 
Parts. 
Parts. 
Parts. 
Parts. 
Sulphate of lime... 
.. 0.110 
0.075 
0.102 
0.160 
Chloride of sodium. 
.. 0.083 
0.058 
0.136 
0.163 
Carbonate of Hoda. 
.. 0.010 
- 
- 
Carbonate of lime.. 
.. 0.028 
0.018 
0.018 
0.045 
Silica 
.. 0.069 
0.047 
0.093 
0.221 
Oxide of iron 
.. 0.002 
0.002 
0.002 
0.002 
Organic matter.... 
.. Trace. 
Trace. 
Trace. 
Trace. 
- 
- 
■ 
- 
0.302 
0.700 
0.351 
0.491 
Temperature 
.. 122° F. 
88-95° F. 
99° F. 
99-107° F. 
Indications.-There are two thermal establishments, 
with the usual appliances for douches, sprays, etc. The 
complaints for which the waters are prescribed are, above 
all things, articular rheumatism, chronic and acute, and 
sciatica, and then gout, rheumatic gout, liver complaints, 
obstruction and tumors, paralysis, cutaneous diseases, 
fractures, contusions, and the like. Constantin James- 
referring, it is to be presumed, more particularly to the 
tepid Source de la Promenade, which is especially cred- 
ited with this effect-speaks of them as at the same time 
tonic and soothing to the nervous system. It should be 
borne in mind, however, that the climate of Bains is de- 
cidedly variable. 
Accommodation.-The newly built Grand Hotel is 
comfortable and commodious. There is a Casino under 
the same roof, a theatre, concert-room, card-rooms, etc. 
There are many pleasant shaded walks in the vicinity. 
Season, May to October. There are also several less pre- 
tentious and more moderate hotels, as well as a variety 
of lodging-hoftses. Edmund C. Wendt. 
BALARUC-LES-BAINS.-A watering-place in the De- 
partment of Ilerault, France. 
Location.-Balaruc is near Cette and Montpelier, not 
far from the Mediterranean Sea, and on a peninsula 
projecting into the Talu. It is only slightly elevated 
above the sea-level, but the little valley is healthy and 
enjoys an agreeable climate. There is a saline spring 
having a temperature of 116° F., and flowing very 
abundantly. 
Access.-From Paris to Cette on the Paris, Lyons 
& Mediterranean Railroad, thence by carriage to Bala- 
ruc. 
Analysis.-In 10,000 parts of the water there are 
found : 
Parts. 
Chloride of sodium 68.02 
Chloride of magnesium 10.74 
Sulphate of potassium 0.53 
Sulphate of magnesium 0.43 
Sulphate of lime 7.55 
Carbonate of lime 3.05 
Bromide of sodium 0.03 
Bromide of magnesium 0.32 
Silica 0.13 
Total solids.... 90.80 
Taken in quantity this water acts as a purgative, and 
it has even been observed that the bowels may remain 
loose for some time after the termination of a course of 
treatment. The water is also largely exported. 
Indications.-Scrofula, struma, paralysis, rheuma- 
tism, metallic intoxications, anchylosis, and chlorotic 
conditions are said to be quite successfully treated 
at Balaruc. Patients suffering from paralytic conditions 
dependent on hysteria should, however, not be sent there. 
Although the place is a warm one, the principal thermal 
establishments are closed during the winter season. There 
is a large military bathing - place, maintained by the 
French Government. 
Accommodation.-The thermal establishments are not 
as perfectly comfortable and modern in appliances as 
could be desired. But the usual douches, sprays, etc., 
are administered. Amusements are only sparingly pro- 
vided, and "bath-life" is decidedly dull at Balaruc. 
Fashionable throngs avoid it. Edmund C. Wendt. 
88 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Ha» iiolles* 
Bertrich. 
BAREGES. A much-frequented w'atering-place in the 
Hautes-Pyrenees, France. 
Location.-The village of Bareges is situated in a 
narrow valley, formed by the Bastan. It is 4,000 
feet above the level of the sea, and is thus the most ele- 
vated of the spas in the Pyrenees. The surrounding 
mountains are barren, and the spot has no particular nat- 
ural charms to recommend it. There are, however, some 
nine or ten mineral springs, which have given the vil- 
lage its great reputation as a health-resort. The French 
maintain a military thermal establishment there. Harsh 
■climate. 
Access.-The village is thirty miles from Tarbes, and 
is reached by a tedious road. Pierrefitte is the nearest 
station on the Bordeaux Railway. 
Analysis.-According to Louchamp, one quart of 
the waters contains: 
Grains. 
Sulphate of sodium 0.649 
Sulphuret of sodium 0.771 
Chloride of sodium 0.618 
Silica 1.034 
Lime 0.030 
Magnesia 0.005 
Caustic soda 0.077 
Caustic potash traces 
Ammonia traces 
Total solids .. 3.184 
The temperature of the ten springs varies from 85° F. 
to 112° F. The water is clear, but has a disagreeable 
•odor and taste, often producing nausea and vomiting. 
Indications.-Bareges enjoys an excellent reputation 
in the treatment of chronic diseases, such as indolent ul- 
cers, caries, necrosis, skin diseases, syphilis, and old 
rheumatism. The waters, being stimulating and excit- 
ing, should not be used in acute troubles, in debilitated 
people, in cardiac troubles, and anaemia. Season, June to 
September. 
Accommodation.-Only passable, owing to the fact 
that the number of foreigners visiting the springs is not 
large. Hotel des Princes is the principal hotel. 
Edmund C. Wendt. 
BARMOUTH. A popular English sea-side resort, said 
ito be suitable even in winter! ?) for phthisis. The place is 
situated on Cardigan Bay, and with Aberystwith (farther 
■south), belongs to a group of favorite British resorts on 
the west coast of Wales. The climate is alleged to be 
■equable, dry, and mild, and while it is exposed to west- 
erly breezes, there is good protection from the harsh 
north and east winds. The proximity to the splendid 
mountain scenery of Wales contributes to the popularity 
•of these places. The bathing is good, there being a fine 
sandy beach, with a gradual descent. Good drinking- 
water, and sanitary arrangements. Season in the early 
summer. The place is reached from London (Euston) in 
.about eight hours. Edmund C. Wendt. 
BENZANILIDE (Phenyl-benzamide). This is one of 
the three anilides that have proved active medicinally. 
The others are salicylanilide and acetanilide. In benz- 
anilide the salicylic acid or acetic acid of the others is 
replaced by benzoic acid. It is obtained by the action of 
benzoyl chloride or of benzoic acid on aniline, in chem- 
ically equivalent proportions, at the boiling-point. It 
occurs in small, white, shining scales, tasteless, odor- 
less, insoluble in water, soluble in alcohol, 1 in 60. It is 
chemically and therapeutically allied to acetanilide. 
Kahn and Hepp, when investigating antifebrine, used it 
in a number of cases and found it to possess similar 
properties. Dose, two to ten grains. The advantages 
claimed for it are that it possesses less toxic properties 
and after its use the rise of temperature is more slow. 
Beaumont Small. 
BERTRICH. A spa in Rhenish Prussia, often spoken 
of as the " mild Carlsbad on the Moselle." 
Location. -The " Konigliches Bad Bertrich " is in- 
sufficiently known outside of Germany. Dr. Greenwood 
appears to be about the only English author who has 
hitherto mentioned the place. Dr. Rieth, who is the 
Royal Bath Physician at Bertrich, informed the writer, 
at San Remo, that only quite recently were the claims of 
this spa to an assured place among the continental resorts 
being recognized beyond the limits of Germany. In the 
British Medical Journal, August 8, 1891, Dr. Greenwood 
has briefly alluded to this watering-place as follows : 
" Bertrich is about five miles from Alf, on the Moselle. 
It is situated in a deep ravine among richly wooded 
hills. The valley of the Alf, with its numerous side 
branches, is one of the most beautiful on the Moselle. 
Bertrich is now' becoming more than a local health-resort, 
as it is more accessible than formerly. It possesses tw'o 
thermal springs, giving a large supply of water (92° F.), 
and having a composition similar to that of Carlsbad. It 
is, however, much less concentrated, not altogether a dis- 
advantage, as in the opinion of Dr. Lauder Brunton the 
amount of water consumed is a very important factor in 
the treatment of certain diseases. Particularly is this the 
case in biliary concretions, a class of diseases which 
derive marked benefit from treatment at Bertrich. The 
town possesses good hotels and boarding-houses, the 
charges being exceedingly low. There are daily open-air 
concerts. Reunions and other entertainments are also 
freely provided." From Dr. Rieth I gather that the 
mountain air of Bertrich is pure and bracing, although 
the place is only 500 feet above the level of the sea. 
The climate is equable. 
Access.-The interesting towns of Trier and Coblenz 
are only a little over one hour's ride by rail from Bert- 
rich. The station for Bertrich on the Moselle Railway is 
Bullay, and a good carriage road leads in less than one 
hour to the spa. Steamers also ply between Alf, Trier, 
and Coblenz. 
Analysis.-For purposes of comparison the analysis 
of the Bertrich thermal water is placed side by side with 
those of Carlsbad and Marienbad. 
In 1,000 parts of Water: 
Bertrich. 
Carlsbad. 
Marien* 
BAD. 
Trink-oder 
Bergquelle 
(R.Fresenius 
and 
E. Hintz, 
1890). 
Miihl- 
brunnen 
(Ragsbjs 
1S62). 
Ferdinands- 
brunnen 
(Kersten). 
Sodium sulphate 
0.886009 
2.3387 
5.0477 
Sodium carbonate 
0.728315 
2.0024 
1.8228 
Sodium chloride 
0.217757 
1.0246 
2.0047 
Lithium carbonate 
0.001843 
Trace 
0.0143 
Ammonium carbonate 
0.000720 
Calcium carbonate 
0.167511 
0.3794 
0.7839 
Strontium carbonate 
0.002773 
0.0011 
0.0009 
Magnesium carbonate 
0.152230 
0.0524 
0.6899 
Iron protoxide 
0.002564 
0.0041 
0.0849 
Manganese protoxide 
0.000232 
0.0009 
0.0216 
Potassium sulphate 
0.031828 
0.2236 
0.0423 
Sodium bromide 
0.000599 
? 
Trace 
Sodium iodide 
0.000009 
? 
Calcium fluoride 
0.0035 
Trace 
Sodium phosphate 
0.000130 
Calcium phosphate 
0.0002 
0.0019 
Aluminium phosphate 
0.0003 
0.0017 
Sodium arseniate 
0.000213 
Sodium nitrate 
0.0034S9 
Sodium borate 
0.001448 
Trace 
Organic compounds 
Trace 
Trace 
Silicic acid 
0.049100 
0.0806 
0.0964 
Total 
2.246770 
6.1118 
10.6130 
Amount of free carbonic acid in 
1,000 c.c. water 
43.13 
180.304 
1127.74 
Temperature of the water 
32.9° C. 
52.5° C. 
9.0° C. 
(See Chemische Untersuchung der Trink-oder Bergquelle des Konigl. 
Bades Bertrich. Wiesbaden, 1891.) 
Indications.-Most diseases of the stomach are said to 
do well at Bertrich. The following morbid conditions 
are also treated with good results there : Abdominal 
plethora, hepatic affections, lithaemia, diabetes mellitus, 
obesity, and, finally, various nervous affections of the 
neurasthenic type. Catarrhal affections of the upper air- 
passages are also included in the rather large category 
89 Bertrich. 
Blood-Stains. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
of complaints treated at Bertrich. Season, May to the 
end of September. 
Accommodation.-There are a number of hotels man- 
aged on the German plan, and a few apartment and 
boarding-houses. There are pleasant walks and drives, 
and the management is now liberal in the way of pro- 
viding amusements. Nevertheless Bertrich is still 
rather "quiet and dull." There .is a 
Kurhaus, and the thermal bathing estab- 
lishments are excellent. For patients of 
limited means, who need a mild Carlsbad 
treatment, a course at Bertrich may be 
advised. Edmund G. Wendt. 
BETA-NAPHTHOL BENZOATE 
(C10II7O, C7H6O). Obtained by the re- 
action that takes place between beta- 
naphthol and benzoic acid. It is a whit- 
ish, crystalline powder, very slightly solu- 
ble in water, freely soluble in chloroform 
and alcohol. 
It is recommended as a substitute for 
betol, having the advantages that benzoic 
acid possesses over salicylic acid. When 
introduced into the intestines it breaks up 
into beta-naphthol and benzoic acid. The 
former remains in the intestines until ex- 
creted by them ; the latter is absorbed 
and eliminated with the urine. 
The dose is from four to seven grains, 
frequently repeated. Beaumont Small. 
BETOL. The beta-naphthol ether of salicylic acid, 
analogous to salol, which is the phenyl ether of salicylic 
acid. It is obtained by the reaction between beta-naph- 
thol and salicylic acid in the presence of a dehydrating 
agent. It forms in small, white, brilliant crystals, almost 
devoid of taste and odor. Insoluble in water, soluble in 
alcohol and oils. Betol possesses antiseptic and anti- 
pyretic properties. It is not acted on in the stomach, 
but when it reaches the alkaline fluids of the intestines it 
breaks up into beta-naphthol and salicylic acid. It is 
recommended as a substitute for salol in rheumatic 
affections, cystitis, intestinal catarrh, etc. It has the 
advantage over salol of being composed of less toxic con- 
stituents. The dose is from five to eight grains. In 
combination with salicylate of bismuth it is particularly 
recommended in the treatment of the summer diarrhoea 
of children and in typhoid fever. Beaumont Small. 
BEX. A popular thermal and climatic station in the 
Canton of Vaud, Switzerland. Famous " salines." 
(SUPPLEMENT.) 
level. The little village is well known in Europe, but 
only very slightly in America. The writer, having spent 
several seasons at this resort, knows it to deserve greater 
recognition than has been hitherto accorded to it in our 
country. The "salines" themselves are of no mean im- 
portance, and the principal bathing establishment is a 
modern and commodious one. As for milk-, whey-, and 
Fig. 53.-The Valley of the Rhone, near Bex. 
grape-cures, there are few places where these can be 
more advantageously taken than at Bex. Invalids have 
also rare opportunities there for beautiful walks through 
a charming landscape, and, for the more hardy, distant 
mountain excursions offer strengthening recreation. 
Access.-Bex is a station on the railroad running 
through the valley of the Rhone. The village and Grand 
Hotel des Salines are reached by carriage or stage in 
fifteen minutes. From Paris the route is vid Geneva. 
Analysis.-The brine is conducted to the bathing 
establishment from the distant salt-mines. Ten litres of 
the brine contain (Bischoff) 1,703 gms. of solids. 
The principal ingredients, in ten thousand parts, are : 
Parts. 
Chloride of sodium 1567.0 
Chloride of potassium 26.5 
Chloride of magnesium .. 10.8 
Sulphate of lime 67.6 
Ten to twenty quarts of this brine are used for a bath. 
The diluted brine is also employed internally, after 
having been charged with carbonic 
acid gas. It contains, in addition to 
the salts mentioned above, a small 
proportion of iodides and bromides. 
Indications. - Apart from its ad- 
vantages as a climatic resort, specially 
emphasized by the late Professor Le- 
bert, Bex is now recognized to be an im- 
portant bathing station. The climate 
is about that of Montreux, although, 
in spite of its mountain-protected po- 
sition, harsh blasts occasionally sweep 
through the valley. The annual mean 
of the temperature is about 50° F. 
The following class of cases do well 
at Bex : Scrofula in all its manifes- 
tations, rheumatism in its subacute 
forms, catarrhal affections of the air- 
passages, paretic and paralytic states 
after diphtheria and other infectious 
diseases, asthma, neurasthenia of the 
milder type, and the earlier stages of 
phthisis. Certain uterine affections, 
such as metritis, subinvolution, etc., 
are also benefited by a mild course of the baths. All 
patients in whom even moderate stimulation of the ner- 
vous system is liable to do harm should be warned 
Fig. 52.-View of Bex, Looking Toward the Dent du Midi. 
Location.-Bex is beautifully situated in an expan- 
sion of the Rhone Valley, and at" no great distance from 
Vevey, on the lake of Geneva. It is 1,400 feet above sea- 
90 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Bertrich. 
Blood-Stains. 
against using the Bex treatment. The thermal establish- 
ment is thoroughly equipped with inhalation cabinets, 
sprays, douches, and the usual outfit for hydrotherapy. 
The quality of the grapes used for the cure is excellent. 
Accommodation.-The Grand Hotel des Salines is an 
excellent establishment of its kind, situated at some dis- 
tance from and about 150 feet above the village proper. 
In the latter very reasonable and fairly good board is 
obtainable. The Pension du Crochet is a popular family 
hotel on a small scale. Edmund C. Wendt. 
BILIN. A watering-place in Bohemia, where the 
famous " Sauerbrunn," or "cold Vichy," is found. 
Location.-Bilin is only two miles south of Teplitz- 
Schonau, the oldest watering-place in Bohemia. It is 
situated in the fertile valley of the Bila. The town has 
6,000 inhabitants. The famous castle of Lobkowitz is 
located in this place. Over three millions of bottles of 
this saline water are annually exported, but it is not a 
largely frequented resort. 
Access.-Bilin is now a station on a branch line of the 
Bohemian Railway. 
Analysis.-In one thousand parts of the Bilin water 
there are contained : 
Parts. 
Sodium carbonate 3.363 
Sodium chloride 0.381 
Sodium sulphate 0.719 
Magnesium carbonate 0.171 
Lithium carbonate 0.010 
Carbonate of lime 0.410 
Total solids 5.054 
Free carbonic acid gas 1.409 
The springs have a temperature of 53° F. 
Indications.-Catarrhal conditions, Bright's disease, 
gravel, gout, diabetes, obesity, hemorrhoids, dyspepsia, 
and many affections of the genito-urinary system are 
said to derive benefit from a course of these waters. 
Accommodation.-There is a Kurhaus, several hotels 
and boarding-houses. Edmund C. Wendt. 
BISKRA. A new winter resort, in the province of 
Algiers, Africa. According to Dr. Madison Taylor (the 
Climatologist, November 15, 1891), Biskra is an oasis at 
the north edge of the desert of Sahara. The author 
named gives the following account of this new place : 
"Here the fashionable world, especially the French- 
speaking monde and those who follow in their wake, 
claim that they have found the most charming place 
■wherein to spend the winter. They have already stimu- 
lated capitalists to build handsome, thoroughly equipped 
hotels there, and the tide of fashion is steadily setting 
that way. It may be briefly described as the terminus of 
the railroad running south from the great ports on the 
North African coast, the chief of which are Algiers and 
Philippeville. From either harbor railroad communica- 
tion is to be had, via Constantine, to the very edge of the 
desert, Biskra. Here is the centre of the various caravan 
routes across the Sahara." Among the attractions " the 
charm of Oriental scenes " is mentioned. 
" As to the climatic advantages of all this region, it need 
only be said that it is sufficiently high, being practically 
on the sides of the Atlas Mountains, to enjoy all the at- 
mospheric charm of elevated table-land. Near by, on 
many sides, are snow-capped mountains throughout the 
bulk of the year. Southward the enormous expanse of 
sand absorbs and retains the heat of the tropical sun, 
over which almost no cloud passes throughout the entire 
year. In the immediate neighborhood of the mountains, 
however, local vapor condensations occur, and showers 
are numerous enough at certain times ; but the character- 
istic of the climate is steady, uniform, dry warmth. The 
elevation of the place modifies this to just about the 
proper degree. There is, then, a practically uniform 
climate throughout the year. It is not only dry, but 
bracing, at no time cold, and only in midsummer un- 
bearably hot as the equatorial rays become completely 
vertical. The season is, therefore, a long one ; the possi- 
bility of malaria almost nil, because of the intensely 
(SUPPLEMENT.) 
drying properties of the vast volume of sun-heated, sand- 
reflecting desert air. In the valleys there is a little 
verdure in some places, very charming to behold, the 
sight of which, seen here and there on looking down 
upon the desert oases, inexpressibly gladdens the eye. 
Among the charming possibilities of the place are visits 
on horseback to other oases lying near by. " 
Access.-Biskra is now accessible from Gibraltar, 
from Marseilles, or from Genoa. The North-German 
Lloyd steamers sailing to Genoa stop at Gibraltar. From 
Marseilles the voyage to Algiers is only a little over 
twenty-four hours. Edmund C. Wendt. 
BLACKPOOL. A popular seaside resort in Lan- 
cashire, England. It is situated to the north of the 
estuary of the Ribble, about sixteen miles west of Preston 
by rail. It can be easily reached from Manchester and 
Liverpool. Dr. Yeo ("Climate and Health Resorts"} 
gives the following account of this place: "Blackpool 
has no protection to speak of, and lies fully open to the 
westerly winds which prevail on this coast. It has a 
fine seaport, bracing air, and miles of good sands for 
bathing." The sanitation, drinking-water, and provisions- 
for amusements are quite satisfactory. Season, May to 
October. Edmund G. Wendt. 
BLOOD-STAINS. In the examination of stains upon 
weapons, clothing, or other objects, in medico-legal cases, 
the objectshave often been partly washed or subjected to- 
influences which render identification difficult and some- 
times impossible, especially when the quantity of material 
for examination is small.. The methods of examination 
by the guaiacum test and by the spectroscope have been 
fully treated in the article on Blood-stains in Vol. I. of 
the Handbook. 
The micro-chemical examination of stains to produce 
hamin crystals, or crystals of hsematin, or Teichmann 
crystals, when only minute stains are to be examined, is 
so important that we deem it desirable to give the follow- 
ing directions, which we have translated from " Precis de 
Medecine Legale," by Ch. Vibbert: 
" The Teichmann crystals are so characteristic that 
when once seen they are afterward easily recognized. 
The operations for obtaining them are exceedingly simple, 
but require great care and patience. To avoid failure, 
persons but little accustomed to these minute investiga- 
tions should follow carefully the methods here described, 
especially if, as often happens, only minute portions of 
the suspected material are available for these researches. 
"(a) Solution of the Stain.-If the stain is small and no- 
speck or clot to be removed can be seen, cut out the stain, 
following the edges of the stain, with scissors ; place the 
stained piece of cloth on a glass slide, and put on it a few 
drops of water, just enough to moisten it, for it is better 
to get a solution somewhat concentrated After macera- 
tion till the liquid is considerably colored, press out the 
liquid with a scalpel or a needle, and remove the cloth, 
leaving the colored fluid on the slide. Avoid spreading 
the liquid, but dry it slowly so that it shall make a small, 
deeply colored spot on the glass, not entirely opaque but 
somewhat transparent, so that the preparation can be- 
examined with the microscope. 
" If the stains are very small several may be taken and 
macerated together to obtain sufficient coloring matter 
for the subsequent manipulations. If the stain is on 
wood, a thin layer of the wood may be removed with a 
sharp knife or lancet, and treated as directed for a frag- 
ment of cloth, only the maceration should be continued 
much longer. 
" If it is not possible to lift the stain from the object, a 
ring of wax may be formed around it, making an enclos- 
ure that will hold a little water, which may be applied ta 
absorb the stain. When the water has absorbed the 
coloring matter, it may be transferred to a slide by means 
of a pipette. 
" (&) Evaporation of the Liquid.-We may allow the 
liquid to evaporate spontaneously, but it may be hastened 
by heat, only it is necessary to heat it very moderately, 
not exceeding a temperature of 60° Centigrade ; for if the 
91 Blood-Stains. 
Blood-Stains. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
heat is sufficient to coagulate the albumin it will interfere 
with the production of crystals. We generally warm the 
slide over the flame of an alcohol lamp, being careful 
that the temperature does not exceed that which is not 
uncomfortable when the slide is laid upon the back of 
the hand. It is important to heat the liquid around the 
borders and not in the centre, so as to prevent the liquid 
spreading over the slide, which would much interfere 
with subsequent operations. 
"(c) Action of Reagents.-To the evaporated residue a 
little common salt should be added. Too much is injuri- 
ous. It is better to make a solution of 1 part of chloride 
of sodium with 500 or 1,000 of distilled water, and add 
one or two drops of this solution. It is more conven- 
ient to use this solution in the first place for dissolving the 
stain, instead of using simple distilled water. It saves 
time and nothing is changed. Sometimes crystals can be 
obtained by treatment with acetic acid without the 
addition of salt, there being sufficient chloride of sodium 
in the blood, but it is better to add the salt than risk a 
failure in an important case. 
" In whatever part of the process the chloride of sodium 
has been added, the preparation must be thoroughly dried 
afterward before the acetic acid is applied. This acetic 
acid monohydrate is called glacial or crystallizable. (It 
solidifies at the freezing-point, or zero Centigrade, and 
does not again liquefy until the temperature is raised to 
17° Centigrade.) The addition of a small quantity of 
water transforms it to acid hydrate, which interferes with 
this reaction. 
" Place a drop of the acetic acid monohydrate on the 
preparation and evaporate with heat, which may be in- 
creased and continued, but which succeeds better if it 
does not quite reach the boiling-point. When there is 
but a small quantity of the suspected material, it is es- 
pecially important to use all these precautions. The 
acid should be taken up with a tube drawn out to a fine 
point, so that only a very small drop may be added at a 
time ; place the droplet iii the centre of the red deposit 
•on the slide, and allow it to spread a little, but not to 
spread beyond the limit of the stain ; for this purpose 
the heat of the lamp should be applied around the bor- 
ders at various points, tipping the slide as may be neces- 
sary to retain the fluid on the red deposit only; a red 
line is thus formed about the borders when the coloring 
matter becomes thickened, and the acid remains on the 
stain till evaporation is completed. It is on this border 
that the crystals are commonly formed, and they are to 
be looked for by aid of the microscope. 
" It is not common to find crystals after adding only a 
single drop of acid, but it is generally necessary to add 
drop after drop, evaporating each with the greatest care, 
examining the specimens from time to time where the 
red lines are formed one after the other as it is repeatedly 
treated with acid and dried. When this experiment is 
performed under favorable conditions, a multitude of 
distinct crystals are found. Often, however, we find 
only irregular masses of brown or dark coloring matter, 
and the remainder of the preparation filled with coagu- 
lated albumin and foreign bodies, which have become 
mixed with the stain. If we have added solid particles 
■of chloride of sodium to the coloring matter, we are apt 
to find crystals of this salt formed in cubes, in stars or 
small, colorless globules, and even lance-shaped crystals 
of acetate of sodium may be formed. All these crys- 
tals, arranged together in beautiful forms, may often be 
found. 
" In such cases, we select a point where the coloring 
matter is collected in considerable quantity, and there 
apply another small drop of acid and let it evaporate as 
before. By repeating this operation we sometimes ob- 
tain a large collection of very small crystals mingled 
with other matter, but when we find crystals in the form 
of a cross or in stars, it is very certain that they are 
chlorohydrate of hsematin, and we may perfect the prep- 
aration by the addition of small drops of acetic acid. 
" If doubt still remains in regard to the nature of the 
crystals, the specimen should be examined by the aid of 
polarized light. The albuminous or saline substances 
(SUPPLEMENT.) 
allow the field to remain dark, but the crystals of hsema- 
tin appear bright on a dark field. 
" By carefully following the precautions stated above, 
one can almost always obtain crystals of haematin, even 
with a very minute quantity of blood. The reaction is 
successful with very old stains. Many experts have ob- 
tained crystals of haematin from stains of blood ten, 
fifteen, and even forty years old. It sometimes hap- 
pens, however, that it is impossible to obtain crystals 
when the stains are only a few months old. This is es- 
pecially the case when the blood has been allowed to 
putrefy before drying. Contact with perspiration, grease, 
or tannin also appears to interfere with the formation of 
crystals. 
" Two sources of error are to be noticed in connection 
with this test for blood. Crystals of murexide (purpu- 
rate of ammonia) have a form very similar to crystals of 
haematin, but they are of a bright red, and they acquire 
a violet color by contact with a solution of potash ; but 
it is very difficult to imagine how it can be possible to 
obtain crystals of murexide by treating a stain with com- 
mon salt and acetic acid. A mistake may easily occur 
with crystals formed from indigo. Cloth colored with 
this material will sometimes furnish a deposit of crys- 
tals, which will not dissolve in acetic acid and which 
have a form very similar to crystals of haematin. Their 
color is blue, it is true, but when the color is very deep 
it can scarcely be distinguished from brown. Descoust, 
by simply w'ashing with water a piece of flannel of blue- 
violet color obtained crystals of the form and reddish- 
yellow color almost exactly like crystals of haematin. 
This is a more serious cause of error than is generally 
admitted in books on legal medicine. 
"When a stain to be examined is found on clothing 
colored with indigo, it is important before examining the 
stain itself to examine pieces of the garment which are 
not stained to see whether they will deposit crystals of 
indigo. The comparison between these crystals and 
those obtained from the stain may remove all uncertainty 
if, for example, the crystals obtained from the stain are 
very numerous, and those obtained from the unstained 
cloth are very few and of a blue color. If the similarity 
of the two species of crystals is very close we may try 
the guaiacum test. The crystals of hsematin will color 
the guaiacum blue, while the indigo has no effect upon it. 
" When the crystals of haematin have been obtained 
they may be preserved for an indefinite period by adding 
a little glycerine and covering the preparation with thin 
glass. The expert should preserve the preparation with 
care as a proof of the correctness of his conclusions." 
Microscopic Examination. - In the examination of 
blood-stains it is found that some of the corpuscles are 
more easily separated from the clot than others. Where 
the stain shows specks of dried clot which can be sepa- 
rated from the fabric they are more likely to resume 
their normal form and size than when the stain is thin- 
ner ; yet single corpuscles can often be found here and 
there on threads or on fibres of wool, cotton, or silk. If 
a few drops of a solution of iodine or of eosine are added 
to the solvent the corpuscles are more likely to remain 
visible. The chief difficulty is, that any solvent which 
will liberate the corpuscles from the fibrin will at the 
same time dissolve the coloring matter of the corpuscles 
and render them so transparent that they are practically 
invisible. 
Stains upon weapons of iron or steel are often so 
mingled with rust that great difficulty is encountered in 
recovering the corpuscles. If the colored substance, 
supposed to consist of rust mingled with blood, is placed 
upon a slip of glass and a drop of dilute hydrochloric 
acid added, the acid will dissolve the rust and some- 
times bring to view the blood-corpuscles, which may be 
measured before they are destroyed by the acid. 
It often happens, where the stain is old or very minute, 
that while corpuscles may be identified, the haemoglobin 
is so changed or decomposed that no absorption bands 
can be seen in the microspectroscope, and no haemin 
crystals can be obtained by treating with acetic acid and 
chloride of sodium. So also the stain, if old, will gener- 
92 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Blood-Stains. 
Blood-Stains. 
ally be so changed that the number of corpuscles to be 
seen and measured is small compared with what might 
otherwise be expected from the extent and color of the 
stain. 
Since my article on blood-stains was written, in 1885 
(see vol. i., pp. 575-589), increased attention has been 
given to this subject by medico-legal writers, and mod- 
ernized views have been published, mingled with much 
that was written before the great improvements in the 
microscope revolutionized the work of medical experts. 
Professor John J. Reese, M.D., in the second edition of 
his "Text-Book of Medical Jurisprudence," 1889, says, 
p. 132 : ' ' Given a skilled and careful microscopist, with 
a good instrument of proper amplification, it will gener- 
ally be possible to diagnosticate a human blood-stain 
from that of any of the lower animals, with the possible 
exception of the guinea-pig and opossum. (We exclude, 
of course, those few animals, more rarely met with, 
■whose corpuscles are larger than the human, viz. : the 
elephant, great ant-eater, walrus, whale, sloth, and capy- 
bara.) It will always be possible absolutely to distin- 
guish between human blood and that of the ordinary 
domestic animals-the ox, pig, horse, sheep, and goat- 
with which it is most likely to be confounded." 
In apparent opposition to the above quotation from 
the Professor's book we find in the Medico-Legal Journal 
of New York, for September, 1892, a letter from Pro- 
fessor Reese, addressed to the editor, Clark Bell, Esq., 
in which he says : 
" Certainly (as stated in Taylor's) there is no difficulty 
in detecting corpuscles much smaller than toVo of an 
inch, as, e.g., those of the horse, sheep, and goat. The 
present general idea seems to be that while it is ad- 
mitted that a skilful microscopist can certainly distin- 
guish between a human corpuscle and one of a horse, 
cow, pig, sheep, and goat (domestic animals with which 
it would be likely to be confounded), still, in a murder 
trial, where human life is at stake, the expert is hardly 
warranted to swear that the blood is anything more than 
that of a mammal." 
The proper bearing of the above statement we shall 
consider below. 
In " The Law of Expert Testimony," by II. W. Rogers, 
A.M., LL.D., St. Louis, Mo., 1891, we find much that 
is interesting on the subject of blood-stains. Brief ab- 
stracts of testimony in the famous Cronin case are given. 
The most important for our purposes are the views of 
Professor Marshall I). Ewell, M.I)., who testified in that 
case, giving his opinion " that in the present state of 
science it was impossible to determine in the case of 
a specimen of dried blood by the measurement of the 
blood-corpuscles anything more or further than the 
mere fact that it was the blood of some mammal." He 
said: "I am very decidedly of the opinion, judging 
from my experience, that in the present state of science 
it is impossible to determine certainly, even under the 
most favorable circumstances, that any given specimen 
of fresh blood is human blood." 
In the Medico-Legal Journal, September, 1892, p. 178, 
Professor Ewell claims that the possible imperfections of 
micrometers which have not been carefully tested by a 
common standard may account for the different average 
dimensions of blood-corpuscles as reported by different 
observers. Also that the personal equation of the ob- 
server causes a difference in the results as shown by sam- 
ples reported. Third, that measurements by the Jackson 
micrometer, when low powers are used, are less accurate 
than measurements by the filar micrometer, but that with 
high magnifying powers there is little difference in accu- 
racy between the Jackson micrometer and the filar mi- 
crometer. 
Next, Professor Ewell shows that there are appreciable 
differences in the average dimensions of blood-corpuscles 
taken from the same person on different days, and in 
different circumstances ; and, further, that the average 
diameter of the human blood-corpuscle is greatly affected 
by different diseases. 
Lastly, that when blood has been dried on weapons, 
clothing, or other objects, and exposed to unknown con- 
(SUPPLEMENT.) 
ditions, there is no certainty that any treatment will re- 
store the corpuscles to their normal diameter, so as to 
allow an expert to determine from what animal the blood 
was derived. 
From the above considerations, illustrated by careful 
observations reported in his paper, Professor Ewell for- 
mulates the following conclusions : 
Summary (by Professor Ewell).-" (1) The only pro- 
posed methods of identifying blood that are worthy of 
discussion are (a) Teichmann's process of obtaining hse- 
min crystals; (b) the guaiacum test; (c) the spectro- 
scopic test; (d) the microscopic identification of red 
blood-corpuscles; and (e) the micrometric test. The 
last method only will be here discussed. 
"(2) In the use of the micrometric test no confidence 
can be placed in the result, unless the errors of the mi- 
crometer used, with reference to some authentic standard, 
are known. 
" (3) Where the subject continues during a short period 
in substantially the same condition of good health, there 
appears, in the hands of the same observer, to be an 
average size of the fresh corpuscles, provided at least one 
hundred corpuscles are measured. 
" (4) There are such large discrepancies between the 
averages obtained from the measurement of the fresh 
blood-corpuscles of animals of the same species, and 
between measurements of the same objects by different 
observers, as to throw doubt upon the published results. 
Several tables of measurements are given (by Professor 
Ewell) to prove this statement. 
" (5) There is no advantage in using very high power 
in such investigations. 
" (6) Drying the blood-corpuscles in a clot multiplies 
the difficulty of identification. It has never been proven 
that dried corpuscles can be restored to their normal 
proportions. 
' ' (7) The mean size of the red corpuscles of very young 
animals is larger, and their size varies between wider 
limits, than in adults. 
" (8) Many diseases alter the size of the red corpuscles; 
especially is this so in microcythaemia. 
"(9) Fasting diminishes both the size and number of 
the red blood-corpuscles. So also in the case of various 
drugs. 
"(10) In view of the foregoing it is impossible in the 
present state of science to say of a given specimen of 
blood, fresh or dry, more than that it is the blood of a 
mammal." 
As the paper by Professor Ewell, of which the above 
are his conclusions, has been largely quoted in the third 
edition of Reese's " Medical Jurisprudence," and as Pro- 
fessor Ewell is now the most prominent opponent of 
medical experts on blood-stains, the above conclusions 
will be examined in detail. 
As a general proposition Professor Ewell's statement 
(it will be readily admitted) that no certainty of accurate 
measurement can be claimed unless we have micrometers 
graduated and tested by some acknowledged standard, is 
true, yet it is a remarkable fact that the measurements of 
human blood given by Gulliver, in 1875, ; Wormley, 
in 1885, ; Schmidt, in 1848, 3^; French Medico- 
Legal Society, in 1873, 3^7- ; Masson, in 1885, tzVt ; Hans 
Schmid, in 1878, ; Woodward, in 1875, ; For- 
mad, made at distant intervals and without com- 
parison by a common standard, differ by less than one- 
sixth of the difference between the blood of man and that 
of the pig. 
This objection does not apply to comparative measure- 
ments of blood of different animals, where the expert, 
using always the same micrometer, bases his diagnosis on 
his own measurements alone. At present, however, it is 
easy for the expert to obtain micrometers made by skilful 
workmen and carefully rated by comparison with a re- 
liable standard. 
In regard to the discrepancies noticed by Professor 
Ewell between the measurements of blood-corpuscles 
made by different observers, it is to be noticed that the 
different writers fail to state whether they measured from 
outside to outside of the dark border of the corpuscle, or 
93 Blood-Stains. 
Blood-Stains. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
whether, like Dr. Woodward, they measured from the 
centre of the dark border on one side to the centre of the 
dark border on the other side, or whether they rejected 
the whole of the dark border on both sides, considering 
that as only a shadow and not a part of the corpuscle. 
We claim that the whole of the dark border on both 
sides is to be measured. This we have proved by grind- 
ing glass disks in the form of the corpuscle, with rounded 
edges, and examining such disks with the microscope. 
We have also studied the blood-corpuscle by reflected 
light, by means of Beck's patent illuminator, measuring 
it with the micrometer when no dark border was shown, 
and then with transmitted light again measuring the 
same corpuscle. In both conditions the measurement 
was the same. 
Another source of difference in measurement is in the 
mode of obtaining and preparing the blood for measure- 
ment. If a string is tied around the finger or the circu- 
lation is impeded in any other manner, and the blood 
is obtained by pricking with a needle, and is then spread 
upon a slide, the corpuscles, deprived of a portion of 
serum, will measure less than if obtained from a cut with 
a lancet where the circulation is not obstructed. * 
So also, if the blood is drawn from the prick of a needle 
in a warm and dry atmosphere, the corpuscles begin to 
contract before they can be spread upon a slip of glass. 
None of these considerations enables us to reconcile all 
the discrepancies noticed by Professor Ewell in the writ- 
ings of different authors ; but the great fact is shown, by 
the unanimous consent of all microscopists, so far as we 
can ascertain, that less than three thousand five hundred 
(most writers say less than three thousand three hundred) 
corpuscles of human blood are required to measure an 
inch, when placed side by side ; while more than four 
thousand corpuscles of the pig are required to measure 
an inch, and for the horse, ox, cat, sheep, and goat still 
more are required. Hence all authors agree that there 
is a remarkable difference between the average diameter 
of the human blood-corpuscle and that of any domestic 
animal except the dog. 
Taking the pig as the representative of domestic ani- 
mals, because its corpuscles are larger than those of the 
ox, horse, cat, sheep, or goat, the following comparison 
between the blood of the pig and human blood is very 
significant. 
To determine the extent of the possibility of mistak- 
ing the blood of the pig, ox, horse, sheep, or goat for 
human blood, we will examine the table of measure- 
ments made by J. B. Treadwell, M.D., using a ^-inch 
objective made by R. B. Tolles, and Jackson's Eye-piece 
Micrometer, made by Tolles, ruled by Professor Rogers, 
and a stage micrometer ruled, tested, and rated by Pro- 
fessor Rogers. 
In this table the measurements of 3,000 corpuscles are 
given, 200 having been taken from each of fifteen differ- 
ent persons. The measurements are given maximum 
and minimum by tens, by twenties, by fifties, and by one 
hundreds, and by two hundreds. Six hundred corpus- 
cles from pigs were measured, 200 from a pig three weeks 
old, 200 from one of two months, and 200 from a pig 
three months old. 
As the corpuscles of the pig have a larger average than 
those of the ox, horse, sheep, or goat, we make our com- 
parison between the blood of man and the blood of these 
three young pigs. 
Mikrons. 
Smallest twenty from man 7.662 
Largest twenty from the pig 6.466 
Difference 1.196 
This equals 0.000047 of an inch = inch- 
Smallest fifty from man 7.768 
Largest fifty from the pig 6.246 
Difference 1.522 
This equals 0.000060 of an inch = Tt>kw inch. 
Smallest hundred from man 7.852 
Largest hundred from the pig 6.169 
Difference 1.683 
This equals 0.000066 of an inch = ts j-jy inch. 
We thus see that where only ten corpuscles are meas- 
ured in man, taking the smallest average of ten consecu- 
tively measured, this average for an adult man is one- 
sixth larger than the largest average of ten consecutive 
corpuscles measured from a young pig only three weeks 
old ; while the average of the smallest one hundred from 
man, taken consecutively, is about one-fifth 4s larger 
than the largest one hundred taken from the young pig. 
I fully agree with Professor Ewell that there is no 
advantage in using very high powers in measurement of 
blood-corpuscles. By this is meant that for actual work 
and careful measurements a magnification of 1,000, or at 
most 1,500, diameters is quite as good as the use of higher 
powers. Beyond this limit increased enlargement is ob- 
tained at the expense of clearness of outline. Mathemat- 
ical demonstration proves that the apparent thickness of 
the object increases as the square of the apparent diame- 
ter increases. (See Naegeli and Schwendenef on the Mi- 
croscope ; also Carpenter on the Microscope, edited by 
Dallinger.) 
I have no controversy with those who have used pow- 
ers of 3,000 or 4,000 diameters ; I have myself photo- 
graphed blood-corpuscles with about 4,000 diameters 
linear, but the results are no better than with an enlarge- 
ment of 1,500 diameters. 
Gulliver's measurements were made with powers of 
about 600 diameters and yet they present but insignifi- 
cant variations from the work of the latest observers, 
who have used magnifying powers of 2,000 to 3,000 
diameters. 
Professor Ewell's sixth proposition is apparently, more 
than all the others, the one on which he depends for sup- 
port of his final conclusions. He says : " Drying the 
blood-corpuscles in a clot multiplies the difficulty of 
identification. It has never been proven that dried cor- 
puscles can be restored to their normal proportions." 
I would call attention again to the table on p. 587, Vol. 
I. of the Handbook, giving the measurements of 3,000 
corpuscles of fresh human blood, including males and 
females, of all ages, from infants at birth to the man of 
seventy. The measurements are in mikrons. 
Number of 
individuals. 
Number 
ofcor- 
puscles. 
Aver- 
age. 
Max. 
Min. 
By 
10s. 
By 
20s. 
By 
50s. 
By 
100s. 
By 
200s. 
15 persons 
as stated. 
1 3,000 
7.938^ 
4.233 
10.160 
7.658 
8.298 
7.662 
8.191 
7.768 
8.079 
7 852 
8.046 
7.918 
7.983 
Blood-stains, 
1,000 
7.910 4 
6.101 
5.570 
9.687 
7.700 
8.184 
7.723 
8.010 
3 young 
Pigs- 
000 
3.849 
8.391 
5.418 
6.520 
5 757 
6.466 
5.880 
6.246 
6.028 
6.169 
6.069 
6.144 
Mikrons. 
Man, smallest ten 7.658 
Pig, •• " 5.418 
Man, smallest twenty 7.662 
Pig, " " 5.757 
Man, smallest fifty ... .... 7.768 
Pig, " " 5.880 
Man, smallest hundred 7.852 
Pig, " " 6.028 
Mikrons. 
Largest ten 8.298 
" " 6.520 
Largest twenty 8.191 
" " 6.466 
Largest fifty 8.079 
" " 6.246 
Largest hundred 8.046 
" " 6.169 
Here we see that the average of 1,000 corpuscles re- 
stored and measured from stains of human blood is 7.910 
mikrons, all probably being stains from the blood of 
adults ; while the average from fifteen persons (three be- 
ing infants) is 7.938 mikrons. The maximum, where 
infants are included, in fresh blood is a little more 
widely separated from the minimum than in the restored 
stains from adults. So also the range, when taken by 
Mikrons. 
Smallest ten from man 7.658 
Largest ten from the pig 6.529 
Difference ... 1.138 
This equals 0.000045 of an inch = 222^ inch. 
94 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Hlood-Stains. 
Hlood-Stains. 
tens or by twenties, is a little less for restored blood than 
for fresh blood, for the same reason. No closer simi- 
larity of results could have been expected had all the 
measurements been taken from fresh blood ; one set in- 
cluding infants and the other being taken from adults 
alone. The fact that there is this difference given above 
goes to show the great accuracy and perfect restoration 
■of dried blood-corpuscles to their normal dimensions. 
As a further confirmation of the possibility of restor- 
ing dried blood-stains to a condition in which their di- 
mensions can be properly compared with fresh blood-cor- 
puscles, I copy by permission the following table from 
Professor Wormley's " Micro-Chemistry of Poisons." 
If we take Wot of an inch or 7.937 mikrons as the gen- 
erally accepted average diameter of human blood-cor- 
puscles, and with it compare the average obtained by 
Professor Ewell from blood in disease, we find his lar- 
gest average in plumbism, or lead-poisoning, is 8.65 mi- 
krons, or one-twelfth part larger than the normal average. 
Now, if we take the young pig, which, excepting the 
dog, is the domestic animal having the largest corpuscles, 
and to the normal average, 6.101 mikrons, add one-twelfth 
its diameter, or 0.508 mikrons, we shall obtain for a pos- 
sibly diseased pig an average diameter of 6.609 mikrons ; 
smaller by 1.318 mikrons than the average human blood- 
corpuscle. Certainly no microscopist of ordinary skill 
would be in any danger of confounding blood of such a 
diseased pig with human blood recovered from a stain. 
The only remaining possibility of mistaking stains 
from blood of a pig, ox, horse, sheep, or goat for human 
blood, when fifty or one hundred corpuscles have been 
measured and found to average 7.9 mikrons, or even 7 
mikrons, is to suppose it possible that the expert has 
wickedly and purposely measured only the largest corpus- 
cles and has not done honest work. With a magnifying 
power of 1,000 diameters, a Jackson's micrometer meas- 
ures with great certainty to Ww of an inch. Professor 
Ewell's filar micrometer, as he states, is graduated to one 
millionth of an inch, and is certainly reliable to of 
an inch. Hence, no expert can have any difficulty in 
recognizing with absolute certainty differences of 1.3 
mikrons equal Tvhrii of an inch. 
Professor Ewell says that, " by selecting the corpus- 
cles, it would be possible for a dishonest observer to 
make the average much larger or smaller than the above 
given (in his table) without the possibility of detection ; 
a fact, the bearing of which upon the value of expert 
testimony upon this subject is so obvious as to need no 
comment." I have never claimed, and shall not now 
claim, that it is any more difficult for a witness to swear 
falsely in regard to blood-stains than in regard to any 
other subject. But it would be quite possible on cross- 
examination to ask the expert whether, in measuring the 
corpuscles obtained from a stain, he had measured all the 
well-defined corpuscles in the field of the microscope, or 
whether he had selected the large corpuscles and rejected 
others which were smaller. 
In treating blood-stains with solvents of fibrin, to lib- 
erate the corpuscles for measurement, it has been found 
in many cases that the'corpuscles were smaller than in 
fresh blood unless maceration was long continued, old 
stains requiring several weeks before the corpuscles were 
in a condition to be measured. When a biconcave blood- 
corpuscle is placed in water, the coloring matter (haema- 
globin) is dissolved out, the corpuscle swells up, thickens 
at the edges, becomes transparent and spherical. In this 
condition the diameter of the corpuscle becomes less 
than normal. It thus happens in examining blood-stains 
that all corpuscles which have lost their color or have 
become spherical are by some experts rejected and not 
measured. Some corpuscles in fresh blood have much 
more coloring matter than others, and these corpuscles 
retain their color and form (as we think) much longer 
than paler corpuscles. We are not aware that any fluid 
used or likely to be used for softening blood stains will 
cause the corpuscles to become larger than normal. 
If the corpuscles obtained from a stain do not recover 
their normal dimensions it is almost absolutely certain 
that their average measurement will be less than normal 
and never greater than normal. Thus, in the language 
of Professor Wormley, we may confidently say : " Thus, 
then, while the blood of man might on account of contrac- 
tion in diameter of the blood-corpuscles be confounded with 
that of some animal having smaller corpuscles, the reverse 
could never occur." 
From this discussion I claim that it has been proved 
beyond any reasonable question : 
(I) That in favorable cases blood-stains can be so treat- 
ed that reliable measurements and credible diagnosis of 
their origin can be given, as shown in the tables given 
and in others which might be referred to. 
(2) That if error occurs on account of imperfect resto- 
Animal. 
Age of stain. 
Remarks. 
Average. 
Fresh 
blood. 
■(I) Human .... 
2 months old. 
Stain, unknown. 
Inch. 
1-3358 
Inch. 
1-3250 
{2) Human .... 
2^ " " 
Stain... 
1-3236 
1-3250 
(3) Human .... 
3 
Stain 
1-3334 
1-3250 
(4) Human .... 
19 " 
Clot 
1-3290 
1-3250 
(5) Elephant... 
13 " 
Clot 
1-2849 
1-2738 
(6) Dog 
4 
Trace of stain un- 
1-3626 
1-3561 
(7) Rabbit 
18 " " 
known 
Clot 
1-3683 
1-3653 
(8) Ox 
16 " " 
1-4544 
1-4495 
1-4219 
1-4219 
(9) Ox 
32 " " 
Stain, unknown. 
(10) Ox 
44^ years " 
Clot... 
1-4535 
1-4219 
(11) Buffalo .... 
18 months " 
Clot 
1-4312 
1-4351 
(12) Goat 
17 " 
Stain 
1-5S97 
1-6189 
(13) Ibex 
18 " 
Clot 
1-6578 
1-6445 
Examination of Old Blood-Stains. 
"In the case of the human blood No. 1, two months 
old, the deposit was in the form of a thin stain on mus- 
lin, and its nature, other than that it was mammalian 
blood, was unknown at the time of examination. The 
corpuscles were readily found, and two series of thirty 
corpuscles were measured. In the human blood two and 
a half months old, fifty corpuscles ranging from anTX to 
Wr? of an inch, were measured. 
" The blood-stain of the dog, No. 6, was prepared by 
Dr. Frankenberg, and consisted of a single stain so mi- 
nute as to be barely visible to the naked eye ; its nature at 
the time of the examination was unknown. In this in- 
stance only fifteen corpuscles were measured. In the 
bx blood four and a half years old, the corpuscles were 
rather readily obtained, and two closely concordant series 
of measurements were made." 
Another table, quoted by Clark Bell, Esq., in his arti- 
cle on " Blood-Stains" in the Medico-Legal Journal, Sep- 
tember, 1892, p. 157, is worthy of careful study in this 
connection. It shows results of examinations of blood 
dried on knives, glass, wood, cloth, paper, and stone, with 
measurements corresponding very closely with measure- 
ments of fresh blood. 
I take great pleasure in acknowledging my obliga- 
tions to Professor Ewell, from whose valuable articles 
on micrometric study of 4,000 red blood-corpuscles, pub- 
lished in the Medico-Legal Journal for September, 1892, 
I have compiled the following table : 
Source of Blood. 
Number of 
corpuscles. 
Mean in 
Mikrons. 
Maximum. 
Minimum. 
By hundreds 
Maximum. 
By hundreds) 
Minimum, j 
Robust man 
650 
8.03 
9.98 
5.03 
8.28 
7.95 
Boy thirty-six hours old 
200 
8.86 
11.39 
5.70 
9.06 
8.65 
Adult man 
100 
7.85 
9.32 
6.73 
Purpura htemorrhagica 
200 
8.26 
10.87 
3.45 
8.28 
8.25 
2 cases pseudo-leucocythaemia. 
400 
8.04 
11.04 
6.56 
8.55 
8.42 
Tuberculosis anaemic 
100 
8.35 
10.70 
5.35 
Plumbism 
100 
8.65 
10.10 
5.18 
Gastritis 
100 
8.32 
10.18 
6.22 
2 cases syphilis 
200 
8.11 
9.32 
3.97 
8.11 
8.11 
Erysipelas 
100 
7.83 
9.15 
6.90 
Pernicious anaemia 
100 
7.69 
9.93 
6.04 
Menstrual blood 
100 
7.71 
8.80 
5.76 
Whole number measured... 
2,350 
8.14 
11.39 
3.45 
9.06 
7.95 
95 Blood-Stains. 
Bourbonne. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
ration of the form and diameter of the corpuscles obtained 
from a stain, proved (by, a, the guaiacum test ; b, the 
spectroscope ; c, by the production of haemin crystals) to 
be blood, the error, if any, will be to make human blood 
appear like that of one of the inferior animals, and never 
to mistake the blood of the ox, pig, horse, sheep, or goat 
for human blood. 
(3) In general, when a stain has been proved to be 
blood by the above tests, it may be decided certainly 
whether it is or is not mammalian blood. So, also, a 
stain from the blood of the ox, pig, horse, sheep, and 
goat maybe distinguished from human blood, thus con- 
firming the claim of an accused person in many cases 
that his clothes are not stained with human blood. This 
negative testimony is certainly quite as important in 
many cases as testimony inculpating a prisoner. 
Lastly, the expert can say, when the average of a suit- 
able number of corpuscles from a blood-stain corresponds 
with the average of fresh human corpuscles, that the 
stain is certainly not from the blood of the ox, pig, sheep, 
or goat. 
Such testimony by a skilled microscopist is of untold 
importance in saving the lives of the innocent, and often 
in overthrowing the plea of those who are guilty. Such 
testimony is quite as reliable and important to the welfare 
of society as that of the chemist who testifies to the pres- 
ence or absence of poison that might have some resem- 
blance to the many recently discovered ptomaines. 
The testimony of the expert might take the following 
form, as recommended by C. II. Vibbert, " Precis de 
Medecine Legale : " 
" This stain is not composed of the blood of such an 
animal (ox, sheep, horse, pig, or goat) as the accused 
claims. It is like the blood of man, or some animal 
having corpuscles very nearly the same size as those of 
man, as the dog or rabbit." 
Or the declaration may take the reverse form, thus : 
" This stain is not composed of human blood ; it might be 
the blood of a horse, ox, pig, sheep, or goat, as claimed 
by the accused." 
Such declarations are justified, then, and then only, 
when the examination has been conducted with great 
care and the measurements have been made with reliable 
instruments. Moses C. White. 
BOOKLET. A thermal station .near Kissingen, Bavaria, 
much frequented by patients from Kissingen. 
Location.-This little village is only a few miles, in a 
northerly direction, from Kissingen. Its strong chalyb- 
eate springs are often used by patients taking at the 
same time a course of treatment at the larger spa. Ils 
climate is mild, and it is a simple little village, affording 
more quiet and cheaper comforts than are obtainable at 
the crowded spa of Kissingen. 
Access.-By carriage or on foot from Kissingen. 
Stages run between the two places. 
Analysis.-In one pint there are contained : 
Grains. 
Carbonate of iron 0.67 
Carbonate of lime 0.54 
Carbonate of magnesia 3.60 
Chloride of magnesium 4.43 
Chloride of sodium 6.55 
Sulphate of sodium 4.54 
Sulphate of magnesium 3.23 
The spring is also very rich in free carbonic acid gas. 
Indications.-Anaemia, chlorosis, neurasthenia, dis- 
eases of women, especially when associated with ten- 
dency to constipation. Diabetics are also said to be 
benefited there. 
Accommodation.-There is a Kurhaus, small hotels, 
and a number of boarding-houses, all moderately good. 
Edmund C. Wendt. 
BONE TRANSPLANTATION. One of the most in- 
teresting of the various fields opened up since the advent 
of aseptic and antiseptic surgery is that of grafting and 
transplanting tissues from one part to another of the same 
or different animal or person. The success with which 
(SUPPLEMENT.) 
this can be done in the case of the skin is well known. 
Failure is the exception. Far different is the result 
when other tissues are made use of. Experiments with 
muscle, nerve, and tendon transplantation are, in almost 
all cases, failures ; very few successful cases have so far 
been reported. As regards the results, osseous tissue oc- 
cupies a position midway between these two groups ; the 
skin on the one hand, and muscle, nerve, and tendon on 
the other. While in the case of certain bones the re- 
sults are so favorable that bone transplantation is con- 
stantly employed, in others only isolated successful cases 
are reported. As a result of a large series of experi- 
ments, Adamkiewicz (Centralblatt fur Chirurgie, 1889, 
Nos. xi. and xxxviii.) reaches the following conclusions : 
Pieces of bone, from one-half to three-fourths centimetre 
in diameter, unite perfectly well when they are replaced 
after having been removed, as by trephining. The pieces 
can lie exposed to the air or in a two to three per cent, car- 
bolic acid solution, five or ten minutes without impairing 
the result. Larger pieces, over one centimetre in diameter, 
also unite perfectly well, even when the edges are not 
entirely smooth. Bony union takes place where osseous 
structures come in contact and the interstices are filled 
with a fibrous tissue. There is no need of taking any 
special care that the edges fit accurately. The surfaces 
of the transplanted bone retain their original form and 
smoothness. He claims that the periosteum takes no 
necessary part in the process ; that the same results are 
obtained by transplanting pieces entirely stripped of 
their periosteal covering. The highly cellular connect- 
ive tissue filling in the interspaces later becomes ossified, 
either by separate centres of growth, or by the ossification 
proceeding from the periphery inward, until union is 
complete. The amount of space which may thus be 
bridged over is not stated, but probably it is not very 
great. 
These results hold good, not only for the same indi- 
vidual or another of the same species, but also when the 
bone is taken from entirely different species. 
Moisson (" Th^se de Paris," 1892), from a very thor- 
ough study of the literature of the subject, comes to 
practically the same conclusions as Adamkiewicz. Both 
of these authors base their conclusions on studies and 
experiments connected chiefly with the cranial bones, 
and so far as those are concerned there is no doubt as 
to their correctness. The great activity in brain surgery 
the past few years has furnished large numbers of cases 
for clinical experimentation in this line. If the disk re- 
moved be small it may be replaced entire, and in the 
great majority of cases bony union will result. When 
the chisel is used, the chips may be strewn over the dura, 
and they usually adhere and live. Large buttons may 
be cut up and used in the same way. In case there is 
too large a defect to be covered by the bone in hand, 
pieces may be taken from the front of the tibia, or even 
from animals, with a very fair prospect of success. In 
some cases, however, the implanted bone is absorbed 
after a time, and in others it becomes necrosed and has 
to be removed. 
Ollier read a paper before the International Medical 
Congress in Berlin, in 1890 {British Medical Journal, 
August 16, 1890), giving the results of his very exten- 
sive experience in this branch of surgery. He divides 
these operations into three classes, first, the autoplastic, 
in which the same bone is used to repair some deficiency 
in itself, and the bone is only partially severed from 
its connections ; second, the homoplastic, where the graft 
is taken from the same individual but not from the same 
bone; and third, the heteroplastic, where the bone is 
taken from another individual or animal. He says the 
first and second methods are all but failures, and the 
third quite so, that is to say, the implanted bone could 
never grow. He further says it is perfectly hopeless to 
expect any permanent or complete growth of bone, un- 
less the periosteum surrounds it. It is, indeed, true that 
if the parts were aseptic for a time the new bone or im- 
planted bone, as the case might be, seemed to grow, but 
this was only for a time. Within six months necrosis 
takes place and the dead bone if loose, is thrown out, or 
96 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Blood-Stains. 
Bourbonne. 
it may remain encysted in some instances, and while it 
may do no harm it is certainly of no advantage to its 
possessor. Notwithstanding what has been said to the 
contrary, he says there is no exception to this rule. 
These statements, coming as they do from such an au- 
thority as Ollier, carry great weight with them, yet they 
are at variance with the experience of most surgeons. As 
regards trephining, as we have seen, the mass of evidence 
is against them, and aside from these there are a large 
number of isolated cases of bone transplantation reported 
which tend to refute at least his final remark that there is 
no exception to the rule of failure. P. Berger {Gazette 
des Hopitaux, January 14, 1892), reports a case where be 
successfully covered the defect due to spina bifida by a 
piece of bone taken from the shoulder-blade of a young 
rabbit. Almost every surgeon has had one or more suc- 
cessful results from re-attaching ends of digits entirely 
severed. 
For the purpose of replacing the loss of the nasal bones 
or cartilages, transplantation of animal bone is sometimes 
successful. I have under observation now one case where 
two years ago I elevated the nasal bridge by the introduc- 
tion of four cat-ribs under the skin. Thus far the bridge 
is solid and firm, and has not sunk in. 
In another case where there was a sinking in from loss 
of the alar cartilages, a perfect elevation was procured by 
splitting the alae and introducing flat pieces of bone taken 
from the front of the tibia. In a third case, to obtain 
the desired result, part of the shoulder-blade of a cat was 
used. All of these operations were done over a year ago, 
and the bone is still retained an4 is firm and solid, and 
there is no irritation. In only one case have I had to re- 
move the transplanted bones. Necrosis in this case was, I 
think, due to the pieces being kept in a 1 to 1,000 bichloride 
of mercury solution by mistake. However, even then it 
was found that at the ends they were so firmly united as 
to require considerable force to extract them. That the 
bone was living and healthy at the ends, was shown by 
the shreds of living tissue adhering to them, and by the 
healthy pink color of the transverse section. 
A very interesting experiment is reported by Phelps 
(New York Medical Record, February 21, 1891). In or- 
der to repair an ununited fracture of the leg of a boy, 
he inserted a portion of the leg bone of a dog, which was 
kept in connection with the animal until union had 
taken place. There was primary union of the soft parts, 
but unfortunately he was obliged to sever the graft on 
the eleventh day, owing to its becoming loosened from 
the muscular twitching. There was free oozing of blood 
from the cut surfaces, showing that circulation had be- 
come established between the patient and the dog. At 
the end of five weeks, no union having taken place, the 
graft was removed. It showed on its surface new 
formation of bone, and the medullary cavity was par- 
tially filled with new bone. The operation was a failure, 
and yet it seems as if more extended experiments in the 
same direction might lead to useful results. 
In conclusion, it may be said that while, with few ex- 
ceptions, the results obtained by bone transplantation 
are by no means satisfactory, yet they are such as to en- 
courage a more extended trial. The most rigid asepsis 
rather than antisepsis should be employed in all these 
operations. The pieces of bone should be as small as 
will serve the purpose, several small pieces doing better 
than one large one, and where it is possible bony con- 
tact should be secured. If it be impracticable to replace 
or transplant the pieces immediately, they should be 
kept in a warm sterilized salt solution rather than in 
antiseptic fluids. 
It is only by the most careful attention to all the de- 
tails that a successful result can be secured. 
William Barnes. 
BORMIO. An ancient thermal station in the upper 
Valtellina district of Lombardy, Italy, now chiefly pat- 
ronized as a climatic resort. 
Location.-Bormio is situated near the river Adda, 
surrounded by massive rocks and precipices, and some- 
thing like 4,000 feet above the level of the sea. The 
thermal waters are indifferent gypsum springs, and have 
been described by Pliny. The season is a short one, 
being restricted to the months of July and August, 
although the climate of Bormio is possibly a trifle more 
equable and mild than that of the Engadine, near which 
the place is situated. There is a barren and sombre 
look to the landscape at Bormio, but the village leads to 
some points where grand mountain views may be enjoyed. 
Access.-By railroad as far as Botzen, then on through 
Meran, and over the Stelvio Pass ; or by way of Como, 
and up the valley of the Adda ; or through Coire, and 
then by " diligence" up the mountains. 
Analysis.-There are eight springs, issuing from the 
calcareous precipices, near the foot of the Monte Brauglio. 
There is an abundance of water, something like 300 
gallons a minute. The springs are hot, up to 120° F. 
Analysis of the San Martino Spring at Bormio.- 
Ten thousand parts of water contain : 
Parts. 
Chloride of sodium 5.112 
Sulphate of sodium 0.604 
Sulphate of potassium 0.181 
Sulphate of magnesium 2 520 
Sulphate of lime 4.863 
Carbonate of lime 1.735 
Carbonate ol iron (>.025 
Carbonate of manganese 0.014 
Silicic acid 0.207 
Total solids 10.261 
Carbonic acid gas 0.474 
Indications.-Gout, rheumatism, cutaneous affections, 
hepatic and splenic disorders, hysteria, and scrofula are 
the principal diseases treated at this mountain resort. 
Accommodation.-The old thermal establishment 
Bagni di San Martino is rather primitive, but the new 
building, lower down and near the village, is a modern in- 
stitution, where all the appliances for inhalations, massage, 
hydro-therapy, gymnastics, etc., are found. Milk- and 
whey-cures. Terms moderate. The old road over the 
Stelvio Pass into the Tyrol passes through Bormio. 
Edmund C. Wendt. 
BOULOGNE-SUR-MER. A French sea-side resort, 
largely frequented by the English. 
Location.-Boulogne-sur-Mer is a fortified seaport of 
the Department Pas de Calais. It is on the shore of the 
English Channel, at the mouth of the river Lianne. It 
consists of two parts, the Old Town, located on the hill, 
and the New Town, along the water. Daily communica- 
tion by steamboat with England, vid Folkestone. The 
beach is fine. The town is a fishing centre, and is dirty 
but interesting. There is also a chalybeate spring not 
much used. Bathing is on the French system. The town 
is half English. 
Accommodation.-Several good hotels, and a vast 
number of poor ones. There is a Casino, where plenty of 
gambling goes on. Also a theatre, concert-halls, etc. It 
is no longer a fashionable resort, being mostly frequented 
by the middle classes. It is a favorite place for excur- 
sions from England, and resembles our own Coney Island 
in many respects. Edmund C. Wendt. 
BOURBONNE-LES-BAINS. A watering-place in the 
Department of Haute Marne, France, the Aquae Bor- 
monis of the ancients. 
Location.-Bourbonne is an attractive little place, 
surrounded by hills and mountain spurs of the Jura 
formation. Mr. Wolff says of it, in his interesting work 
on the Vosges watering-places : " As in its geological 
position, so of course in the character of its waters does 
Bourbonne differ very materially from the other ' Wa- 
tering-places of the Vosges.' Its springs are strongly 
mineralized, containing over seven grammes per litre of 
solid matter, and very hot-much hotter than anyone 
could bear their application. People who have accident- 
ally dropped into this water, in which an egg is thoroughly 
boiled in fourteen minutes, are reported to have become 
in a few minutes so thoroughly flayed as to bring on 
death. Of the medicinal effects of the waters there has 
97 Bourbonne 
Brain. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
never been any doubt. It seems a veritable bank of 
Bethesda. Along it hobble and limp, and are wheeled 
and carried, halt, lame, and cripples, people bent double 
with rheumatism, palsied with paralysis, misshapen with 
deformity-scrofulous, pale, and delicate children. Bath- 
chairs and crutches and sticks appear to be the rule 
rather than the exception." 
Bourbonne is 850 feet above sea-level. Its climate is 
not equable and rather relaxing. Dr. Macpherson has 
called it the French Wiesbaden. Dr. Yeo says life is 
simple and cheap there. The French State maintains a 
thermal establishment here, chiefly used by military 
invalids. Few foreigners make use of the baths, although 
the place is attracting more attention now than formerly. 
Access.-From Paris there are through trains in seven 
hours. From other places the local branch line and 
omnibuses are used, but are inconvenient. 
Analysis.-In 1,000 parts : 
General Analysis. 
Silica. 0.0604 
Carbonate of lime 0.0751 
Carbonate of magnesia ; 0.0035 
Carbonates of iron and manganese 0.0038 
Fluoride of calcium traces 
Sulphate of lime 1.3550 
Chloride of calcium 0.1340 
Chloride of magnesium 0.0483 
Chloride of lithium 0.0826 
Chloride of sodium 5.2034 
Chloride of potassium, rubidium, and caesium 0 1925 
Brontide of sodium 0.0671 
Iodine, arsenic, and ammonia ; traces 
Total of solids 7.2257 
Free carbonic acid ,. 0.0097 
Carbonic acid in combination 0.0726 
Temperature 122° to 149° Fahrenheit. 
Source Puisard Romain. 
Carbonic acid (free) 0.0703 
Carbonic acid (in combination) 0.0263 
Silica 0.0748 
Carbonate of lime 0.0743 
Carbonate of magnesia 0.0032 
Carbonates of iron and manganese 0.0023 
Fluoride of calcium traces 
Sulphate of lime 1.3980 
Chloride of calcium. 0.0785 
Chloride of magnesium 0.0538 
Chloride of lithium 0.0887 
Chloride of sodium 5.2020 
Chloride of potassium, rubidium, and caesium 0.1992 
Bromide of sodium 0.0644 
Iodine, arsenic, and ammonia traces 
Total 7.3358 
Temperature 149° Fahrenheit. 
Indications.-The waters being hot bromo-iodurated 
saline ones are useful in rheumatism, scrofula, paralysis, 
engorgement of abdominal viscera, and certain forms of 
neuralgia. Dr. Macpherson holds them to be curative in 
rebellious malarial fevers. Mr. Wolff says that bathing 
combined with douches, and often electricity, forms the 
basis of treatment. Massage is not held in excessive esti- 
mation, and the local doctors consider that their douches 
de haute pression-for which the water is pumped up to 
a height of 54 feet-are fully equal in effect to any rub- 
bing and shampooing. Electricity, is however, much 
resorted to, especially in the Military Baths-which form 
an entirely distinct establishment, locally separated from 
the general Thermes-where, in the officers' annex, model 
appliances for its use may be seen. Of their douches the 
Bourbonne people are exceedingly proud, and they em- 
ploy them in every form, from the finely divided pulveri- 
sation up to the heavy jet which, one would think, 
would have sufficient force almost to knock a man down. 
Drinking is not prescribed for everyone, and rarely ex- 
ceeds a daily dose of two or three tumblers. A course of 
treatment at Bourbonne lasts from three to four weeks. 
Accommodation.-The Hotel des Bains is a good hotel. 
The bathing establishments are fitted up with the usual 
requirements. There are luxurious private baths and 
cheap general baths. There are amusements in modera- 
tion, but the place is not in any sense a fashionable spa ; 
real invalids intent on being made well are its chief 
visitors. There is a typical French Casino, adjoining the 
Civilian Thermal Establishment. Numerous French 
officers and soldiers enliven the scene by their pretty 
uniforms. Edmund C. Wendt. 
BOURBOULE (La). One of the most important spas 
in France, although less frequented than the more neu- 
tral but fashionable resorts. The springs are strongly 
arsenical. 
Location.-La Bourboule is in the Department of 
Puy de Dome, in one of the prettiest regions of Au- 
vergne. The district is very mountainous and the village 
is situated about 2,700 feet above the level of the sea. It 
is only five miles from Mont Dore ; it is less shut in 
than that resort. The hills in the immediate vicinity are 
of comparatively gentle slope. The mountain climate is 
on the whole mild, though rather changeable. The 
springs furnish hot arsenical waters. 
Access.-From Paris, on the Paris, Lyons & Medi- 
terranean Railroad, vid Clermont, to Laqueille ; thence, 
in an hour and a half, by carriage to Bourboule. 
Analysis.-One litre of the water contains : 
Grammes. 
Arseniate of soda 0.0284 
Chloride of sodium 2.8406 
Chloride of potassium 0.1623 
Chloride of lithium traces 
Chloride of magnesium 0.0320 
Bicarbonate of soda 2.8920 
Bicarbonate of lime 0.1$K>5 
Sulphate of soda 0.2084 
Peroxide of iron 0.0021 
Oxide of manganese traces 
Silica 0.1200 
Ahiminia traces 
Organic matter traces 
Carbonic acid (free) 0.0518 
Indications.-La Bourboule has a wide range of ap- 
plicability and enjoys a growing reputation, probably in 
part due to an energetic and intelligent management. 
The springs are now controlled by a stock company. 
Dr. Yeo states that the waters may be taken with ad- 
vantage in the following conditions : 
1. In anaemic and chlorotic girls and weakly chil- 
dren with scrofulous tendencies, or who are convalescing 
slowly from surgical operations, especially when under- 
taken in connection with scrofulous diseases of the bones 
or other organs, and particularly in those cases in which 
the preparations of iron prove inefficacious or unsuitable. 
2. In herpetic eruptions of the skin and in eczema 
and psoriasis. 
3. In affections of the throat and respiratory passages, 
especially when found associated with a tendency to 
cutaneous eruption. In granular pharyngitis, chronic 
laryngitis, and asthma. In slow forms of chronic phthi- 
sis. associated with a tendency to glandular affections ; 
but it is not to be recommended in cases with a tendency 
to haemoptysis or to troublesome dyspepsia. 
4. In certain forms of intermittent fever which resist 
the ordinary forms of treatment. 
5. In chronic rheumatism, especially in those very 
troublesome cases known as cases of " arthritis defor- 
mans." 
6. In the gouty dyscrasia when there is no tendency to 
acute attacks. 
7. In diabetes, especially in emaciated subjects in 
whom the waters of Vichy or Vais have been inefficacious, 
and particularly if the disease be associated with erup- 
tions. 
Accommodation.-There are good hotels and private 
lodgings. Besides the large Etablissement des Thermes, 
used by the better class of patients, there are three 
other bathing establishments, thoroughly well fitted up 
and ably managed. They offer all the appliances of 
modern times, such as single, sitz-baths, general baths, 
steam-baths, inhalation and spray rooms, douches of 
every description, burettes, etc. 
All the springs are hot, the Perriere spring having a 
98 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Hourbon ne. 
Brain. 
temperature of about 125° F. There is a good Casino, 
and the ordinary amusements of French spas. Season, 
June to October. Edmund C. Wendt. 
BOW-LEGS. The simplest and most effective brace 
for the correction of those cases of bow-legs in which 
the bones may still be bent, con- 
sists of a strip of flat bar-iron 
along the concavity of the 
curve, an inch longer than the 
distance from the garter-line to 
the sole of the shoe. The lower 
end is forged round, bent at a 
right angle, and passed into a 
hole, or a tube, in the heel of the 
shoe. At the garter-line a pad- 
ded band is riveted, reaching 
two-thirds around the leg, and 
just above the malleoli a like 
band is attached. The splint 
applied, the leg is firmly band- 
aged to the bar. 
When the deformity has been 
corrected a broad leather strap 
may be used in place of the 
bandage. In cases where the 
deformity is due in a measure to the laxity of the ex- 
ternal ligaments of the knee-joint the brace is carried 
above the knee, and a posterior bar is added, as in the 
splint for knock-knee. John Ridlon. 
BRAIN.* Gross or Macroscopic Anatomy.-§ 1. 
The primary object of this article is to indicate briefly 
the principal additions to our knowledge of the subject 
since the preparation of the article having the same name 
in Vol. VIII. of the Reference Handbook. But the 
writer desires first to supply certain omissions in that 
article, and to correct the errors that have been detected 
therein. Some of these are obvious and perhaps of no 
great importance, but others are serious and due to the 
writer's imperfect observation or interpretation of speci- 
mens at that time.f 
§ 2. Fig. 4684.-A. Many of the boundary lines are 
too faintly indicated, e.g., that of the section of the 
chiasma. A continuous line representing the pia should 
have surrounded all the cut surfaces in close contact there- 
with. Another line representing the arachnoid should 
follow the general contours, as stated more fully in con- 
nection with Fig. 4711. 
B. The segmental name, diencephal, hides most of the 
oval area indicating the medicommissure ; this last should 
have been named and should not be dotted ; although it 
may contain some fibres it consists mostly of cells. 
C. The heavy black line representing the endyma 
should extend farther into the stem (infundibulum) of 
the hypophysis, as in Fig. 4711. At the second e of the 
abbreviation mesen the endymal line should not be 
interrupted. The interruption opposite the n of the 
abbreviation meten represents the metapore (Foramen of 
Magendie), and should have been so designated as in Fig. 
4711. 
§ 3. Fig. 4689.-A. On the right (left of the figure) 
the words torus and Iura should be transposed. The 
former is the mononymic substitute for tuber cinereum, 
the elevation ; the latter designates the orifice, foramen 
infundibuli, left by the removal of the hypophysis. 
B. On the opposite side from the word preoperculum 
a line should extend to the brain parallel with the line 
from olfactory crus. 
C. The two crura should be equal in width. 
D. The word vallecula should be vallicula, although 
the former is commonly used. 
§ 4. Fig. 4698.-On the left the numbers 4 and 5 should 
be transposed. 
§ 5. Fig. 4702.-In the upper figure the endymal line 
should be continuous in the roof of the mesocoele. 
§ 6. Fig. 4703.-The area surrounded by the dotted 
circle should be marked 2 instead of 1. Since it repre- 
sents the medicommissure, a bar crossing the diacoele 
(Fig. 4727), it might well have been left blank in this 
figure of the cast. In the description, near the middle, 
top should be tip. 
§ 7. Fig. 4711.-In the description, first line, 8 should 
be .8 ; second line, for subfalcial, read falcial; fourth 
line, for falcicula, readfalcula. 
§ 8. Fig. 4715.-A. Near the tip of the temporal lobe, 
just under the end of the line from postoperculum, there 
is really an independent triradiate fissure, consisting of 
a stem directed toward the tip of the lobe, with branches 
extending respectively dorso-caudad and ventro-caudad. 
The intermediate branch, a continuation of the stem from 
the place of radiation into the tip of the supertemporal 
fissure, should be erased. 
B. This will leave the supertemporal fissure with a 
long spur extending caudad and slightly ventrad ; the 
shorter, darker portion of this spur represents a true 
branch of the fissure ; the longer, fainter part represents 
an artificial crack and should be erased. 
C. The ventral end of the exoccipital fissure presents 
a branch extending cephalad and another (12) extending 
ventrad and slightly caudad. At the point of divergence 
enters the fissure marked 13 ; the junction of this latter 
is not deep, as appears, but shallow. 
D. Just dorsad of the insula is an apparently simple 
junction of the subfrontal fissure with the precentral. 
Really there is a branch from each fissure, and they 
overlap slightly midway, the subfrontal branch being 
dorsad ; there is thus a narrow isthmus, as in Fig. 4777, 
between the branches of the central and precentral 
fissures. 
E. In the explanation, after 14, the word presylvian 
shopld be subsylvian.* 
§ 9. Fig. 4728.-At the end of the lowest line, indicat- 
ing the most dorsal portion of the inverted region, should 
be the word postyeminum. 
§ 10. Fig. 4729.-Proplexus should be paraplexus, and 
liypocampa, hippocamp. 
§ 11. Fig. 4731.-The line A, B, C, should have been 
merely dotted to indicate the planes of section on Fig. 
4730. 
§ 12. Fig. 4740.-In the explanation, eighth line, for 
precornu read paracoele. 
§ 13. Fig. 4742.-A. In the explanation, fourth line, 
for precornual read lateral or paraccelian. 
B. In view of the claims of some that natural outlets 
exist from the paracoele into a subarachnoid space (§ 
55, T), perhaps the word presumably should be inserted 
before artificial. 
§ 14. Fig. 4746.-Compare Fig. 51 and the accom- 
panying commentaries. 
§ 15. Fig. 4748.-At the upper left-hand corner, fossi 
should fossa. 
§ 16. Fig. 4750.-At the left, second name from the 
top, for endyma read paratela. See § 53. 
§ 17. Fig. 4751.-A. From the word medicommissure 
a line should reach the light strip just ventrad of the 
diacoele. 
B. Near the tip of the lower line from B the outline 
of the thalamus is defective. 
C. Between the left paraplexus and the tenia the 
membranous floor of the paracoele is the paratela. 
§ 18. Fig. 4760.-On the temporal lobe, just dorsad 
of the pons, the apparent fissure is an artificial crack. 
§ 19. Fig. 4767.-A. The short, vertical fissure be- 
tween the word operculum and the number 1 is merely a 
notch or superficial branch of the presylvian fissure, the 
main portion of which lies ventrad of 2 ; hence the 
Tig. 54.-The Thomas Bow- 
leg Brace. 
* Exclusive of the Membranes of the Brain, which are treated of in a 
separate article under the title Meninges. 
+ The writer ventures to advise that the changes and corrections 
indicated be marked in the text or upon the illustrations. A suggestion 
as to the desirability of prompt or periodical self correction is offered 
in his paper, The Morphological Importance of the Membranous or 
other Thin Parietes of the Encephalic Cavities, Jour, of Comp. Neurol- 
ogy. i., p. 201. 
* Fig. 4723, the word crus should be prepcduucle. 
99 Brain. 
Brain. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
triangular area (1) is part of the operculum. The pre- 
operculum is (2) and the subsylvian fissure is probably 
represented by a short indentation, visible only when the 
postoperculum (3) is removed. From the name presyl- 
vian f. a line should reach the dark space dorsad of (2). 
In this connection it may be added that corresponding 
changes should be made in § 208, D, § 234, E, and § 
241, L. 
8 20. Fig. 4778.-The two fissures named presylvian 
and subsylvian are probably to be regarded as branches 
of the former, and the latter is represented by a short 
one concealed, as in Fig. 4767, by the overlapping post- 
operculum. The number of the specimen should be 318. 
§ 21. Fig. 4779.-As in Figs. 4767 and 4778, the 
presylvian is to be regarded as having a dorsal branch ; 
the true subsylvian as concealed. 
§ 22. Fig. 4784.-The fissure named supercallosal is 
the paracentral ; here, as often, the two are continuous. 
§ 23. The following verbal changes should be made 
in the same article : 
A. In § 80, vallecula should be vallicula ; after it 
should be added Figs. 4689 and 4716. 
B. In § 82, C, typical should perhaps be simple ; sel- 
dom, in adult brains, has the writer observed the con- 
ditions represented in Fig. 4715. 
C. In § 218, the interparietal fissure of Ecker was 
first called by Turner intraparietal, and this name should 
be used unless, as held by the writer, it is admitted to 
consist of two integers, the parietal and the paroccipital. 
§ 24. Subfrontal Gyre.-By an inexcusable oversight 
the more common name of this functionally important 
region, viz., Broca's gyrus, is not given ; but it is employed 
in other articles, viz., II., 34, and VIII., 206. Since the 
article was prepared there has appeared Herve's mono- 
graph, "La Circonvolution de Broca," Paris, 1888. 
§ 25. Encephalic Variations.-In § 63 mention should 
have been made of the brief account of anomalies of the 
brain in Krause's " Anatomie," pp. 192-195. 
§ 26. Order of Treatment.-This will follow the series 
of definitive encephalic segments from the myel (spinal 
cord) cephalad. 
I. General matters of nomenclature and structure ; 
§ 27-29. 
II. Metencephal (postoblongata and caudal part of 
"fourth ventricle"). For convenience the metapore 
(foramen of Magendie) will be considered in the article 
Meninges. 
III. Epencephal (cerebellum, pons, and preoblongata). 
The cerebellar ectocinerea (cortex) and entocinerea (den- 
tatum ami tectal " nuclei") ; §§ 30-38. 
IV. Mesencephal (crura and gemina or optic lobes). 
V. Diencephal (thalami, etc.).* The medicommissure, 
conarium, paraphysis, and mesal eye ; §8 39-41. 
VI. Prosencephal (cerebrum and olfactory lobes). 
Bhinocoele or olfactory ventricle, § 42 ; fornix, § 44 ; 
hippocamp, § 45; pseudocoele (fifth ventricle), § 46 ; in- 
dusium of the callosum, § 47 ; incallosal brains, § 48; 
relations of thalamus to paracoele (lateral ventricle) in 
the sheep, etc., § 49 ; in apes, § 52 ; in man, §§ 53-55 ; 
transitory fissures, §§ 56-59 ; permanent fissures, §§ 60- 
78 ; brain weight, § 79. 
VII. Bibliography. 
§ 27. Neuraxis or neuron.-It has now become a 
serious question which of these short mononyms shall 
be employed as a substitute for cerebrospinal axis, my- 
elencephalon, etc. Neuron was proposed by the writer in 
1884 (Neio York Medical Journal, August 2, p. 114), and 
employed in 1885 in addresses before the American Neu- 
rological Association (as president), " Paronymy versus 
Heteronymy as Neuronymic Principles," and before the 
Biological Section of tile American Association for the 
Advancement of Science (as vice-president,) "Educa- 
tional Museums of Vertebrates also in the second edi- 
tion of " Anatomical Technology." It has been adopted 
in this sense by Minot, "Embryology," 1892, by Waters 
(Zool. Anzeiger, 1891, p. 362), and others. 
(SUPPLEMENT.) 
But, on discovering in the "Diet, de Medecine " of 
Littre and Robin (1877) that neuraxe had been used (by 
whom not stated) in the same sense, the writer aban- 
doned neuron in favor of neuraxis, the presumed Latin 
antecedent of the French neuraxe, and used neuraxis in 
the articles in the Handbook. It likewise has been 
adopted by several writers. Furthermore, neuron has 
been taken by Waldeyer {Berliner klin. Wochensehr., 
July 13, 1891) to represent a " nerve-entity," consisting 
of : (g) a nerve-cell; (b) the nerve-process ; (c) its collat- 
erals ; (d) the end branching ; " see the abstract by Alex- 
ander Hill in Brain, vol. xiv., p. 569. In this sense also 
it is used by C. L. Herrick, Jour. Comp. Neurol., ii., 137, 
December, 1892.* 
The writer has no prejudice, and trusts the matter 
Fig. 55.-The Central Part of the Cerebellum near the Dorsal End of Its 
Cavity, the Epicoele. From Stilling, Fig. 57a ; X 8. 
This represents a part of themesal aspect of the right half of a medi- 
sected cerebellum. The entire surface is shown on a smaller scale and 
without histological differentiation in Vol. VIII., Figs. 4684, 4711, 4718, 
4719. In the last the organ is represented approximately erect, i.e., 
extending dorsad from the oblongata ; in the present figure, as in the 
other three, it is in the natural attitude, tilted caudad, so that the apex 
of the epicoele looks caudad rather than dorsad. 
1. Pia dipping into the rimulas between the foliums : 2, ectal fibro- 
cellular layer of the cortex, neuroglia, etc. ; 3, layer of the cells of 
Purkinje ; 4, granular layer ; 5. fibrous centre, the alba or medulla ; 
6. 9, cephalic (anterior) decussating commissure; 7, deep rimula be- 
tween lobes of the postvermis; 8, cephalic (anterior) branch of the 
arbor (vitae) ; 10, layer designated by Stilling as composed of ''guir- 
landenformigen Fasern ; " 11, caudal (posterior) branch of the arbor. 
may be considered by some of the committees on nomen- 
clature for an authoritative recommendation as to usage. 
It will probably occur to others that neuron is a more 
* After this article was completed there reached the writer three im- 
portant papers by His in the Archiv fur Anat. u. Physiol., Anat. Abth., 
1892, v. u. vi. Heft., viz., Zur Nomenclatur des Gehirns und Riicken- 
markes. pp. 425-428; Die Entwickelung der Menschlichen und thier- 
ischer Physiognomien, pp. 384-424 ; Zur allgemeinen Morphologic des Ge- 
hirns, pp. 346-383. The last is profusely illustrated with representations 
of embryonic brains, mostly of animals. On the first page is a list of 
terms employed (in gratifying conformity to the suggestion made by the 
writer in Vol. VIII., p. 528, § 72). The summary is as follows: 
" 1. Die allgemeine Morphologie des Gehirns eine notwendige Grund- 
lage fiir die Deutung der Faserbahnen bilden muss. 
" 2. Eine solche allgemeine Morpholoeie nur dann endgiiltig zu 
gewinnen ist wenn wir auf die allerersten Bntwickelnngsstufen zuriiek- 
greifen. Nur von dieser ersten A nfangsstufe aus lasst sich der Bau sicher 
auffiihren, dadurch dass wir die friihesten topographischen Beziehungen 
der einzelnen Abschnitte des Markrohres zu einander genan feststellen 
und dann an der Hand dieser Merkmale die Verwickelung der Formen 
verfolgen." 
* Respecting thalamcncephalon and analogous terms, see Vol. VIII., 
p. 529, § 74, note. 
100 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Brain. 
Brain. 
natural associate of axon and enteron, and that it is the 
legitimate substantive of the adjective neural; also that 
neuraxis might very appropriately designate the axis 
cylinder of a nerve-fibre. Perhaps, however, as with 
cilium (either an eyelash or a microscopic filament), the 
two uses are not incompatible. 
§ 28. Is there a Rhinencephalic Segment ? - The ad- 
dress by Professor William Turner before the Anatomi- 
cal Section of the Tenth International Medical Congress, 
at Berlin, in 1890 (Jour. Anat, and Physiol., xxv., pp. 
1-53, with 42 figures), is not merely a valuable and 
suggestive study in the comparative anatomy of " The 
Convolutions of the Brain," but also is based upon a rec- 
ognition of the significance of the fundamental and uni- 
versal separation of the pallium, or 
strictly cerebral portion of the prosen- 
cephal, by a rhinal fissure from the 
olfactory bulb, crus, and hippocampal 
lobe, which he includes under the 
name Rhinencephalon. 
As may be seen from Vol. VIII. (p. 
112, § 15, A ; p. 134, § 122), the writer 
sympathizes with this recognition of 
the morphological consequence of the 
olfactory nervous apparatus ; but he 
deprecates the employment of a seg- 
mental term like rhinencephalon in 
what is now a third sense. Owen used 
it for the olfactory bulbs, actually 
united only in tailless amphibia; the 
writer (at one time adopting this view) 
has suggested (Vol. VIII., p. 114, 
note) that perhaps the bulbs, their 
crura, the olfactory portion of the pre- 
commissure, and a part of the aula, 
might be recognized as constituting a 
sixth definitive segment ; but-unless 
the word encephalon in composition is 
to be shorn altogether of segmental sig- 
nificance-it should no more be used 
for a ventral portion of a region than 
for a dorsal portion, e.g., the cere- 
bellum, without the supporting preob- 
longata. * 
§ 29. The Endymal Cilia.-In Vol. 
VIII., p. 118, § 43, in stating the sim- 
plest expression of an encephalic seg- 
ment, the constant ental constituent of 
the parietes, the endyma (ependyma of 
some writers), was mentioned as a cili- 
ated epithelium. There is considerable 
divergence of statement among authors 
as to the presence of cilia, especially 
in adults. P. A. Fish has described 
(Amer. Monthly Micros. Jour., xi., p. 
256, November, 1890) the ciliated cells 
in the encephalic cavities of the cat, 
both old and young. He urges the 
importance of thorough preservation 
by the injection of the preservative 
into the cavities ; states that a mag- 
nification of not less than six hundred diameters must 
be employed, and intimates that the failure to recognize 
them in man may be due to defective methods of prepa- 
ration or examination. 
§ 30. The Cerebellar Cortex.-In none of the medisected 
brains represented in Vol. VIII. (Figs. 4684, 4711, 4718, 
4719) was any effort made to show the thickness or con- 
stitution of the cortex of the cerebellar foliums ; this 
omission is in a measure supplied by the accompanying 
figure (55) from the magnificent work of B. Stilling, 
" Neue Untersuchungen uber den Bau des kleinen Ge- 
hirns des Menschen," etc. Q., pp. 357 and Ixxviii. ; 
Folio Atlas of 21 plates. Cassel, 1878. 
S 31. Points illustrated by Fig. 55.-A. The trian- 
gular form of the apex of the epicoele, whence the term 
fastigium (a gable), applied to its immediate roof. 
B. The absence of a layer of cinerea (entocinerea) im- 
mediately ectad of the endyma. 
C. The non-appearance, upon an accurate medisection, 
of any of the disconnected masses of cinerea represented 
in Figs. 56, 57, 58. 
D. The irregularly trapezoidal outlines of the medulla 
(alba) forming the central cone about the apex of the epi- 
coele. 
-geminum. 
semicircular fibres. 
epicoele. 
nod ulus. 
postpeduncle. 
■ globuli. 
cinerea of the dentatum. 
fibres of the dentatum. 
rimula. 
vallicula. 
Fig, 56.-The Dentatums and Prepeduncles. From Stilling, Fig. 99, somewhat modified : X 2 -. 
Preparation.-The plane of section was oblique, so as to coincide with the general direction 
of the prepeduncles as shown in Vol. VIII., Figs. 4721, 4722. 
Defects.-By an inexcusable oversight the prepeduncles are not indicated by a line and the 
name; but they are readily recognized as the fibrous tracts at the sides of the epicoele, converg- 
ing from the dentatums to the geminum. There is no representation of the "fleece," the layer 
of fibres radiating from the ectal surface of the dentatum; see Edinger's "Twelve Lectures," 
etc., Fig. 85. 
E. The extension of the medulla as branches, whence 
the more comprehensive name arbor (vitae) applied to 
the entire cerebellar alba. 
F. The constitution of the cortex by several layers ; 
for their microscopic structure see treatises on the sub- 
ject. 
§ 32. The Cerebellar Entocinerea.-In Vol. VIII., p. 128, 
§ 92, brief mention is made of four pairs of masses of 
cinerea (gray tissue) in the central part of the cerebellum, 
near the apex of the epiccele ; but through a misappre- 
hension they were neither figured nor described in detail. 
They are commonly referred to as roof-nuclei, or tectal 
nuclei. 
§ 33. The Dentatum.-This is the largest and most 
easily recognized of the four masses ; see Figs. 56, 57, 
58. It has the form of a corrugated capsule, open meso- 
ventro-cephalad. for the reception of the fibres of the 
prepeduncle (Fig. 56). In any cerebellum, whether 
* In this connection it may be added that the word neuromere, intro- 
duced by the writer (V. Y. Med. Jour., 1885, p. 356. and " Anat. Technol- 
ogy," 2d ed., 1886, p. 400d) as a mononym for definitive neural (or en- 
cephalic) segment, was adopted in 1887 by Orr (Jour. of Morphology, I., 
p. 335) in the sense of potential segment, and this application was ac- 
cepted by the writer in 1889 (Handbook, VIII., 113, § 23) ; in this 
sense it is also employed by Minot ("Embryology," pp. 604-606) and 
other embryologists. 
101 Brain. 
Brain. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
fresh, or hardened in chromic acid compounds, or even 
alcohol, it is readily recognized upon transections or 
upon sagittal sections begun about one centimetre either 
side of the meson and continued laterad for two or three 
centimetres.* The dentatum has received the following- 
additional names, of which the last only is used with any 
frequency : Nucleus dentatus ; corpus denticulatum, s. 
fimbriatum, s. lenticulatum, s. ciliare; Eng., ciliary body. 
§ 34. The Fastigatum.-This, more often called " fas- 
tigial nucleus," is close to the meson, directly in the roof 
(fastigium) of the epiccele; Figs. 57, 58. It is rounded 
cephalad, but the caudal end presents two or three pro- 
jections. 
§ 35. The Embolus and Globulus.-These smaller masses 
of cinerea lie between the dentatum and the fastigium, 
and somewhat dorsad of the latter. Their forms are in- 
dicated by their names, and are well shown in Stilling's 
figures as reproduced in Figs. 57 and 58. More common 
(and cumbersome) titles are Nucleus globosus or gldbuli- 
formis, and Nucleus emboliformis. 
§ 36. Points illustrated by Fig. 56.-A. The constitu- 
tion of the dentatum as a corrugated capsule of cinerea, 
open cephalo-ventrad. 
B. The entrance of the fibres of the prepeduncle 
B. The lack of precise symmetry in the forms of these 
masses; of one set, the globuli, there are three on the 
left and two on the right, the more cephalic, perhaps, 
representing the fusion of two. 
C. The form of the dentatum as a corrugated capsule 
with an opening or hilum toward the meson; this is 
shown better in the following figure. 
- monticulus. 
pi a. 
-rimula. 
.. medulla. 
^globulus. 
-embolus. 
-dentatuin. 
^fastigatum. 
-prepeduncle. 
-1 
.lateral recess. 
■geminum. 
-prepeduncle. 
■medipeduncle. 
■oliva. 
-rhaphe. 
- lingula. 
- commissure. 
- embolus. 
Fig. 58.-Transection of the Cerebellum and Oblongata. From Stilling, 
Fig. 84 ; modified somewhat ; X 2 - . 
Preparation.-The section is stated by Stilling to cut the higher 
part of the monticulus (see Vol. VIII., Figs. 4716-4719). It evidently 
passed caudad of the pons and right medipeduncle, cutting the left 
obliquely, the lateral recess being opened on the right. This lack of 
symmetry is not, perhaps, a serious defect. 
-globulus. 
- fastigatum. 
- dentatum. 
§ 38. Points illustrated by Fig. 58.-A. The relative 
positions of the cinereal masses in the epiccelian roof, as 
seen in transection ; compare the view presented in 
Fig. 57. 
B. The relative positions of the prepeduncle and medi- 
peduncle; see Vol. VIII., Figs. 4721, 4722. 
C. The resemblance of the dentatum of the cerebellum 
to the corrugated capsule in the oliva, which is some- 
times called dentatum oliva. 
D. The distinctness of the rhaphe or mesal seam of the 
oblongata. 
§ 39. Medi commissure (middle or gray commissure).- 
According to Wenzel, as stated in Vol. VIII., p. 132, 
§ 113, this secondary junction of the thalami is absent 
once in six or seven individuals. With five exceptions 
all of the adult and late foetal brains in the museum of 
Cornell University have been either medisected or so pre- 
pared as to exhibit the location of the medicommissure ; 
out of the whole number (98) the commissure is absent 
in only one, a male child at term. 
The writer ventures to suggest that some of the re- 
ported cases may have been based upon inadequate evi- 
dence. Unless the brain is medisected while fresh, or 
prepared by the injection of a preservative into the ar- 
teries or the cavities, or both, the medicommissure com- 
monly fails to be reached ; its peculiar softness causes it 
to break easily ; and the imperfect preservation of the 
adjacent thalamic surfaces might lead to the non-recog- 
nition of the slight elevation indicating its existence. 
If the specimen is allowed to dry slightly, and is then 
held so that the light is reflected from the smooth endy- 
mal surface of the thalamus, then the presence of the 
remnant of the commissure will be indicated by the ab- 
sence of such reflection from an area corresponding with 
its usual location. There is no other part of the brain 
where an error of observation is more likely to occur. 
§ 40. Conanum.-The development of this (epiphysis 
postvermis. 
vallicula. 
Fig. 57.-The Dentatum and other Masses of Cinerea in the Central Part 
of the Cerebellum. From Stilling, Fig. 98, somewhat modified ; X 2 -. 
Preparation.-This is commonly designated as a " horizontal " 
section. Really, the plane cannot be indicated in such simple terms. 
The central part of the figure, including the cinereal masses, is 
through the fastigium, the roof of the apex of the epiccele. Cephalad 
are parts of the lingula, the prepeduncles, and the mesencephal; can- 
dad the foliums of the postvermis, the mesal vallicula, and parts of 
the lateral lobes. 
Defects.-No attempt has been made to represent the fibrous con- 
stitution beyond the purely diagrammatic indication of the cephalic 
(anterior) decussating commissure. 
through the hilum of the dentatum to connect with its 
cells. 
§ 37. Points illustrated by Fig. 57.-A. The exist- 
ence, near the apex of the epiccele, of four pair of cinereal 
masses, representing, perhaps, dislocated portions of the 
cerebellar entocinerea. 
* Here and in the writer's other articles the occurrence of the termi- 
nation re in words like metre, fibre, centre, etc., is in conformity with 
the rule adopted for the entire work; he regards it as distinctively 
French; see Vol. VIII., p. 527, § 06, I. 
102 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Brain. 
Brain. 
or pineal body) in various vertebrates has been studied by 
Heckscher of Copenhagen ; the literature of the subject 
is also fully presented by him. 
§ 41. The Paraphysis.-Under this name (and Stirn- 
organ) Seienka has described {Biol. Gentralblatt, vol. x., 
323-326, 1890) a second mesal appendage of the brain 
just cephalad of the conarium. It has been observed 
also by C. Hill. An abstract respecting it is given by 
Minot ("Embryology,'' p. 690). 
§ 41. The mesal (parietal or conarial) eye has been 
recently considered at some length by Beraneck, under 
the title, " Sur le nerf parietal et la morphologic du 
troisieme ceil des vertebres," Anat. Anzeiger, Oct., 1892, 
674-689. 
§ 42. The Rhinocoele.-The persistence of the cavity 
of the olfactory crus and bulb in other forms than man 
(and perhaps apes) was mentioned in Vol. VIII., p. 137, 
§ 122. In a paper, " The Partial Occlusion of the Olfac- 
tory Lobe in the Canidae '' {Amer. Monthly Micros. Jour., 
5. Atrophy is not a necessary concomitant of occlusion. 
6. Domestication, and the consequent disuse of olfac- 
tion as a means for procuring sustenance, may be a factor 
in promoting occlusion. 
7. In the classifications of Broca and Turner the dog 
seems to hold an anomalous position, in that he gives 
every external evidence of macrosmatic power ; but by 
the almost total occlusion of his rhinocoele he approaches 
structurally the conditions found in the microsmatics. 
Physiologically he is macrosmatic ; morphologically he 
is microsmatic. 
§ 43. Points illustrated by Fig. 59.-A. The general 
similarity to the corresponding aspect of the human brain 
as shown in Figs. 4684, 4711, 4718, and 4719. 
B. The slighter encephalic flexure. 
C. The smaller relative size of the cerebrum, permit- 
ting the cerebellum and even the olfactory bulbs to ap- 
pear in a dorsal view of the organ. 
D. The possibility of transecting each segment, except- 
ing the diencephal, without cutting 
other segments. 
E. The large size 
of the medicommis- 
sure. 
IcOMNUS- 
\pURC 
[pR ZQCMIH U M / 
[gekcbeYlum 
pPd S TGLJ^l NUM 
'■Zpicoclc 
DIACOCLD 
.CRURA 
A/terArc: la 
mctacoczj: 
Fig. 59.-Mesal Aspect of Right Half of 
Sheep's Brain ; X 2- From the writer's 
" Physiology Practicums," Fig. 25. . . 
This figure is semi-schematic, certain albicans 
details being omitted for the sake of 
clearness, e.g., the divisions of the cerebellum, the 
vessels, and the membranes arachnoid and pia. 
The pia, however, is represented by the line be- 
tween the rostrum and the crista. 
\HYPOPHYS1S 
xii., 49-52, March, 1891), P. A. Fish describes and fig- 
ures cases of partial obliteration of the terminal, ex- 
panded portion of the rhinoccele, and complete occlu- 
sion of the narrower crural part; so far as his observa- 
tions go, this is true of all domesticated varieties and of 
the coyote {Ganis latrans) and the Australian wild dog, 
dingo. In view of the attention given to the subject by 
Broca and Turner (both of whom have based groupings 
of mammals upon the known or assumed relative devel- 
opment of olfaction and its organ), Mr. Fish's conclu- 
sions are here given with some modification : 
1. The facts do not warrant Broca's statement as to the 
existence of a true ventricular axis (core of solid material 
in place of the primitive cavity) in the olfactory bulb, 
even in rat-terriers. 
2. The bulb is not completely, but partially occluded, 
or perhaps in process of becoming entirely so. 
3. The cavity of the crus, in some wild forms as well as 
domestic, is completely closed, thereby cutting off all 
communication between the paracoele and the cavity of 
the bulb. 
4. The acuteness of the sense of smell is not essentially 
dependent upon the relative size of the rhinoccele. 
F. The distinctness of the crista in the adult sheep; 
Vol. VIII., § 57, N. 
G. The non-extension of the callosal rostrum, as a 
copula, to join the terma, as in man and the chimpanzee, 
and the consequent closure of the narrow pseudocoele 
by the pia only. 
H. The absence, as in mammals generally, of small 
foliums upon the lingula ; see Fig. 4719. 
I. The absence, as in mammals generally, of a meta- 
pore (Foramen of Magendie). 
J. The completeness of the endymal continuity or 
coelian circumscription. 
§ 44. The Fornix.-This difficult portion of the brain 
is monographed by Honegger in the Recueil Suisse (zool- 
ogie), 1890, v., 311-434. 
§ 45. The Hippocamp.-Variations in the form of the 
hippocamp and the collateral eminence are described by 
Howden in Journ. Anat, and Physiol., xxiii.,p. 283, Jan- 
uary, 1888. The hippocamp has been treated by Alex. 
Hill, in a paper of which an abstract is published in the 
Royal Society Proceedings, vol. lii., p. 5. 
§ 46. The Pseudocoele.-This cavity (the fifth ventricle, 
or ventriculus septi pellucidi) has interesting morphologi- 
103 Brain. 
Brain. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
cal and zoological relations; see Vol. VIII., p. 139, § 146, 
and Figs. 4734, 4735, and 4833. 
In the adnlt cat, sheep, and most other mammals, the 
two halves of the septum are in contact, and a pseudo- 
coele can hardly be recognized. The rostrum of the cal- 
losum also ends in a point, as shown in Fig. 4698 and 
Anat., xxxvii., pp. 298-334), the pseudocoele arises as ar 
indentation or mesal cleft in the proton * of the callosum 
fornix ; by the extension of the parts this becomes longes 
and triangular; its sides, the halves of the septum, be 
come practically portions of the mesal walls of the re 
spective hemicerebrums, but if his account is correct 
they cannot be said (as in Vol, 
VIII., p. 139, § 145) to be prima- 
rily such. The complete clos- 
ure cephalad is accomplished 
by the ventro-caudad extension 
of the copula so as to reach the 
terma at about the fifth month. 
Probably more remains to be 
done upon this region. 
§ 47. The Indusium.-This 
term (coupled with the adjec- 
tive griseuni), is given by Ober 
Steiner (p. 82) to the thin layei 
of cinerea upon the dorsal sur 
face of the callosum. The 
presence of this continuation ol 
the cortex upon the callosurr 
was first noted by Giacomin 
(Giornale cl. r. Accad. Med. 
Torino, 1883), and has since 
been confirmed by Blumenan 
(Arch.f. Mikros. Anat., xxxvii. 
1-15). 
The indusium is not repre 
sented by Reichert, and seems 
not to have attracted the atten 
tion of Dalton, although some 
of the beautiful photographs 
of his transections present faint 
indications of it. The writes 
feels compelled to record, wit! 
some chagrin, that, upon s 
series of transections of ai: 
adult brain (1824) hardened ir 
a mixture of ammonium di- 
chromate and alcohol, the con 
tinuity of the cinerea upon the 
callosum was recognized ir 
October, 1880 ; notwithstand 
ing its significance, further ex- 
amination and publication were 
deferred. 
The ridges and lines knowr 
as stria mediates et latencies are 
interpreted by Blumenau as as 
sociated with thickenings of the 
indusium. It is probable that 
there is considerable variatior 
in the thickness of the layer, and that it may not always 
be complete at the meson. 
§ 48. Incallosal Brains.-A case of total absence of the 
callosum and fornix is described and figured with un 
olfactory bulb 
transected 
1 
PRECORNU 
2 
genu 
hemiseptum 
PSEUDOCCELE 
caudatum 
PARAPLEXUS 
callosum 
HIPPOCAMP 
splemum 
MEDICORNU 
3 
paraplexus^ 
FIMBRIA- 
hippocamp - 
10- 
Fig. 60.-Sheep's Brain, the Paracceles (Lateral Ventricles) Exposed ; X 2. From the writer's *' Physi- 
ology Practicums," Fig. 29. 
Preparation.-By the removal of successive slices the paracceles have been opened ; the left has then 
been more completely exposed by oblique sections, and the paraplexus trimmed off so as to expose the 
wide fimbria and the furrow between it and the hippocamp. The plane of section did not coincide ex- 
actly with the callosum ; the caudal three-fifths of this is represented by the transverse lines ; also the 
cephalic end, the genu ; but an intermediate portion is wholly removed, exposing the narrow pseu- 
docoele (" fifth ventricle ") and its thin lateral walls, hemiseptums. 
Defects.-The cerebral cortex is not represented. The caudal half of the cerebellum is omitted. 
1, Intercerebral fissure ; 2. callosal fissure ; 3. vessel; 4, interrupted lines indicating the continuation 
of the paraccele into the rhinocoele ; 5, precornu ; 6, caput of the caudatum ; 7. Sylvian fissure crossed 
by arachnoid ; 8, vessel at bottom of fissure; 9, cauda of caudatum ; 10, part of caudal wall of paraccele. 
this volume, Fig. 59. In man and in a chimpanzee brain 
prepared by the writer (No. 265 in the Museum of Cor- 
nell University) the rostrum continues caudo-ventrad to 
join the terma, and the pseudocoele is therefore com- 
pletely circumscribed. 
The earlier conditions in man are less well ascertained ; 
strictly their consideration does not lie within the scope 
of this article, but something must be said in qualifica- 
tion of the account given in Vol. VIII. 
According to Marchand (" Ueber die Entwickelung 
des Balkens im menschlichen Gehirn," Archie. fur Mikr. 
* This neuter noun is employed to designate the primitive, undifferen- 
tiated mass or rudiment of a part, thus in the sense of Anlage of the 
German embryologists (as adopted by Minot and others), and of funda- 
ment, as proposed by Mark (''Comparative Embryology"). It avoids cer- 
tain obvious objections to those terms as English words, and is in har- 
mony with the following phrases from Aristotle, kindly quoted by Pro- 
fessor B. I. Wheeler: to npwrov ; i) ttpwtt; ; r, irpurrq atria. 
(Fig. 61.)-1. Cut surface, extending meso-ventro-cephalad ; 2, cut surface of the genu, the cephalic curvature of the callosum : part of its natu- 
ral, pial surface lies just cephalad ; the transverse lines on the areas 2 and 9 are introduced merely to indicate the direction of the callosal fibres, 
not as representations of microscopic structure; 3, point of disappearance of the pin as a result of cutting away part of the lateral convexity 
of the cerebrum ; 4. meeting-place of the two oblique cut surfaces caused by the exposure of the medicornu ; 5, point of reappearance of the pia, 
which was interrupted at 3; 6, is an area just caudad of the left calcarine fissure ; 7, the occipital fissure ; 8, the occipital eminence (see under 
Defects); 9, oblique cut surface of the splenium, of which a part of the natural surface is shown just caudad; 10, the cut edge of the paratela 
covering the thalamus; from 10 a line should pass mesad to the narrow area between the two lines. 
Defects.-The alcohol had so bleached the cinerea as to render the recognition of its outlines somewhat difficult, so the width of the cortical 
zone is only approximately accurate, and the " white line of Vicq d'Azyr," shown in Fig. 4746, is not indicated. 
The absence of shading upon the larger part of the surface would imply that it is all upon one level ; really, however, the highest part cor- 
responds nearly with the length of the exposed portion of the right caudatum, and from that level there are gentle slopes cephalad, caudad, and 
laterad. The cut edges of the hemiseptums are also at a lower level than the adjacent lateral parietes. Not all of the arteries are represented. 
The occipital eminence (8) is indistinct upon the right and made too small upon the left. The cut edge of the paratela (10) is made too thick and 
the relations of parts are indistinct: see § 55. 
On the left, near the word fimbria, is a defective patch of shading due to a blemish in the paper. 
The arachnoid is represented distinct from the pia at only two places, viz., on the right, near the cephalic end, where the former crosses the wide 
mouth of a fissure, while the latter dips into it as a fold, and at the callosal fissures, just caudad of the splenium. 
104 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Brain. 
Brain. 
(SUPPLEMENT.) 
- CORTEX 
-intercerebral f. 
-MEDULLA 
^GENU of the CALLOSUM 
TRECORNU 
-ENDYMA 
PIA I 
ARACHNOID 
-CAPUT of the CAUDATUM 
-FSEUDOCCELE 
HEMISEPTUM 
-PORTA 
central f 
-MEDICORNUAL VEIN 
- PARAPLEXUS 
TENIA 
-TENIAL VEIN 
CAUDA of CAUDATUM' 
-FIMBRIA 
Sylvian f/ 
supertemporal f. 
.POSTCORNU' 
'occipital f । 
• CALCAR 
calcarine f. 
Fig. 61.-The Paracceles (Lateral Ventricles) of an Adult Male, Exposed from the Dorsal Side. Specimen 2867, Museum of Cornell University ; X 1.2. 
Preparation.-The entire body (an emaciated consumptive, weighing only 37.71 kilogrammes, 83.25 lbs.) was alinjected through the femoral 
artery. Eight and one-half litres were introduced on the first day, and some escaped from the mouth. On the second day, and again on the 
fourth, another litre was injected. On the fifth day there was injected a litre of Pansch-Gage starch mixture (see article Methods, etc., in this 
volume, § 24). When the brain was removed, on the eighth day, the only odor was of the alcohol. The substance had already hardened some- 
what and the arteries were well filled, notwithstanding some of the mass had extravasated into the thorax. The brain was transected through 
the mesencephal (see Methods, § 25, E), and the paracceles exposed by removing the dorsal portion of the cerebrum in thick slices down to the level 
of the callosum ; then in thinner slices and wedge-shaped pieces till the desired condition was reached. On the left the medicornu was exposed 
into the part extending cephalad ; the terminal portion extending also mesad could not be shown without cutting away an undesirably large mass. 
It is indicated in Figs. 4703 and 4707, although inadequately. On the left also the occipital lobe was cut to a slightly lower level than on the 
right; hence, on the right appears the dorsal slope of the calcar, while on the left the plane of section coincides with the line of its greatest eleva- 
tion. and the width of the postcornu is correspondingly reduced. To lessen the width of the figure a part of the lateral convexity was removed 
by dorso-ventral incisions between 3 and 4. and 4 and 5. so the line representing the pia ceases at 3 and 5. Finally, the left paraplexus was 
trimmed off quite closely. (For the rest of this explanation, see at bottom of page 104.) 
105 Brain, 
Brain. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
usual fulness by Alex. Bruce in Brain, xiii., 171-190. 
There are included abstracts of previous cases and re- 
duced copies of the illustrations of some. 
In Vol. VIII., p. 192, the writer figured and briefly 
described one of three incallosal cat brains in the Mu- 
seum of Cornell University. At the Boston meeting of 
the Association of American Anatomists, December 29, 
1890, he showed the brain of a sheep lacking the 
callosum and fornix ; but this specimen, fortunately 
unmutilated and thoroughly hardened, has not yet been 
figured or described. 
49. The Relations of the Thalamus to the Paraccele.- 
With the cat, dog, sheep, and all other animals examined 
by the writer, excepting the apes, the rima ("great trans- 
verse fissure ") is just wide enough to admit the intrusion 
of the paraplexus, and there is no sign whatever of the 
entrance of the thalamus into the composition of the 
paracoelian floor. 
§ 50. Points illustrated upon Fig. 60.-A. The close 
contact and even interdigitation of the mesal aspects of 
the frontal lobes concomitantly with the absence of a 
falx. 
B. The width of the fimbria and hippocamp, and 
thence of the entire fornix, as compared with the human. 
C. The apparent absence of the tenia. 
D. The total exclusion of the thalamus, even in ap- 
pearance, from the paracoelian floor. 
§ 51. The same condition exists in man during the 
earlier half of gestation ; Vol. VIII., Fig. 4749. 
§ 52. In a chimpanzee and orang examined by the 
writer (Nos. 265 and 2548 in the Museum of Cornell 
University) the rima is widened, especially in the middle 
of its length, so that a narrow zone of the thalamus may 
be recognized, covered, however, by the paracoelian 
endyma; see the writer's paper, "The Relation of the 
Thalamus to the Paraccele, especially in the Apes" (Js- 
sociation American Anatomists, Record, 1889, p. 20). 
§ 53. In the human adult, apparently concomitant- 
ly with the thickening of the subjacent thalamus, the 
two margins are forced apart, as seen in Fig. 4751. But 
this does not produce a rupture in the floor. The endy- 
ma yields or grows correspondingly, and forms a thin 
portion of the floor, resting upon the thalamus and 
adapting itself to its contour. Sometimes, as in Fig. 
4749, the endyma maintains its independence and con- 
stitutes a separable paratela; in other cases the pia 
primitively covering the dorsum of the thalamus dis- 
appears, and the paracoelian endyma becomes so inti- 
mately united with the thalamus as to seem to belong to 
it. Finally, as brains are commonly removed, preserved, 
handled, and dissected, there is almost sure to occur a 
rupture along some line between the tenia and the 
fimbria, so that the thalamus actually appears within the 
paraccele as represented in most figures-e.g., Fig. 4746. 
This subject is somewhat fully considered in the writer's 
paper, ' ' Th8 Relation of the Thalamus to the Paraccele " 
(Jour. Nerv. and Mental Disease, July, 1889, pp. 436-443), 
where the term paratela was first employed. 
§ 54. Points illustrated on Fig. 61.-A. The general 
relation of the paracoeles (lateral ventricles) to the cere- 
brum ; although relatively much smaller than in the fce- 
tus, they are absolutely extensive ; here their natural ex- 
tent has been maintained by the injection of alcohol ; 
when examined in a fresh brain or in one hardened in the 
usual way their walls are often found nearly in contact. 
B. The terminal dilatation and squareness of the post- 
cornu, as contrasted with the pointed form which usually 
exists in brains not prepared by filling the cavities; 
sometimes, indeed, there has been doubt as to the extent 
of the postcornu, as admitted by Huxley, " Zool. Soc. 
Proceedings," 1861, p. 250 ; in Krause's "Handbuch," 
Fig. 479, the postcornua are merely linea. 
C. The great thickness of most of the parietes as 
compared with their thinness in the foetus, Fig. 4708. 
D. The retention of the foetal tenuity of a portion of 
the mesal wall, viz., the hemiseptum (halves of the sep- 
tum lucidum) ; see, however, § 46. 
E. The considerable length and width of the human 
pseudoccele (fifth ventricle) ; so far as the writer has ob- 
served it is wider than in any other animal; in Fig. 60 
(of the sheep) it is unnaturally wide. 
F. The relation of the cortex (cerebral ectocinerea) to 
the medulla (alba), as an ectal layer following the fissu- 
ral indentations. 
G. The relation of the insula to the Sylvian fissure ; 
the former is a typical subgyre, the latter is a typical 
superfissure ; VIII., p. 160, §§ 260, 261. 
H. The relation of the claustrum to the insular cortex 
ectad and the lenticula entad ; see also Fig. 4785. 
I. The constitution of the caudatum by two regions, 
a larger cephalic, the caput, and the cauda, narrow, and 
following the curve of the medicornu. 
J. The junction of the occipital and calcarine fissures 
so as to constitute as it were a single bifurcate fissure ; 
VIII., Fig. 4768, and this article, § 76. 
K. The size and distinctness of the collateral emi- 
nence, an ental elevation or colliculus, corresponding to 
the collateral fissure upon the ventro-mesal aspect of the 
cerebrum ; VIII., Fig. 4768, 4770. 
L. The existence, on the left, of an elevation, the oc- 
cipital eminence, corresponding with the occipital fissure. 
This colliculus is distinct in the foetus (Figs. 4748 and 
4764), and in some adults (Fig. 4736), is better marked 
than in this specimen. 
M. The location of the portas (foramina of Monro), 
and their visibility in a direct dorsal view of the para- 
coeles ; by reference to Vol. VIII., Figs. 4740, 4744, it 
will be seen that each porta opens into the corresponding 
paraccele obliquely, looking laterad, cephalad, and also 
dorsad ; hence it is visible from three different directions 
at right angles with one another. 
N. The distance between the two portas. Deducting 
the slight length of the passages themselves, this dis- 
tance represents the width of the aula, the mesal division 
of the prosocoele, which is commonly reckoned as 
merely the cephalic part of the " third ventricle." 
O. The continuity of the hemiseptum, a part of the 
mesal wall of the paraccele, with the fimbria, a part of 
its floor; indeed, their topographical relations may be 
illustrated by bending a sheet of paper or metal, and 
holding it so that one portion is vertical and the other 
nearly horizontal ; the former will represent the hemi- 
septum, the latter the fimbria. 
P. The narrowness of the human fornix as measured 
by the distance between the lateral margins of the two 
fimbrias in their horizontal portions ; compare the sheep, 
Fig. 60. It is true the word fornix does not occur on 
the figure ; but, as somewhat fully discussed in VIII., 
p. 138, the fornix is constituted by the two hippocamps, 
with their fimbrias, united at the meson by the forni- 
commissure (Fig. 4751) ; in this dissection the fornicom- 
missure is invisible, being upon a lower plane, so the 
fornix, as a whole, cannot be indicated. 
Q. The smallness of the paraplexus as compared with 
its foetal condition, Fig. 62 and Vol. VIII., Fig. 4708. 
R. The formation of the free margin of the paraplexus 
by the medicornual vein, considerable in size and more 
or less contorted, by which the blood of the plexus is 
returned to the velar vein. 
S. The considerable width of the attached portion of 
the paraplexus. This appears on the left side where 
the plexus has been trimmed quite closely. The rima 
is the line of apparent interruption of the parietes for 
the intrusion of the paraplexus, and is unusually wide 
in this specimen. 
T. The completeness of endymal continuity and 
ccelian circumscription. These terms are discussed in 
Vol. VIII., pp. 122, 123, as exemplified upon the mesal 
aspect of the brain. Fig. 4711. There only the mesal 
cavities are visible. In the present figure (aside from 
the pseudoccele, which is not a true member of the series) 
there appear only the great lateral cavities of the prosen- 
cephal. The continuity of the endyma is represented 
by the uninterrupted heavy line surrounding either para- 
coele. Likewise is the endyma a continuous sheet upon 
the sides and floor of this cavity. At the margins of the 
rima it may be traced as a smooth surface upon the in- 
truded paraplexus, and its cut edges are represented on 
106 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Brain. 
Brain. 
the left in this figure. The writer is aware that several 
authors claim or admit the existence of orifices along 
the medicornu whereby the coeliolymph may escape 
therefrom into the adjacent subarachnoid space ; but lie 
feels compelled, at present, to regard these as artifacts, 
like the half-dozen ruptures of the endyma near the porta 
in the preparation shown in Fig. 4742. 
U. The apparent entrance of the thalamus into the 
composition of the floor of the paracoele. This condition 
is presented on the left side ; on the right it is hidden by 
the overlapping paraplexus. 
§ 55. In what Sense does the Thalamus form Part of the 
Floor of the Paracoele (Lateral Ventricle) ?-So wide-spread 
and so deeply-rooted seems to be the notion that the 
thalamus constitutes a part of the paracoelian floor in the 
same sense as do the caudatum and the hippocamp, that, 
much as he would prefer to avoid criticism, the writer is 
induced to comment upon the current representations 
of this region. 
Admitting, for the sake of occupying common ground, 
that a certain area of the dorsal surface of the human 
thalamus is covered by endyma; that it is continuous 
with the caudatum, and that therefore, like that body, 
it enters into the composition of the paracoelian floor; 
none will deny that an adjoining area of this same dorsal 
surface is as distinctly covered by pia ; that it is con- 
tinuous with the optic lobes (gemina), and like them 
wholly excluded from the encephalic cavity. 
To represent the entire dorsal aspect of the thalamus as 
a smooth, unbroken surface is practically to affirm one of 
two things : either the whole is pial or ectocoelian, which 
would be in contravention of universal belief ; or else the 
whole is endymal or entocoelian, which would involve 
not only the gemina but the cerebellum and oblongata, 
a manifest reductio ad absurdum. 
This, nevertheless, with perhaps a single partial ex- 
ception, is what we find in the accepted treatises on 
Human Anatomy, new as well as old.* The figures pur- 
porting to represent the natural surfaces fail to exhibit 
any lines of demarcation between entocoelian and ecto- 
coelian areas either by a difference in texture or by raised 
edges to indicate where the reflected endyma had been 
divided. The extreme limits of misrepresentation are 
reached in Huguenin (Fig. 49), where the utter absence 
of distinction between surfaces which are said to be 
inside, and other surfaces which are said to be outside 
can hardly fail to mislead or at least confuse the reader 
who is not already thoroughly grounded in correct no- 
tions as to the general morphology of the brain. 
The prevailing misconceptions as to the relations of 
the thalamus to the encephalic cavities are exemplified 
even in the recent translations of Edinger (Figs. 49 and 
55) and of Obersteiner (Figs. 18 and 26). In the last, it 
it is true, there is a semblance of demarcation between 
the diacoelian and paracoelian surfaces of the thalamus, 
a long, narrow line, just laterad of the " sulcus choroid- 
eus;" but in reality that line of reflection of the para- 
coelian endyma is as shown in Vol. VIII., Fig. 4751, 
at a considerable distance from the line of reflection of 
the diacoelian endyma upon the velum. 
Dalton's " Topographical Anatomy of the Brain " was 
designed primarily to aid in recognizing the location of 
pathological conditions ; furthermore, it is evident that 
the mode of removal of the brain, of handling and cutting 
it, would not conduce to the maintenance of membra- 
nous attachments. But in examining Series C, Plates 
VIII., IX., and X., for example, it is disappointing to 
find not only the rupture of these attachments, but also in 
the outline duplicates an unbroken continuity of line 
from the diacoele into the paracoele at either side. 
With Gegenbaur's " Anatomie des Menschen," 3d ed., 
1888, the case is different. This is an anatomical trea- 
(SUPPLEMENT.) 
tise, by a morphological leader. Yet the transections on 
p. 846 and the dorsal aspects on pp. 824 and 834 utterly 
fail to comport with the now universally admitted view 
of the restriction of communication between the diacoele 
and the paracceles to the portas (foramina of Monro). 
§ 56. The Transitory Cerebral Fissures.-In the Jour, of 
Anat, and Physiol., xxiv., 342, D. J. Cunningham makes 
the following important observation bearing upon the 
always interesting problem of the distinction between the 
ordinary mammals and the monkeys, apes, and man : 
" Although I have looked for the transitory fissures 
in cat and dog embryos of different stages I have never 
seen any infolding of the cerebral wall that could be 
compared with those we have described in the human 
brain ; the temporary fissures are in all probability pecul- 
iar to the primates." 
§ 57. Points illustrated by Fig. 62. A. The great size 
lateral fissure. 
pain plexus. 
a mesal colliculus. 
a lateral colliculus. 
a lateral gyrus. 
a mesal fissure. 
part of falx. 
Fig. 62.-Transitory Fissures of a Foetus measuring 5-6 ctms. from 
Vertex to Nates, and estimated at Fourteen Weeks ; 2770 ; X 2.2. 
Preparation.-After the exposure of the brain the frontal end of 
the cerebrum was sliced off so as just to clear the large paraplexuses. 
Of the falx all was removed excepting the fragment shown. The head 
was tilted so that the face is much foreshortened. 
of the paracoeles and paraplexuses at this stage ; compare 
Fig. 4708. 
B. The slight and nearly uniform thickness of the 
parietes. 
C. Suggestion of a wrinkling or corrugation of the 
parietes as if from growth within a confined space. 
D. The approximately symmetrical distribution of 
these corrugations. 
E. The length of the fissure on either side, reaching 
from the Sylvian fossa nearly to the meson. 
F. The absence of any indication of branching; see 
§58. 
§ 58. Do the Lateral Transitory Fissures Branch ?-In 
none of the specimens or figures accessible to the writer 
do the transitory fissures on the lateral aspect present the 
bifurcations which are so common with most of the per- 
manent fissures ; it is to be remembered also that in the 
adult the total fissures (calcarine, occipital, hippocampal) 
are less subject to branching. The question should be 
carefully considered. 
§ 59. In Vol. VIII., p. 148, § 188, it was stated that the 
writer had not yet encountered a foetal brain in which 
(as said by Mihalkovics and repeated by Osborn, Vol. I., 
p. 640) the temporary fissures had vanished before the 
permanent ones appeared, leaving the surface smooth. 
He has since prepared a specimen (No. 2644 in the Mu- 
seum of Cornell University) Miich measures 10 ctm. from 
the vertex to the nates, and 14 ctm. including the legs, 
somewhat flexed ; the age was supposed to be about four 
months. Excepting the Sylvian fossa, the lateral aspect 
of the exposed left hemicerebrum is perfectly smooth ; 
* The exception referred to is Meynert's Psychiatry, where Fig. 16 
includes a line marked L, crossing the thalamus, and more distinct upon 
the left than upon the right; upon the explanation it is named "Linea 
aspera," but there is no further reference to it, and its morphological 
significance is not mentioned : consequently, although it probably does 
represent a torn edge of endyma, the figure alone would not convey any 
definite information. It is just to add that the volume of the tenth edi- 
tion of •• Quain" containing the nervous system is not yet accessible. 
107 Brain. 
Brain. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
the mesal surfaces and the right hemicerebrum have not mainly in the following respects : (a) more secondary 
been exposed. and tertiary fissures are included ; (6) the principal fissures 
§ 60. The Permanent Fissures.-D. J. Cunningham is are more or less sinuous as in actual brains ; (c) a long- 
preparing an elaborate account of the cerebral surface, to arched fissure, practically identical with Turner's intra- 
be published by the Royal Irish Academy as " Cunning- parietal (Ecker's interparietal), is interpreted as consisting 
ham Memoir," * No. vii. of three portions, (1) a cephalic, retrocentralis inferior ; 
In Vols. xxiv. and xxv. of the Jour, of Anat, and (2) an intermediate, intraparietal ; (3) an occipitalis 
Physiol, have appeared abstracts (sometimes illustrated) anterior, for which is given the synonym Affenspalte. 
of his views respecting the following : The Intrapa- This, however, is certainly not the writer's exoccipital, 
rietal (parietal and paroccipital of the writer) ; the Com- but the transverse occipital of Ecker, which the writer 
plete Fissures (the writer's transitory and permanent has shown to be the caudal part of the paroccipital, 
total) ; the Rolandic (central) Fissure ; the Sylvian; the which Eberstaller does not separate from the intrapa- 
Insular. rietal. 
The undeniably great value of these abstracts and of (d) A needless and-in the writer's judgment-unwar- 
the work which they anticipate is somewhat impaired by ranted change of names; e.g., the short fissure cutting 
a tendency toward pcecilonymy (see Vol. VIII., p. 528, the dorsal margin a little cephalad of the central was first 
§ 72), i.e., the employment of more than one name for described by Lussana s&solco inflesso, and that was Angli- 
the same part in the same paper (e.g., " Fissure of Ro- cized by the writer as inflected fissure ; by Broca it was 
lando " and " Rolandic sulcus "), and by an ignorance or called incisure preovalaire, and by Schwalbe sulcus para- 
neglect of American fissural literature. centralis; disregarding priority and brevity, Eberstaller 
(SUPPLEMENT.) 
superfrontal f. 
medifrontal f. 
precentral f. 
supercentral f. 
central f. D 
postcentral f. 
parietal f. 
paroccipital f. 
occipital f. 
subfrontal f. 
presylvian f. 
central f. y Sylvian f. 
'supertemporal f. 
Fig. 63.-The Left Hemicerebrum of a Philosopher (Chauncey Wright), from the Dorso-Lateral Aspect : X .9. 
Preparation.-See Vol. VIII., Fig. 4779. The figure is based upon a photograph taken as nearly as possible at an angle of 45° with the meson, 
so as to present the dorso-lateral aspect. The line connecting the superfrontal and medifrontal fissures was made inadvertently. 
The numerals 1 to 22 are at the same points as in Vol. VIII., Fig. 4779; on that figure 23 is designated the central isthmus, which here has the 
word printed upon it; 33 is just at the end of the short inflected fissure. 
There is also in the Brit. Med. Jour., August 2, 1890, 
an article by Cunningham discussing general questions 
connected with tiie fissures ; a brief abstract is given by 
Hill, Brain, xiii., p. 552. 
§ 61. Eberstaller has published an admirable account 
of the fissures and gyres, especially of the frontal region, 
under the title, " Das'Stirnhirn ; ein Beitrag zur Anat- 
omie der Oberflache des Grosshirns," 0., pp. 140, with 
nine figures and one plate. Besides its general excellence 
two features will especially commend themselves, viz., 
the Bibliography of 117 books and papers on the subject, 
and the Lists of Synonyms of each fissure and gyrus. 
The work concludes with a discussion of the homologies 
of the human fissures with those of the other primates and 
the carnivora. 
§ 62. Eberstaller's plate presents what he regards as the 
normal fissural pattern of tl'e lateral aspect only. From 
the writer's diagram (Vol. VIII., Fig. 4769) it differs 
calls it sulcus pr&centralis mediates ; again, the perfect 
title subfrontal, applied by Owen and the writer to the 
fissure forming the dorsal boundary of Broca's gyrus, has 
been applied to a fissure or combination of fissures on 
the mesal aspect. 
§ 63. Owen's names, although as a whole the best ever 
proposed, are in no case ascribed to him, and the consid- 
erable section of his "Anatomy of Vertebrates" treat- 
ing of the fissures and gyres appears to be unknown to 
Eberstaller. 
§ 64. Even more specialized is the monograph of G. 
Herve, "La circonvolution de Broca"[in man and apes], 
O., pp. 164, with 4 plates, Paris, 1888. The writer is not 
prepared to discuss Herve's conclusions as to the degree 
of representation of the subfrontal gyre in apes ; but 
he is compelled to dissent from the statement (p. 22) that 
of the two branches of the Sylvian fissure " ascending" 
and " horizontal " (corresponding respectively to the writ- 
er's presylvian and subsylvian) the latter is the more con- 
stant. 
§ 65. In neither of these papers, nor, indeed, in any 
* Since the above was written the writer has learned that the memoir 
has been published, but he has not yet received it. 
108 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Brain. 
Brain. 
(SUPPLEMENT.) 
others known to the writer, does there seem to have been 
adopted what he regards as an essential requisite to the 
elucidation of the subfrontal region, viz., the removal of 
the postoperculum and of other parts in order to expose 
the depth and relations of the fissures. 
§ 66. Points illustrated by Fig. 63 (mostly in addition 
to those which are enumerated in Vol. VIII., p. 158).- 
A. The unfamiliar appearance of a hemicerebrum when 
viewed from this oblique aspect. 
B. The distinctness of the angles between the cephalic 
and the dorsal and ventral outlines ; this was commented 
upon by the first describer of this brain, Professor 
Thomas Dwight, and appears in Vol. VIII., Fig. 4779, 
though less markedly. 
C. The completeness and width of the isthmus between 
the dorsal and ventral portions of the central fissure ; in 
Fig. 4779 this is marked 23, but is so much foreshort- 
ened as to be hardly visible. 
D. The simple, curved form of the dorsal part of the 
central fissure, with no bifurcation such as exists at both 
ends of the ventral portion. 
E. The independence of the supercentral fissure. 
F. The presence of a medifrental fissure subdividing 
the large area between the subfrontal and superfrontal 
fissures. 
G. The junction of the postcentral fissure with the 
parietal, and the continuity of the parietal with the par- 
occipital ; whether this junction occurs at 1 or at 2 can- 
not be determined at present. 
H. The great length of the supertemporal fissure and 
the complexity of its dorsal end. 
I. The absence of a distinct exoccipital fissure. 
J. The presence of a long and curved fissure, 6-7, on 
the lateral aspect of the occipital lobe. 
§ 67. The Homologies of the Central and Cruciate Fis- 
sures.-Upon several grounds, zoological, physiological, 
and even psychological, it is very desirable to ascertain 
whether the central fissure ( f. of Rolando) of man, apes, 
and monkeys is represented in the Carnivora, and whether 
the carnivoral cruciate fissure is represented in the Pri- 
mates. * 
In Vol. VIII., on pages 115 (§ 32, G, Fig. 4698), 160 
(§ 258), and 134 (Fig. 4729) the question is stated and 
held to be unsettled. It has since been discussed by W. 
Turner {Jour, of Anat, and Physiol., xxii., pp. §54-581), 
and by M. Benedikt {Ibid., xxv., p. 213). The latter's 
views merit high consideration, and although the writer 
is far from ready to adopt them, they shall be here set 
forth, with the remark that the lack of figures and a cer- 
tain vagueness of description render the original some- 
what hard to interpret. For the convenience of Ameri- 
can readers the publications necessary to cite will be indi- 
cated as follows: Broca, " Memoires sur la cerveau de 
1'homme," 1888; Meynert, " Psychiatry," translated by 
Sachs, 1885 ; Wilder, "Anatomical Technology," 1882, 
1886, 1892, and Handbook, 1889. 
A. Broca's view that the central fissure is represented 
in Carnivora by the presylvian of Meynert (superorbital 
of Wilder) is combated upon the ground that the latter 
lies cephalad of the psychomotor areas and the group of 
giant cells of Betz; "therefore it is proved that the 
presylvian fissure cannot represent the central fissure ; 
and it is not a consoling spectacle when anatomists, 
seduced by the error of an eminent man, have so little 
respect for the results obtained by physiologists and his- 
tologists." 
B. Benedikt then states that the cruciate fissure lies in 
the " anterior limit of the psychomotor areas," and con- 
cludes that the central is represented by " a transverse 
fissure on the anterior end of the first primitive fissure 
in very many non-primate species." This is apparently 
the ansate fissure of Krueg and the writer ; in Anat. 
Technology, Pl. I., Fig. 1, it is independent on the right, 
but on the left connected with the lateral ; in the Hand- 
book, Vol. VIII., Fig. 4698, it may be recognized on the 
right, but is not designated. In this connection it must 
be noted, however, that Cunningham {Jour, of Anat, 
and Physiol., xxiv., 153), says " it is now very generally ad- 
mitted that the sulcus coronalis (coronal fissure of Krueg 
and the writer) has its homologue in the fissure of Ro- 
lando." 
C. According to Benedikt the carnivoral cruciate fis- 
sure is represented in man by two short fissures, viz., (1) 
" on the inner surface, an arcuate fissure which repre- 
sents the anterior limit of the paracentral lobe ; (2) a little 
transverse fissure on the outer surface limits generally the 
superior part of the anterior central gyrus from the an- 
terior part of the frontal lobe, and represents that part 
of the cruciate which enters in the outer surface in ani- 
mals." 
It is evident that Benedikt's mesal fragment (1) corre- 
sponds to the cephalic part of the paracentral fissure, as 
shown in Figs. 4766 and 4768 ; but his description leaves 
one in doubt whether the lateral fragment is the inflected 
fissure or the supercentral or some third fissure. 
It is surely unfortunate that a subject so important 
should be involved in needless obscurity by the lack of 
figures or explicit descriptions. 
§ 68. In the Revue scientifique, vol. xlviii., pp. 555-563, 
1892, Topinard discusses " Le type des circonvolutions 
cerebrales dans la serie des mammiferes. 
§ 69. The cerebral fissures of a child of twelve and 
one-half years have been studied by Zilgien in the Jour, 
de I'Anat, et de la Physiologie, xvii., 613-621, 1891. 
§ 70. Although made primarily for the determination 
of physiological and psychological correlations, Donald- 
son's careful " Anatomical Observations on the Brain and 
Several Sense-Organs of the Blind Deaf-Mute, Laura 
Bridgman" {Amer. Jour, of Psychology, iii. and iv., 
1890-91) involved a detailed description of the fissures 
and gyres and the collation of much literature. 
§ 71. In his study of the brain of a murderer {Amer. 
Neurol. Assoc. Transactions, 1892, 54) Donaldson adds to 
the mass of doubt respecting the validity of Benedikt's 
claim as to the significance of fissural confluence; see 
Vol. VIII., p. 163. 
§ 72. Several Chinese brains have been described by 
Benedikt and by Dercum, the latter in the Jour. Nerv. and 
Mental Disease, July, 1889, and September, 1892. An 
Australian brain is described by A. D. Rolleston in the 
Anthropological Institute Journal, 1887, pp. 32-42. 
§ 73. Sir William Turner's address, " The Convolu- 
tions of the Brain : a Study in Comparative Anatomy,'* 
Jour, of Anat, and Physiol., October, 1890, 105-153, has 
been referred to in another connection (§ 28).* 
§ 74. A case of remarkable fissural malformation and 
asymmetry is described and figured by W. Turner in the 
Jour. Anat, and Physiol., xxv., 327-348. The subject was 
an epileptic, twenty-six years old, and the entire (alco- 
holic) brain weighed 1,107 grammes (39£ oz.) ; the left 
hemicerebrum 530 grammes, the right 437. The left fis- 
sures are stated to have had a normal development and 
arrangement, but on the right the Sylvian fissure was 
wide open so as to expose the insula largely ; the central 
fissure was wholly absent, together with the precentral and 
postcentral; the lateral surface presented three arched 
fissures, demarcating four arched gyres about the Sylvian 
fissure, a condition analogous to that in the dog and many 
other Carnivora. The interest and importance attaching- 
to this case, as to the even more extraordinary malforma- 
tion described by the same anatomist and referred to, 
with a figure, in Vol. VIII., 193, would have warranted a 
larger number of better figures, and a representation of 
the left hemicerebrum. 
* Other recent publications on Assures are the following: Lussauer : 
Circumvolutionum cerebrnlium, etc., Patavia, 188S, O., pp. 19, 30 plates. 
Schnopfhagen: Faltungen des Grosshirns, Neurol. Centlbl., vii., p. 549. 
Benedikt: Beitriige zur Anat, der GehirnoberHiiche, Wien. Med. Jahrb., 
iii., p. 39. 1888. Eberstaller : N<x:h einmal die Insula Reilli, Anat. Anz., 
iii.. 13, 1888. Mingazzini, L. : Ueber die Entwickelung dor Furchen u. 
Windungen des menschlichen Gehirns, Unters. zur Naturl. d. Menschen 
u. d. Thiere, xiii., p. 49^ 1888. Mingazzini. G. : Intornocei solchi e le 
circonvoluzioni cerebrali dei primati e del feto umano, Estratto degli, 
Atti della R. Accad. Med. di Roma, iv., p. 48, 1888. Turner, W. : Com- 
parison of the Convolutions of the Seals and Walrus with those of the 
Carnivora and of Apes and Man, Jour. Anat, and Physiol., xxii., p. 
554, July, 1888. Falcone, C. : Studio sulla circonvoluzione frontale in • 
feriore, Rendiconto dell' Accad. delle scienze. fisiche e matem., Napoli, 
xxvii.. p. 195, 1888. Mahaudeau : Coupes descirconvolutions cerebrales, 
Bull, de la Soc. d'Anthrop. de Paris, x., p. 771.' 
109 Brain. 
Brain. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
§ 75. Four cases of non-union of the occipital and cal- 
carine fissures, in white idiots, have been described by 
Dercum (Jour. Nerv. and Mental Disease, July, 1889). 
Among all the hemicerebrums prepared by the writer this 
condition exists in but one, the right of an adult female 
paretic (Fig. 64). Such cases are instructive on both mor- 
phological and zoological grounds. 
When first formed the two fissures are commonly in- 
dependent, and in the adult there is often a vadum or 
shallow at the place of junction. A.complete separation, 
such as is shown in Fig. 64, is a retention of a common 
foetal condition. 
In most apes and monkeys the two fissures are sepa- 
rate ; but usually the calcarine is the longer, and the oc- 
cipital fails to reach it, a condition comparable with that 
in the foetus shown in Vol. VIII., Fig. 4761. In one case, 
therefore, the interruption is a calcarine isthmus, in the 
other an occipital isthmus. Cases of occipito-calcarine 
independence have been observed also by II. C. Chap- 
man (Acad. Nat. Science Proceedings, 1892, p. 208) and 
G. the considerable extension or the central upon 
the mesal aspect ; Vol. VIII., p. 157, § 236. 
H. The presence of a subcalcarine fissure. 
§ 77. The Need of Particular Brains.-From the phys- 
iological and psychological stand-point it is clearly de- 
sirable to study the cerebrums of persons whose men- 
tal or physical powers were marked and well known. 
The present condition of things is illogical and unpro- 
fitable. We scrutinize and record the characters and 
attainments of public men, clergymen, and friends, 
whose brains are unobtainable. We study the brains 
of paupers, insane, and criminals, whose characters are 
unknown or perhaps not worth knowing. 
It is at once a reproach and an irreparable loss to 
science that the community has not yet been convinced 
that the preservation and study of one's brain is an honor 
to be coveted. Who can set a limit to the results that 
might have been attained from the examination of the 
brains of soldiers like Grant, Sherman, and Sheridan; of 
preachers like Beecher, Brooks, and Howard Crosby ; 
of naturalists like Agassiz, Gray, and Jeffries Wyman ; 
of lawyers like Tilden, Conkling, and Benjamin Butler? 
How long must science wait for a general sentiment such 
as is embodied in the declaration of an eminent historian, 
that science is as welcome to his 
brain as to his old hat, and that 
he wishes he had ten of them ? 
It is encouraging to know 
that the brain of the late George 
Grote, historian of Greece, has 
been described by John Mar- 
shall in the Jour, of Anat, and 
Physiol., vol. xxvii., pp. 21-68, 
and that the American An- 
thropometric Society has al- 
ready the brains of Joseph Leidy 
(its first president), of his broth- 
er, Dr. Philip Leidy, and Dr. 
James W. White. * 
In Vol. VIII. (§ 280), there- 
fore, the writer urged the pre- 
eminent value of the brains of 
college professors for the eluci- 
dation of the correlation be- 
tween the mind and its bodily 
organ. 
§ 78. The Greater Need of 
Average Brains. - Another as- 
pect of the matter has impressed 
the writer more and more dur- 
ing the past year, viz., the need 
of a fissural standard, based up- 
on the careful comparison of 
large numbers of average, in- 
telligent, educated, and moral 
individuals, excluding the emi- 
nent as well as the immoral, the ignorant and the insane. 
The first step in this direction has been taken in the 
acquisition of the brain of a lawyer embodying all the 
above-mentioned desirable characteristics. In further- 
ance, there have been printed numerous copies of the 
fissural diagrams (Vol. VIII., Figs. 4768 and 4769), with 
explanations,t for distribution to the classes in Physiol- 
ogy at Cornell University. Besides full explanations, 
there are the following admission and suggestion : 
central f. 
paracentral g. 
- precuneal f. 
paracentral f. 
precuneus 
callosal g. 
adoccipital f. 
1 
callosal f. 
callosum 
occipital f. 
.cuneus 
.calcarine isthmus 
.2 
.calcarine f. 
sub-calcarine g. 
splenium 
6 
fasciola 
hippocampal g. 
occipital f. 
■ sub-calcarine f. 
- post-calcarine f. 
■collateral f. 
-3 
collateral f. 
subcollateral g. 
7 
. 4 
-5 
Fig. 64.-Caudal Half of the Mesal Surface of the Right Hemicerebrum of an Adult Female Paretic. 
No. 2358 in the Museum of Cornell University ; X t 
in the white as well as the negro. The relations of the 
fissures to each other and to the common stem (called 
occalcarine by the writer, VIII., p. 153, G) have been dis- 
cussed by D. J. Cunningham, Jour. Anat, and Physiol., 
xxiv., 327-334. 
§ 76. Points illustrated on Fig. 64.-A. The complete 
separation of the calcarine fissure from the occipital by 
a calcarine isthmus. On the other side the two are con- 
nected as usual. 
B. The bifurcation of the calcarine at each end, 
constituting a zygal fissure ; Vol. VIII., Fig. 4773. 
C. The extension of the occipital fissure so as to rep- 
resent what is usually the common stem of it and the 
calcarine, the occalcarine ; Vol. VIII., p. 153, § 213. 
D. The presence of a " spur " extending caudad from 
the occipital toward the calcarine upon the isthmus. 
E.- The appearance of trifurcation, of the dorsal end 
of the occipital. The middle extension, however, is con- 
tinuous with the fissure only superficially ; the cephalic 
branch is apparently the writer's adoccipital ; the caudal, 
although doubtless the dorsal part of the occipital, presents 
an unusual curve and is invisible from the lateral aspect. 
F. The extent of the precuneal fissure. 
* In 1890, following the example of the French Societe mntuelle 
d'Autopsie, there was formed in Philadelphia an American Anthro- 
pometric Society, in which the writer had the honor of being appointed a 
member of the Publication Committee. The requirement that all brains 
should be deposited at the headquarters of the society seemed to the writer 
from the first undesirable, and he withdrew in the following communica- 
tion to the president, dated December 20. 1891 : 
" I hereby resign my membership in the society. Reflection has con- 
firmed the views already expressed to you personally : 1. No other 
institution or locality is entitled to absorb or appropriate in any sense 
the encephalic material or reputation, present or future, of this Uni- 
versity. 2. My own circumstances and plans for investigation would 
preclude any such active co-operation as might naturally be expected. 
With hearty good wishes for the success of the society as a local or 
university organization for the increase and dissemination of important 
and accurate knowledge reflecting the brain, I remain, etc." 
+ These diagrams will be sent to any who ask for them. 
110 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Brain. 
Brain. 
" As is at present usual in collections, most of the 
specimens available for study came from ignorant, in- 
sane, or criminal persons ; it must be borne in mind 
that the fissural pattern of the average, intelligent, educated, 
and moral human being is undetermined. Hence, although 
these are believed to be improvements upon previous 
diagrams, they must be regarded as provisional and im- 
perfect. 
"It is hoped that this and succeeding classes may in- 
clude some who will recognize the desideratum above 
indicated and will follow the enlightened example of 
several graduates and professors of this University in 
giving written directions to the effect that their brains 
shall be saved for high scientific uses rather than wasted 
upon worms. Steps have been taken toward the forma- 
tion of a Cornell Brain Association, and similar organiza- 
tions might well be established at other institutions of 
learning and in many cities." 
Those who have thus devoted their thinking organ 
to the service of thought with their successors are 
present undergraduates of Cornell University, gradu- 
ates, members of the present teaching body, a former 
professor and an eminent non-resident lecturer. Per- 
haps the most interesting results are to be anticipated 
from the comparison of the brains of a brother and 
sister.* 
§ 79. Brain Weight.-In connection with this subject 
(Vol. VIII., pp. 163, 164) should have been mentioned 
the paper by Thurnam in the Jour, of Mental 'Science, 
April, 1866 ; also Topinard's " Elements d'Anthropologie 
Generale," Chaps, xv. and xvi. 
§ 80. The relations between the weight of the brain 
and its parts and the stature and mass of the body, in 
man are discussed by the late John Marshall, in the 
Journal of Anat, and Physiol., xxvi., pp. 445-500, with 
an interest and instructiveness that would have been 
still greater had he discarded the insular ounce and inch 
in favor of the now almost universally used metric meas- 
ures of weight and length. The following significant 
conclusion is quoted from Donaldson's review of the 
paper in the Jour, of Nerv. and Mental Disease, xvii., 
776, October, 1892 : " Dr. Marshall finds that when the 
smaller weight and stature in the female are given their 
proper value in calculations, the encephalon in the female 
is proportionally as heavy as in the male. On this sub- 
ject, see also an Editorial in the New York Medical Record, 
October 26, 1889. 
§ 81. The relative weights of the two halves of the 
human cerebrum are discussed by W. Braune in the 
Arch. f. Anat. u. Physiol., Anat. Abt., 1891, pp. 253, 
270. 
§ 82. A marked exception to the still too confidently 
affirmed generalization as to the correlation between brain- 
weight and intellect is afforded by two brains obtained 
by the writer in 1891 ; one (2870) was from a lawyer and 
writer, the other (2912) from an ignorant black janitor. 
There is little difference in respect to amount of fissura- 
tion ; when fresh, the lawyer s brain weighed 1225 
grammes (43.20 oz.), the janitor's 1250 grammes (44.09 
oz.). The janitor was heavy and strong, the lawyer spare, 
though active ; the former under thirty years of age, the 
latter in his ninetieth year. 
§ 83. Relative Weights of Body and Brain.-In Vol. 
VIII., p. 163, § 287, the writer gave as the "least mis- 
leading statement," the opinion that the human brain is 
relatively heavier than that of any animal larger than a 
cat, in which the cerebrum is fissured. 
This must now be qualified. Through the kindness 
of Director Smith of the Central Park Menagerie, the 
writer lately examined a male baboon (Cynocephalus ha- 
madryas (?), No. 2980). Its body weighed 5738 grammes 
(12.6 pounds), and its brain 171 grammes. The body is 
thus only 33.5 times as heavy as the brain ; as stated in 
Vol. VIII., p. 163, § 286, in healthy human beings the 
ratio is probably about 1 to 45 ; in those dying from dis- 
(SUPPLEMENT 
ease (like the baboon, which died of tuberculosis) it is 
variously estimated at 35.20, 36.46, and 36.50. Unfortu- 
nately the age of this baboon is uncertain ; supposed at 
the Menagerie to be about seven years, the incomplete 
dentition indicates about two. Other baboons should be 
examined in this regard. Burt G. Wilder. 
In addition to the papers already mentioned in connection with 
special topics, the following merit enumeration as new treatises or as new 
editions, or as readily accessible to American readers. 
Dana, C. L. : Text-book of Nervous Diseases ; being a Compendium for 
the Use of Students and Practitioners of Medicine. O., illustrated 
New York. 1893. 
Gray, L. C. : A Treatise on Nervous and Mental Diseases, for Students 
and Practitioners in Medicine. O., pp. 687, with 168 illustrations 
Philadelphia, 1893. 
Edinger, L. : Zwblf Vorlesungen fiber den Bau der Nervosen Central- 
organe. Zweite umgearbeitete Auflage. O., with 133 illustrations. 
Leipzig, 1889. 
Edinger, L., Vittum, W. H. (translator), and Biggs. C. E. (editor) : 
Twelve Lectures on the Structure of the Central Nervous System. O., 
with 133 illustrations. Philadelphia and London. 1890. 
Horsley, V. : The Structure and Functions of the Brain and Spinal 
Cord. O., pp. 223. London. 1892. 
Kronthal, P. : Schnitte durch das Centrale Nervensystem des Men- 
schen. Folio, 18 plates. Berlin, 1891. 
Minot, C. S. : Human Embryology. Bov. O., pp. 815, 463 figures. 
New York, 1892. 
Obersteiner, A., and Hill, Alex, (translator and annotator): The 
Anatomy of the Central Nervous Organs in Health and in Disease. 
O., pp. 432, with 198 illustrations. Philadelphia, 1890. 
Quain, J. (Schafer, E. A., and Thane, G. D„ editors): Elements of 
Anatomy. Tenth ed., in three vols., O. London. 1890-93. (This 
edition has been largely rewritten, has many new illustrations, and 
the titles of recent publications.) 
Wilder, B. G., and Gage, S. H. : Anatomical Technology as Applied to 
the Domestic Cat. Third ed.. from the second revised. O.. pp. 600, 
130 figs., and 4 lith. plates. (Chap. X., pp. 400-503, is devoted to the 
brain.) New York and Chicago, 1892. 
The usefulness of the Anatomischer Anzeiger was mentioned in Vol. 
VIII., p. 164. Special records of neurological literature are made in the 
Journal of Comp. Neurology by the editor, C. L. Herrick (Granville, 
O.), and in Schmidt's Jahrbficher ftir in- und auslandische Medicin, 
by Edinger under the title of "Bericht uber die Leistungen auf dem 
Gebiete der Anatomie des Central Nervensystems, and by Alex. Hill, 
in Brain. 
BRAIN, METHODS OF REMOVING, PRESERVING, 
DISSECTING, AND DRAWING. § 1. The article under 
the above title in Vol. VIII. of the Refebence Handbook 
(pp. 195-201) consisted largely of a series of memoranda 
often so condensed as to be hardly explicit. The present 
contribution will be in some degree an expansion of that, 
with additions and corrections in accordance with what 
has been published by others and the experience of the 
Anatomical Department of Cornell University.* It should 
be borne in mind that these methods are applicable 
mainly to the preparation and dissection of the brain for 
purely anatomical or morphological ends, such as are 
regarded in the articles " Gross Anatomy of the Brain," 
in Vol. VIII. and in the present volume. For histolog- 
ical and pathological purposes, in addition to the pub- 
lications referred to in Vol. VIII., p. 196 (first foot-note), 
consult the works of C. L. Dana and L. C. Gray, named 
on p. Ill of this volume, and the articles by Dana and 
Peabody (New York Medical Record, January 11, 1890, 
p. 53) and Van Gieson (New York Medical Journal, July 
20, 1889, and January and February. 1892) ; the last, on 
"Artifacts of the Nervous System," has been reprinted 
as a pamphlet of 119 pages and 17 plates. 
§ 2. Order of Treatment.-A. Remarks on the need of 
more attention to the subject (§ 3); the importance of 
early recognition of the form and connections of the 
encephalic cavities (§ 4); preliminary work upon animal 
brains (§ 5) ; the utilization of infant and foetal brains 
(§ 6). 
B. Preservation of foetal and infant brains (§§ 7-8). 
C. Preservative liquids : alcohol (§ 10) ; chromic acid 
compounds (§ 11) ; Fish's liquid, a zinc chloride mixt- 
ure (§ 12); dry preparations (§ 13) ; jars (§ 14). 
D. Injection methods: entocoelian (§ 15) ; arterial 
(§ 16) ; starch mixture (§ 24). 
Bibliography. 
* They are orphans, and without other near relatives who might ob- 
ject ; but it is understood in all cases that objections by husbands, wives, 
parents, or children shall be respected. 
* Besides the gentlemen named in Vol. VIII.. § 2, note, the writer 
desires to acknowledge the cordial and efficient cooperation of P. A. 
Fish, B.S.. 1890, Instructor in Physiology and Anatomy in Cornell Uni- 
versity, and of B. B. Stroud, B.S., '91, Assistant in Chemistry. 
111 Brain. 
Brain. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
E. Removing the brain from infants and late foetuses 
(§ 25); from the adult (§ 30) ; removal in the dura (§ 33) ; 
'weighing the fresh brain (§ 36); determining its volume 
(§ 37). 
F. Medisecting the cerebrum (§ 25, G); storage of 
hemicerebrums (§ 38) ; removing the pia (§ 39) ; label- 
ling specimens (§ 41). 
G. Dissection of the brain (§§ 43-45). 
H. Drawing the brain (§§ 46-58). 
§ 3. Need of More Attention to the Subject.-In the large 
city schools considerable time is now devoted to the 
anatomy and physiology of the nervous system, and in- 
struction is given especially in histological methods ; but 
even there the gross anatomy is not always adequately 
worked out by the student himself upon good material, 
and it is to be feared that in some medical colleges the 
conditions described by the writer nine years ago* may 
still prevail. 
Inasmuch as he is permitted to clean scrupulously 
the abdominal muscles before examining the vastly more 
important viscera, the average first-year student is at 
least consistent in deferring the removal of the organ of 
the mind until he has carefully dissected the muscle that 
wrinkles the forehead. With saw and chisel he lacerates 
the brain, tears it in the effort to save entire the sacred 
skull-cap; injures it yet more in the process of extraction,! 
and places it upon a hard, flat surface, where its own 
weight completes the rupture of delicate connections and 
hopelessly distorts its shape. Here he leaves it (having to 
boil or clean some bones), perhaps for a day or two, prob- 
ably drying, and either freezing or decomposing according 
to the temperature. He then transfers it to a basin or pail, 
covers it with strong alcohol, notes with satisfaction that 
the surface hardens rapidly, feels sure of finding out all 
about the brain, and sees himself a future neurological 
expert, perhaps even an asylum superintendent. In due 
time, armed with his " Gray " and a big knife, he succeeds 
in identifying the cerebellum, the chiasma and the pons. 
Upon the cerebrum he recognizes the Sylvian fissure, but 
is doubtful about the central ; moreover, the effort to 
detach the dried-on pia creates so many undescribed 
depressions and fissural confluences that he imagines, d 
la Benedikt, that it belonged to some hardened criminal. 
Lifting the occipital lobes, his fingers readily enter cav- 
ities which must be the " descending horns of the lateral 
ventricles," a triumphant refutation of the opinion of 
certain "theoretical" anatomists that there is no such thing 
as a "great transverse fissure" till artificially produced. 
He then slices the brain secundum professoris artem, and 
is so pleased at demonstrating the ^centrum ovale majus'' 
that he is not seriously disturbed at the presence of an 
unexpected rent in the callosum and an irregular orifice 
at either side. Continuing his operations, he finds the 
interior of the brain a mass of amorphous pulp ; suspects 
that the names in the books have much the same 
significance as those of the heavenly constellations ; 
modestly admits that he may not be sufficiently advanced 
to comprehend the brain, and resolves that, when this 
branch is undertaken again, his armamentarium shall 
consist not of a scalpel but a spoon. 
§ 4. Importance of Early liecognition of the Form and 
Connections of the Encephalic Cavities.-In Vol. VIII., p. 
196, § 35, the recommendation would be more accurate 
were the word details printed in italics. What the writer 
desires to inculcate is the desirability of appreciating the 
fact that the brain has resulted from the unequal thick- 
ening of the walls of a series of mesal cavities which 
were primarily subequal in size, and from the great de- 
velopment of a pair of lateral masses, the hemicere- 
brums, about the lateral extensions, paracceles, of the 
mesal series. This idea may be gained from an em- 
bryo brain (Vol. VIII., Figs. 4691-4693), from a cast 
of the adult cavity (Fig. 4703), and from the mesal as- 
pect (Fig. 4711) and cerebral cavity (Fig. 4740), with- 
out attempting at first to master the exact contours, 
much less to learn the names of all the elevations and 
depressions. 
§ 5. Preliminary Work upon Animal Brains.-In Vol. 
VIII., p. 195, § 3, the brain of the domestic cat was rec- 
ommended. Its advantages are unquestionable in re- 
spect to accessibility, ease of removal and preservation, 
and simplicity of fissural arrangement. The employment 
of the equally accessible and larger brain of the sheep 
has been hindered by the difficulty of extracting it from 
the head with either nippers or saw as commonly em- 
ployed. This was obviated in the spring of 1890 by P. 
A. Fish, who devised the following method : The cra- 
nium is removed from the rest of the head by sawing on 
a plane coinciding with the ventral margins of the orbits 
and of the foramen magnum. The corners of the mass 
are then sawn off, and the cranium nipped away, begin- 
ning with the base.* 
In addition to the practical reasons referred to above 
and in Vol. VIII., the brains of the cat, dog, pig, and 
sheep present this great advantage over that of man, 
viz., there is less preponderance of the cerebrum and 
cerebellum over the other regions and the segmental con- 
stitution pf the organ is thus more easily recognized. This 
is stated and illustrated in Vol. VIII., pp. 114-116. In 
the present volume it is more clearly indicated in Fig. 
5, where the dorso-ventral lines, A-E, transect the several 
segments without involving adjoining segments, although 
the last requires the section to be made from the ventral 
side, and all are more or less oblique.f 
§ 6. Utilization of Infant and Foetal Brains.-The treat- 
ment of this subject in Vol. VIII. (pp. 195, 196, §§ 4, 6, 
28, 29, 30) is unsatisfactory, partly from lack of experi- 
ence since acquired, and partly from excessive condensa- 
tion. The procedures depend upon the object in view and 
upon the age and condition of the specimen. 
§ 7. Early Foetal Brains, Two to Four Months.-Unless 
one has acquired considerable skill in manipulating such 
delicate objects, these should be hardened in place by one 
of the following methods, or by a combination of them ; 
a five per cent, solution of zinc chloride in alcohol is very 
effective with embryo brains : 
A. Injection of the preservative through the umbil- 
ical vein. 
B. Immersion ; if alcohol, or the above solution, is 
used the specimen should be suspended in it. 
C. Injection of the preservative with a hypodermic 
syringe both into the body in general and into the cav- 
ities of the brain.$ The cannula should be pushed 
through the scalp at the margin of the prefontanel, 
obliquely latero-ventrad so as to traverse the thin parietes 
and enter the large frontal portion of the paracoele ; Fig. 
62, Vol. VIII., Figs. 4708, 4709. The success of the in- 
jection is shown by the expansion of the opposite half of 
the head due to the passage of the liquid through the 
portas into the corresponding paracoele. 
The exposure of such brains must be done under or 
over alcohol; the cranium, and dura must be divided to- 
gether at each cut. The operation is tedious, but the 
results are revelations, no matter how often performed ; 
no specimens are more beautiful or instructive; see Figs. 
4697, 4756. 
§ 8. Brains of the middle and later gestative periods 
and at term are most useful for the comprehension of 
the early and simple condition of the fissuresand of the 
♦Methods of Studying the Brain: the " Cartwright Lectures" for 
1884. New York Medical Journal, xxxix., 1884. pp. 141-148. 177-183, 
205-209, 213-237, 373-377. 457-401. 513-510, 653-056 ; xl.. 113-116 : 64 fig. 
Abstracts in New York Medical Record, xxv., 1884, pp. 141-143, 197-199, 
225-227, 365-367, 449, 450, 545. 546. 
+ The article Anatomy in the last edition of the Encyclopfedia Bri- 
tannica (i., 876) seems to acquiesce in the present state of things as 
beyond remedy: "In taking the brain out of the cranial cavity this 
commissure [the medicommissure] is usually more or less torn through, 
and the cavity [diacoele] is consequently enlarged." 
* So expeditions is this method that in 1892 a hardened brain was sup- 
plied to each of the one hundred and sixty members of the general class 
in Physiology for dissection, in addition to the large series of permanent 
preparations, transections and selected half-brains with good mesal 
aspects put in their hands for examination. The study of the sheep's 
brain occupied the class at three exercises of two hours each. The direc- 
tions form part of the writer's " Physiology Practicums," and he hopes 
shortly to publish in detail the methods of removal and preservation. 
+ As to monkey brains see § 8. 
* So far as the writer is aware, this was first done by Professor S. H. 
Gage. May 17, 1892, upon specimen 2947. 
112 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Brain. 
Brain. 
order of their appearance. * The best results are obtained 
by their prompt removal as described in 25-29, and 
hardening in Fish's liquid or other zinc chloride mixture. 
The arterial injection of such brains rarely preserves 
them well, and the gyres are commonly so pressed to- 
gether as to interfere with both the removal of the pia 
and the recognition of their relations. 
§ 9. In Volume VIII., p. 196, § 13, it is suggested that 
the use to be made of a brain be determined upon in ad- 
vance. The city neurologist has perhaps only to decide 
that a brain is needed ; but others, like the writer, may 
find it advantageous to keep in a portfolio (see Vol. VIII., 
p. 198, § 56) slip memoranda of what he wishes to do with 
fresh brains, or heads, adult or young, as the case may be; 
when the opportunity occurs he has only to decide among 
several things that might be done, and little time is lost. 
§ 10. Preservative Liquids.-In Volume VIII., p. 196, 
§ 23, a preference was expressed for alcohol. But the 
brain inevitably flattens in it more or less, and there is 
difficulty in recognizing the cinerea from the alba. 
§ 11. Potassium Dichromate.-This is the chief ingre- 
dient of the well-known " Muller's liquid," which con- 
sists of two parts of it and one of sodium sulphate in one 
hundred parts of water. Beyond increasing the buoy- 
ancy of the liquid, the sodium sulphate seems to have no 
special value for either microscopic or macroscopic pur- 
poses and is often omitted. 
Mr. B. B. Stroud has determined for this article that, 
at the temperature of 20° C. (68° F.), a saturated solution 
of potassium dichromate contains about ten per cent, of 
the salt; at boiling the per cent, is forty-four. His method 
of using it for sheep brains (§§ 5 and 15, notes) was to 
effect the solution rapidly in boiling water ; when cool, 
enough water was added to float the brain just below the 
surface. 
As soon as the brain is firm to the touch it may be 
soaked for a day in water and then in alcohol, at first 
about forty per cent., then stronger, until the alcohol 
ceases to be colored, after which it may be kept in alcohol 
of not less than eighty per cent.f 
The alcohol that is so colored may be used for the same 
purpose with other brains, or in the storage of specimens 
not requiring it to be either colorless or strong. 
The Incompatibility of Alcohol with Compounds of 
Chromic Acid.-A chemist to whom the matter was sub- 
mitted states that when alcohol and potassium dichro- 
mate are mixed in any proportion the salt will be at least 
partially reduced, and there w'ill also be formed, from 
the alcohol, various compounds, as acetic acid, acetic 
aldehyde, etc. These processes will take place in either 
light or dark, but more rapidly in the light. « 
§ 12. Fish's Liquid.-The following combination was 
devised in 1892 by Instructor P. A. Fish, of the Anatom- 
ical Department of Cornell University, and is found to 
answer the three requirements of preservation of shape, 
hardening of substance, and differentiation of tissue 
Alcohol (ninety-five per cent.), 200 c.c. ; water, 800 c.c. ; 
glycerine, 75 c.c. ; zinc chloride, 50 grins. The alcohol 
and water should be mixed first, so as to get a strength 
of twenty-two per cent, as determined by the alcoometer ; 
the variation in commercial alcohol is such as may render 
it necessary to add more to the mixture, but the total of 
the twenty-two per cent, mixture should be only about 
1,000 c.c. ■ When shaken up thoroughly the specific 
gravity of the mixture should be about 1.04; if less, a 
little more glycerine and zinc chloride may be added. 
When the brain is introduced it should rest just at the 
surface, and the vessel should be deep enough to prevent 
its touching the bottom. If any part projects it may be 
submerged by covering it with a thin layer of absorbent 
cotton, the edges of which dip into the liquid. Masses 
having one flat side, e.g., hemicerebrums, should have 
that side up, the reverse of the desirable position when- 
as in alcohol-the specimen sinks to the bottom. If pos- 
sible the liquid should be injected into the cavities, and 
into the vessels, and these injections should be repeated 
daily for a week. 
After one to three days the brain will probably sink to 
the bottom ; the pia should then be removed, preferably 
without taking it from the liquid ; it may be steadied 
with beds of cotton. 
Half of the liquid is now to be replaced by ninety-five 
per cent, alcohol ; this is best done by drawing off a part 
with a syringe and introducing an equal quantity of the 
alcohol. In the lighter liquid the brain will sink to the 
bottom, and for twro days should rest on the fiat side if 
there is one ; if all the surfaces are convex, they should 
be padded with cotton, and the specimen turned fre- 
quently. After two days more half the lighter liquid 
may be replaced by alcohol, and in two or three days more 
all of it. The removed liquid may be utilized in vari- 
ous ways ; the percentage of zinc chloride is hardly great 
enough to be corrosive, and the alcoholic strength may 
be increased by the addition of ninety-five per cent. 
§ 13. Dry Preparations of the Brain.-Laskowsky's 
method was mentioned in Vol. VIII., p. 196, § 27, note ; 
the following is translated from the abstract in the Neu- 
rologisches Centralblatt, vi., 341-342 : 
A. Rinse the fresh specimen in water to remove blood. 
B. Place in a mixture of water, 100 parts; alcohol 
(ninety-five per cent.), 20 parts ; boracic acid, 5 parts; let 
it remain in a cool place [for at least three days ; time not 
given], 
C. Remove the pia. 
D. In a saturated solution of zinc chloride in alcohol 
let the brain remain five or six days ; the bottom of the 
vessel should be covered with cotton. 
E. For fifteen to twenty days soak in a mixture of 
glycerine, 100 parts ; alcohol, 20 parts ; carbolic acid, 5 
parts ; boracic acid, 5 parts. 
F. Let it dry in the air, protected from dust. 
The specimen is claimed to retain its natural volume, 
distinction of color, and elasticity.* 
§ 14. Preserving- Jars.-Besides those mentioned in Vol. 
VIII., p. 199, the following deserve mention from the 
combination of three desirable qualities-width of mouth, 
clearness of glass, and cheapness : 
A. Tall, round, screw-capped jars, with nickel-plated 
caps, cork-lined, three sizes, viz. : 4 oz., 8 oz., and 16 oz.; 
Whitall, Tatum & Co., New York (Fig. 65). 
B. Butter-jar, 10 x 20 ctm., with tin screw-cap, lined, 
capacity about 1 litre ; Excelsior Package Co., 49 Warren 
Street, New York. 
C. Landenberger's Specimen Jars.-These have a rub- 
ber ring and a glass top retained by a wire. The smaller 
size is 3 x 3 in., capacity 6 oz. (180 c.c.); the larger, 3x4 
(high), capacity 10 oz. (300 c.c.) (Fig. 66). 
£ 15. Entoccelian Injection.-To fill with ahardeningand 
preservative liquid cavities surrounded by flexible walls 
would seem to be a natural device both for the better 
preservation of the mass and for the maintenance of the 
forms and relations of the cavities.f 
* The writer desires to reiterate here the conviction expressed in Vol. 
VIII , p. 149, § 195, and on two previous occasions there named, as to 
the inutility of the brains of ordinary monkeys and even of aj>es for the 
elucidation of human fissural problems ; indeed, our present comprehen- 
sion and nomenclature of cerebral elevations and depressions would be 
far better than they are had neither Gratiolet nor any other anatomist 
ever examined a monkey brain. 
+ The specimens may be more completely decolorized by absolute al- 
cohol (W. C. Krauss), oy hydrogen petoxide (Unna, Arch. filr Mikios. 
Anat., xxx.. 48. 1887). or by a one per cent, solution of chloral hydrate 
(Lee. " Microtomist's Vade Mecum "). 
t The microscopical distinction between alba and cinerea is permanent, 
but immersion in alcohol bleaches the cinerea to nearly the color of the 
alba in about a fortnight. 
* Experiments are now in progress in the anatomical laboratory of Cor- 
nell University upon other methods of making dry preparations of the 
brain. Methods have been described by Stieda (Neurolog. Cento alblalt, 
1892, No. 5), by Moeli (C ntralb. ally. Path. u. path. Anat., iii., p. 1, 
888). and by Struthers (Jour. Anat, and Physiol., xxii.. Appendix, p. ix). 
+ The method was first employed by the writer, as assistant to the late 
Professor Louis Agassiz, at Nahant. Mass., in July, 18(17. for permanent 
preparations of great vascular sinuses in rays. Since that time it has 
been applied in the anatomical laboratory of Cornell University to the 
preparation and study of hollow organs of all kinds, stomach, ceecnm, 
heart, uterus, kidney, and brain. In 1880 he first learned that the injec- 
tion of alcohol into hearts was advised in 1860 by Hyrtl, and in 1879 by 
Mojsisovics ; the former ascribes the idea to William Hunter ; the writer 
is not aware that injection of a preservative into the brain cavities was 
practised or suggested by anyone prior to December 14, 1881, when he 
employed it upon a child's brain. 
113 Brain. 
Brain. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
The account of entoccelian injection in Vol. VIII., 
p. 201, § 80, is not only too brief, but requires emen- 
dation in the light of later experience. 
A. Without conceding the existence of other natural 
orifices from the paracoeles (lateral ventricles) (p. 107, § 
54), both human and animal brains present outlets for the 
(SUPPLEMENT.) 
A small glass syringe may be employed for injecting 
preservative liquids into the brain-cavities, either directly 
or by attaching a rubber tube and cannula. 
§ 16. Arterial Injection of the Preservative.-This is re- 
ferred to in Vol. VIIL, p. 196, §§ 20 and 68, and is ex- 
emplified in Figs. 4684 and 4711. As compared with 
immersion it has the great advantages of rapidity and 
thoroughness. Any preservative may be employed, and 
alcohol maybe used at full strength. Alow temperature 
is needless, and even, perhaps, undesirable, as admitted in 
Vol. VIIL, explanation of Fig. 4884. 
Barring a slight shrinkage, the natural conditions and 
relations are maintained.* 
It must be admitted, however, that sometimes the 
gyres are somewhat crowded against each other, so that 
the pial folds are less readily and safely extracted, and 
the fissural relations less easily determined. 
This is not the occasion for a complete history of in- 
jection processes, or for the presentation of claims to 
originality. The transmission of preservative liquids to 
the tissues by a constant pressure apparatus connected 
with the vessels by which blood reached the parts dur- 
ing life is really so simple as well as effectual that it is 
hard to account for its comparatively infrequent sugges- 
tion and adoption. Without previous acquaintance with 
what had been done by others,f on October 7, 1883, with 
the co-operation of Professor S. H. Gage, the writer began 
upon the body of a young chimpanzee (No. 265) an alin- 
jection of the entire body which was prolonged for ten 
days and was completely successful. In November, 1885, 
a manatee (No. 844), 150 elm. long, was prepared in like 
manner: all the cats (75 to 150 per year) used by the gener- 
al class in Physiology are alinjected and packed away till 
wanted ; still-born children are commonly so preserved, 
and the writer recommends that, with alcohol obtained 
free of tax, all anatomical material in medical dissecting- 
rooms be thus rendered innocuous, free from unpleasant 
odor, and fit for prolonged and thorough examination. 
§ 17. Location of the Arteries.-In Vol. VIIL, p. 200, 
S 68, the relations of the arteries were very briefly re- 
ferred to ; the practical importance of the matter war- 
rants a fuller consideration. 
Nearly opposite the hyoid bone, or the cephalic mar- 
gin of the larynx, each common carotid divides into 
an ectocarotid ("external ") and an entocarotid (" inter- 
nal "). In the adult they differ little in size, but may 
be distinguished in that (1) the ectocarotid branches at 
once and lies farther ventrad, while the entocarotid 
continues unbranched to the cranium and is accompa- 
nied by the vagus nerve. 
If the neck was severed close to the head the two 
arteries may be dealt with independently. If at the level 
of the chin (as in the head shown in Fig. 4684) the com- 
mon carotid may be followed up between the muscles, 
using the tracer rather than the scalpel as much as possi- 
ble. But if the neck is entire, and especially if it is to be 
kept so, the ectocarotid may be exposed as for surgical 
ligation by an incision along the ventral ("anterior") 
margin of the sterno-mastoid from the lobule of the ear. 
In any case the ligature must be applied close to the 
bifurcation of the common carotid or the superior thy- 
roid artery (Fig. 2430) may not be included. As to the 
vertebral artery, unless there are special reasons for not 
injuring the vertebrae, the transverse process may be 
nipped away in order to expose the vessel. The cannula 
is to be inserted in one, anil the other tied after the 
arteries have been cleared. Since the two arteries unite 
to form the basilar it makes no difference which has the 
Fig. 65.-Screw-capped jar ; see 
§ 14, A. 
Fig. 66.-Specimen jar; see § 14, 
C. For sale by H. Landen- 
berger, 25 N. 13th Street, Phil- 
adelphia. 
escape of the injected liquid so as to obviate the danger 
of rupturing the thinner parietes under any pressure that 
might be required for filling the cavities. With animals 
the myelocoele (central canal of the spinal cord) is pervious 
through life. With a cat, for example, where 4 ctm. of 
the myel remained attached to the brain, alcohol injected 
into the diacoele (third ventricle) with a syringe escaped 
from the myeloccele in a stream 8 to 10 ctm. long, al- 
though the orifice of exit was 42 mm. from the tip of the 
metaccele and 66 from the place of injection. With 
human brains (excepting early stages when the myelo- 
coele would probably be sufficiently pervious) there is an 
ample outlet at the metapore (foramen of Magendie), 
described under " Meninges ; " the same may be the case 
with apes and some monkeys. Hence the cannula, in- 
stead of fitting loosely, may be tied into the infundi- 
bulum, or made large enough to tit it closely. In the latter 
case the cannula may need a rubber collar to prevent its 
entrance so far as to lacerate the medicommissure or 
parietes. This precaution may be rendered superfluous 
by using a cannula which is bent upon itself at a right 
angle, in the form of a capital letter L, turned one 
quarter way around thus, r- : the shorter arm enters the 
orifice, the longer rests upon the base of the brain and 
has attached to it the tube connected with the syringe or 
injection reservoir. This tube should be short and slen- 
der ; in the intervals of injecting it may be compressed, 
or plugged with a glass or cork.* 
Entoccelian injection, whether repeated or continuous, 
may be accomplished from any artificial orifice. The 
most favorable place is the aqueduct (mesocoele) after 
transection of the brain (§ 25, E); the cannula may be 
selected so as to fit it closely ; with the cerebellar por- 
tion of the brain the metapore would serve as the out- 
let ; with the cerebral it might be necessary to tie the 
infundibulum to prevent too ready escape therefrom ; 
with a small stream at a slight elevation above the brain 
it is probable that any excess would be provided for by 
oozing along the rima, f 
* In this connection, the writer cannot refrain from expressing his re- 
gret at the non application of this and other exact methods of preserva- 
tion and determination to the brain of Guitean ; see N. Y. M<d. Jour., 
February 23, 1S84, p. 206, and Amer. Jour, of the Med. Sciences, Janu- 
ary, 1883, p. 219. 
+ Arterial alinjection of the brain is named or implied by Ecker 
('•Cerebral Convolutions." p. 45). by Mondino {Trans. Koy. Micros. 
Assoc., 1885, p. 904), by Foster and Langley (" Pract. Physiology," p. 
215). by Key and Retzius ("Studien." i.. p. 104), and by the editors of 
the tenth edition of "Quain," vol. iii., Fig. 88. It was done in 1863 for 
Marshall u|>on a Bushman [Philos. Trans., cliv., p. 501) ; the dates 
of its performance for Flower and Owen are mislaid. 
* At the writer's suggestion L-shaped cannulas were used last sum- 
mer in the preparation of sheep brains for the class in Physiology; the 
preparator, B. B. Stroud, succeeded in making these cannulas very small, 
and with the point slightly enlarged so as to be more securely' tied in the 
infundibulum. 
+ For the exposition of the forms and membranous parietes of the en- 
cephalic cavities, nothing seems to promise better than the method 
briefly described under Figs. 4736 and 4751, a combination of arterial in- 
jection with injection into the medicornus opened by cutting off the lat- 
eral regions of the cranium and brain. 
114 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Brain. 
Brain. 
cannula, excepting that there is some convenience in plac- 
ing it and the carotid cannula on the same side. 
§ 18. Securing the Cannulas.-Preferably one cannula 
is to be inserted in the carotid, whichever is the longer, 
and another in the vertebral of the same side. Each is to 
be very securely tied ; if there is no shoulder at the can- 
nula point, then tie also around the rubber tubing at its 
base. All the knots should be the so-called " surgeon's," 
•one end of the thread being passed through twice instead 
of once ; " Anat. Technology," Fig. 41. 
§ 19. Continuous injection necessitates, in addition to the 
means of supporting the brain mentioned in § 34, (first) 
an escape-tube (Fig. 4884) whereby the overflow may 
pass into the escape-jar, (second) some means of sup- 
porting the cannulas and tubes. 
The first requirement may be provided for by inserting 
a metal or glass tube in a hole near the top of a wooden 
pail, or, with a metal pail, having a tube set at that 
place ; in either case a rubber tube conducts the overflow 
to the escape-jar. The second end may be attained in 
•either of several ways: The metal pail shown in the 
figure has soldered to the sides several tubes serving as 
sockets for flexible wire " cranes ; " these wires (of lead, 
•copper, or unannealed brass) may be fixed by wooden 
wedges if they do not fit securely ; with a wooden pail 
they may be pushed into holes bored vertically into the 
rim. In either case the wires should be large and the 
free end beaten out rather thin, so as to be bent easily in 
the fingers about the tubes connected with the cannulas. 
Unless the operator has metallic screw-pinch cocks for 
regulating the flow, so small as not to drag undesirably 
upon the wire, he may secure the same end by fixing to 
.-another wire a wooden spring clothes-pin, by means of 
which the rubber tube may be compressed. 
§ 20. Turning the Head.-There are reasons for believ- 
ing that the position of a head under injection should be 
changed daily, in order that no one region of the cerebral 
surface shall be more than twenty-four hours in close 
contact with the cranial wall. 
§ 21. Repeated Alinjection.-It is probable that the in- 
jection of, say one litre of ninety-five per cent, alcohol, 
morning, noon, and night, for a week, would harden a 
brain very well, but accurate experiments on this point 
have not been made as yet under the writer's observation. 
If it be tried especial care should be taken to exclude air- 
bubbles (§ 22), to keep the brain wholly submerged or its 
base covered with a layer of absorbent cotton dipping 
into the alcohol. Such injections may be made con- 
veniently with an ordinary rubber-bulb syringe. Re- 
peated injection will conduce to the preservation of the 
coelian parietes and of the plexal attachments, but is less 
effectual than continuous for maintaining the size and 
form of the cavities. 
§ 22. Exclusion of Air-bubbles During Arterial Injec- 
tion.-This is accomplished by letting the alcohol run 
until no bubbles appear either in the cannula or in a glass 
tube which is introduced near the can ; the can itself 
•should always be at a higher level than the adjoining tube, 
especially when it is lowered for the introduction of fresh 
alcohol, since bubbles are then most apt to be formed ; 
on this account the tube should be of ample length. 
§ 23. Filtration. - Whatever liquid is to be injected 
into the encephalic vessels must be carefully filtered 
through filtering-paper, or through absorbent cotton 
crowded into the pipe of a funnel. This necessity ap- 
plies to unused alcohol as well as to that which has al- 
ready passed through tissues. 
§ 24. Starch Injection Mixture.-Of the mixture first 
proposed by Pansch, the following modification has been 
■devised by Professor S. H. Gage and the writer : 
Dry starch powder.... 100 c.c. 
Chloral hydrate 10 grms. 
Water 50 c.c. 
Alcohol (ninety-five per cent.) 50 c.c. 
Glycerine 25 c.c. 
Coloring matter. 
After thoroughly mixing the mass it should be filtered 
through one or two thicknesses of wet cheese-cloth. To 
(SUPPLEMENT.) 
prevent the starch from settling, the cloth should be tilted 
from side to side or the mass may be stirred during the 
filtration. If the mass is not freshly prepared for every 
injection, the stock mass should be filtered occasionally 
to remove hair or any other object that might clog the 
cannula. 
Among the colors that are available, probably ver- 
milion, red lead, ultramarine, Berlin blue, chrome orange, 
yellow, or green, are preferable. 
§ 25. Removing the Brain from late Foetuses, Still-boms, 
or Young Children.-This is most conveniently done if 
the cranium and maxillary region are first cut away from 
the neck and mandible by cutting with coarse curved 
scissors from the corners of the mouth to the nape of the 
neck. The mass thus obtained is compact and may stand 
upright in liquid. 
A. Instruments and materials required. Coarse for- 
ceps ; coarse, curved scissors for bone; another sharp 
pair for soft parts ; tracer (Fig. 4880); nippers (Fig. 4881); 
large scalpel; narrow-bladed scalpel, preferably a probe- 
pointed bistoury;* four vessels, holding about two litres 
each ; two of water ; one of preservative ; one of satu- 
rated brine ; if the weight of the brain is to be ascertained 
(§ 36) the body should be weighed before the head is re- 
moved, and there should be provided a fifth vessel of 
normal salt solution (15 to 2,000). 
B. The scalp should be removed completely, together 
with the ears, and temporal muscles as far as the 
zygomas. 
C. Cranium and dura. In young subjects these adhere 
closely ; hence, contrary to what is recommended with 
adults, they should be removed together in pieces. With 
the tracer-point lift the united pericranium (ectal perios- 
teum) and dura near the left margin of the prefontanel, 
and with the scissors or scalpel slit the tough membrane 
so as to expose a little of the brain. Grasp the cut edge 
with the forceps and with the scissors cut out a piece 
including pericranium, dura, and intervening area of 
parietal bone. Continue in this way, using the nippers 
when necessary, until the entire left hemicerebrum is 
exposed. More and more care will be required to avoid 
injuring the delicate brain, either by the instruments or 
the cut edges of bone. 
Leaving the falx undisturbed, expose the right Iremi- 
cerebrum- in the same way, but with even more precau- 
tion and holding the head so that the left is more or less 
completely supported in the brine. 
D. Falx. Cut the veins that pass from the dorsal mar- 
gins of the cereltfum to the longitudinal sinus; they are 
more easily dealt with if the head be slightly tilted 
toward one side. From Vol. VIII., Figs. 4684 or 4711, 
recognize that at about the junction of the cephalic and 
middle third the falx extends only half-way to the cal- 
losum. Lift it with the forceps just enough to steady it 
and cut with the scissors. Draw the cephalic third 
cephalad and cut off. The caudal two-thirds may be 
steadied and cut as near as possible to the line of its 
junction with the tentorium, but must not be pulled 
upon on account of its connection through the falcial 
sinus with the velar veins. 
E. Transecting the mesencephal. Tilt the head 
cephalad. Cut the veins that pass to the dura from 
the sides of the brain and near the caudal end. With the 
scissors cut the vessels and connective tissue and mem- 
branes just caudad of the splenium (Fig. 4711) so as to ex- 
pose the gemina, the dorsal lobes of the mesencephal cor- 
responding to the crura ventrad (Figs. 4689, 4712, 4783). 
This is the narrow region connecting the wider cerebel- 
lar mass with the still wider cerebral portion, and hence 
called sometimes the isthmus. With the probe-pointed 
bistoury or sharp, narrow scalpel cut this just caudad of 
the conarium ; the knife should point almost directly 
at the tip of the nose if the pons is to be wholly avoided. 
* This is practically a longer and stronger syringotome (Fig. 4880), 
the cutting edge being about 5 ctm. (2 in.) long, ending in a probe point. 
The curve is less than that of the syring .tome. It replaces the syringo- 
tome in the dissection of the entire human brain, and it is particularly 
applicable to transecting the brain through the mesencephal, to tracing 
the medicornu and to slitting the pia in following the Sylvian or other 
deep fissures. 
115 Brain. 
Brain. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
F. Cutting the nerves, etc. The cerebral mass is 
now held to the base of the skull by the mesal hypophy- 
sis (Fig. 4712) and by the paired optic nerves and olfac- 
tory crura and bulbs. The slender stalk (infundibulum) 
of the hypophysis is to be cut first ; then the firm fibrous 
optic nerves. The olfactory crura and bulbs are easily 
torn, but if care be taken to avoid pulling upon them 
the latter may be dislodged from their cavities with the 
blunt point of the bistoury or the tips of the scissors. 
G. Medisecting the cerebrum. The cerebrum now 
floats free, and ordinarily should be medisected at once. 
Remove the rest of the head to the normal salt solution. 
Steady the cerebrum by packing absorbent cotton about 
the base. Divaricate the opposed dorsal parts of the 
hemicerebrums till the white callosum is visible. Place 
the edge of the scalpel at the genu and with one sweep, 
steady and perpendicular, divide the callosum, fornix, 
precommissure, medicommissure, and conarium ; the 
halves will then fall asunder so that the chiasma and 
crura may be medisected.* 
H. The cerebellum, etc.-With the scissors cut the 
tentorium at its margins. Turn the head so as to expose 
the cranial nerves and cut them ; lastly, with the curved 
scissors divide the myel as far down as possible. Trans- 
fer to the salt solution. 
I. Weighing. From the pan of brine, each portion 
is to be transferred in turn to the salt-solution, and 
weighed according to the method described in § 36. 
§ 26. Removing the Hemicerebrums Separately.-The 
following modification of the method just described has 
some advantages. After the exposure of the left hemi- 
cerebrum cut the veins as before. Let the head tilt to 
the left so as to oxpose the callosum. Divide it, as di- 
rected above, down to the base of the skull ; then the 
left half of the mesencephal ; then the infundibulum 
and optic nerve; and finally dislodge the olfactory 
bulb. 
These last parts are then to be attended to first on the 
right side ; the falx is easily removed, and the hemi- 
cerebrum comes out as soon as the veins are cut. The 
chief objection to this method is the danger of cutting 
the mesal aspect of one of the frontal lobes. 
§ 27. When there are reasons for not mutilating the 
head, the removal of a child's brain is much less con- 
venient. The body and legs should be wrapped up so 
as to be held and turned easily. Unless the child can 
be held by an assistant, it will be found convenient to 
let it rest in a sort of trough, like a piece of large roof- 
gutter ; or to roll it up in a sheet of lead, which, upon 
pressure, will flatten so as to maintain any desired posi- 
tion. The tray or trough must be supported at a level 
with the rim of the vessel of brine, so that the head may 
liang over into it when desired. Needle and thread 
must be provided for sewing up the scalp. 
§ 28. Ventral Exposure.-For some purposes, e.g., 
when the organ is to be kept entire, or when the nerve- 
roots are to be retained, the young brain may advanta- 
geously be exposed from the ventral side ; this aspect 
should be first studied, as shown in Figs. 4689 and 4711 ; 
then the base of the cranium may be nipped away, or cut 
with the coarse scissors ; it will be well to expose one 
side completely first, so that any errors detected may be 
avoided on the other. With care the hypophysis (Figs. 
4712 and 4728) may be retained. 
This method is less applicable to adult brains, on ac- 
count of the thickness of the skull; this, however, may 
be softened by nitric acid ; Vol. VIII., § 6, note. 
§ 29. On February 1, 1884, the writer removed the 
cranium of a small monkey (Midas, No. 342) by means 
of a dental engine, working a small saw and a burr. 
It may be predicted that in time the work now done 
laboriously with saw and nippers will be accom- 
plished more neatly and expeditiously by some ap- 
paratus like the electro-osteotome of Dr. M. J. Roberts, 
(SUPPLEMENT.) 
whom the writer is proud to claim as a former student 
and assistant; see Virginia Med. Monthly, March, 1887. 
When it is desired to inject the arteries of a subject 
after the removal of the brain, if the arteries (carotid 
and vertebral) cannot be tied or caught with serresfines, 
the regions in which they open may be filled with plas- 
ter-of-Paris. 
§ 30. Removing the Adult Brain.-Portions of the 
operation are described in Vol. VIII., p. 199.* The writer 
is confident that whoever once adopts the plan of making 
a second sagittal section of the calva, one to two centi- 
metres from the meson, will never again attempt to re- 
move the entire calva in the customary fashion. 
A. Saw. There is no special advantage of the ex- 
pensive surgical or anatomical saw over the ordinary 
carpenter's instrument; it should be thin-bladed, fine- 
toothed, kept sharp and well-set, and used for no other 
purpose. 
B. Supporting the brain in brine. Although decid- 
edly firmer than in infancy the adult brain should never- 
theless be supported in brine during the later stages of 
its removal ; this is particularly essential if the organ is 
to be removed entire. 
The brine should be in an ample vessel, and, if wret- 
ting the floor is to be avoided, should stand in a pan or 
tray. The head is to hang over the end of the operating- 
table ; the vessel of brine is therefore most conveniently 
placed upon a revolving stool (like a piano-stool) or in a 
firm chair with some low boxes or thick pieces of board 
whereby it may be raised or lowered according to the 
position of the head. 
C. The longitudinal sinus should be slit to let out the- 
blood, unless the calval dura is to be removed entire ; 
usually, notwithstanding all precautions, the saw has- 
cut the dura at some point. There-or at any other 
point - commence with the scissors or probe-pointed 
bistoury, and cut the dura along the line of the cranial 
edge first on one side. The head and entire body must 
now be turned so that the hemicerebrum is supported in 
the brine. When the dura of the other side is cut the 
falx may be cut near the cephalic end. In lifting it ob- 
serve the precautions mentioned in connection with the 
foetal brain (§ 25, D). The transection at the mesence- 
phal gives no special difficulty beyond the weight of the 
cerebrum and the tendency of the head to assume unde- 
sirable positions; an assistant is wellnigh indispensa- 
ble. The extraction of the cerebellum, etc., is practically 
the same as with the young brain (§ 25, II), and is de- 
scribed in Vol. VIII., p. 199, § 67. 
§ 31. By Removal of the Occipital Region of the Cra- 
nium.-At the meeting of the American Neurological 
Association, June 22, 1883, as reported in its " Transac- 
tions," p. 84, as reprinted from the Journal of Nervous 
and Mental Disease, July, 1883, Dr. Spitzka described 
as follows a method which, he informs the writer, he 
has known to be employed by some German anatomists. 
The writer has not tested this method personally, but is 
disposed to regard it as better adapted to pathological 
than to anatomical purposes, and as such entitled to be 
considered in connection with the usual method, and 
with that described in Vol. V. of this work, pp. 789-791. 
" The scalp is divided in the median line, beginning 
a little in front of the coronal suture, and extending 
down the neck. If it is desired to remove the spinal 
cord the incision is extended to the lumbo sacral region. 
Two lateral flaps are formed in the head region, the soft 
parts being peeled from the dorsal aspect of the cervical 
vertebrae and the posterior half of the skull. A circular 
incision is made [with the saw] in the skull, behind the 
ears, and completely encircling it down to the foramen 
magnum, care being baken not to injure the connection 
between the articular processes of the atlas and the occipi- 
tal condyles ; the posterior half of the skull is removed 
exactly as the calvarium ordinarily is, by taps of a chisel ; 
sometimes a rongeur forceps suffices to complete the 
division near the foramen magnum. The adhesion about 
the lateral [and longitudinal] sinus and torcular Hero- 
♦ Contrary to the suggestion in Vol. VIII., p. 196. § 19, it is probable 
that the best result may be obtained by dividing the callosum first and 
the chiasma last; if the operation is performed in a long vessel of satu- 
rated brine, so that parts do not tear by their own weight, even the 
tender medicommissure may be cut before it yields. 
* See Dr. W. W. Gannett's article in Vol. V., pp. 789-790. 
116 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Brain. 
Brain. 
(SUPPLEMENT.) 
phili can be readily overcome by a home-made apparatus 
like the knife [spatula, or round-pointed knife, curved 
flatwise] shown by Professor Wilder. The advantages 
of this method are : 1, The spinal cord and brain can 
be demonstrated in continuo; 2, the critical operation 
of lifting the hemispheresand gouging out or injuring 
the cerebellum in dividing the tentorium is obviated ; 3, 
the nerves and arachnoidal laminae at the base may be 
divided without allowing the brain to drag by its own 
weight. These nerves are divided from behind, forward. 
As soon as the chiasm is divided, the skull is inclined a 
little, and the brain allowed to fall into the hands of the 
operator by its own weight, it being completely separated, 
except where the olfactory filaments pass through the 
ethmoid ; but these yield readily, and I have gotten the 
olfactory bulb intact as often by this as the other method. 
The removal accomplished, the occipital segment is riv- 
eted back, and a stick of wood inserted in the spinal 
canal and extending to the cranial interior restores the 
strength to the head support, impaired by the breaking 
up of part of the vertebral attachments." 
§ 32. The method of Fere (as briefly described in a 
paper " Procede de coupe du crane," Soc. Anat. de Paris 
Bulletin, it, 206-207, March, 1877) is by a circular in- 
cision very low down from the eyebrows ventrad of the 
auditory meatus to a point between the foramen magnum 
and the dorsal arch of the atlas. This, if successful, 
would uncover the brain very fully and permit its re- 
placement in the calva after extraction ; but it seems in- 
evitable that the petrous bones should give trouble as 
well as be themselves destroyed. 
§ 33. Hemoval in the Dura.-Space will not permit de- 
tailed directions for removing the brain in the dura ; 
suffice to say that with care and patience and anatomical 
knowledge it may be accomplished so that only a small 
part of the dura is absent from the central region of the 
base. For the safe handling of the brain and for alin- 
jection purposes even the dorsal half of the dura is 
worth saving. 
§ 34. Supporting the Brain for Injection.-If the dura 
has been retained, at three places upon each side, frontal, 
temporal, and cerebellar (or occipital if the metepen- 
cephal has been removed) pin to the dura pieces of 
broad, stout tape (or strips of cloth 2 to 3 ctm. wide) 10 to 
15 ctm. long ; in place of pins there may be used gar- 
ment clasps with serrated edges. 
§ 35. For temporary purposes, e.g., examination of the 
base, preparation for injection, and the single injection 
■of amass, etc., the brain, supported as directed in Vol. 
VIII., p. 195, §§ 10 and 11, may be steadied and raised or 
lowered as required, within any vessel of appropriate 
size ; if of wood, the strips of cloth may be secured by 
tacks (artists' ' ' thumb tacks " are most convenient) ; if 
of glass or metal then an elastic band (e.g., a rubber ring 
from a jar, or an elastic tape) may be stretched about the 
rim and the strips passed under it. 
§ 36. Weighing the Fresh Brain.-One method is de- 
scribed in Vol. VIII., p. 198, §50. There the brain is 
added to a pan of liquid already balanced upon the scales. 
After recording the weight required to balance the added 
brain, then-having first wet the hands with a liquid 
identical in composition with that in which the brain is 
immersed-remove the brain and record the loss of 
weight. Theoretically it should be the same as had to 
be added before ; practically there is usually some differ- 
ence, and the average of the two should be taken as rep- 
resenting the true weight. 
In employing the first method, some trouble will be 
avoided if, after the pan of liquid has been counter- 
poised upon the scales by an approximately equal weight, 
say 500 or 1,000 or 1,500 grammes, the exact balancing 
be accomplished by removing or adding liquid with a 
syringe. 
§ 37. Determining the Volume of a Brain.-This is done 
as with any other mass, in either of two ways. 
A. Into a vessel of accurately known capacity pour a 
given volume of liquid ; dip the hands in the same, and 
transfer to it the brain ; then, from a graduated vessel 
add enough more of the liquid to fill the first vessel. 
The difference between the total capacity of the vessel 
and the sum of the two volumes of liquid introduced rep- 
resents the volume of the brain. 
B. Set a vessel in a deep pan, dish, or pail. With any 
liquid (salt-solution, water, or alcohol and water) that is 
lighter than the brain, till the vessel just to the brim. 
Let the brain into it gradually ; the overflow' will repre- 
sent its volume. 
Obviously a combination of the two methods is most 
satisfactory. 
§ 38. Storage of Ilemicerebrums.-The human hemi- 
cerebrum is a somewhat bulky mass, and may occupy a 
six by eight inch Whitall & Tatum jar (Vol. VIII., Fig. 
4883) ; sometimes both halves of a cerebrum may be ac- 
commodated, although the undivided cerebrum or entire 
brain commonly requires a nine by eight inch jar. 
The most favorable method of storing several hemi- 
cerebrums is in jars nine inches in diameter and of any 
desired height; the specimens are set in tiers of three, 
their dorsal convexities against the sides of the jar ; 
successive tiers are so placed that a hemicerebrum rests 
upon the interval between two below. There will be a 
central vacancy which, if the jar is to be transported, 
may be filled w ith absorbent cotton ; the alcohol (ninety- 
five per cent.) should be introduced last. 
§ 39. Hemoval of the Pia.-The early removal of the 
pia* is recommended in Vol. VIII., p. 196, § 33. The 
writer has seen some otherwise valuable cerebrums ma- 
terially injured by faulty methods, and offers here a few 
suggestions. 
A. Begin with the central fissure, if it can be recog- 
nized, and at about the middle of its length. Apply the 
coarse forceps so that their approaching points move in 
the direction of the length of the fissure ; pinch up a fold 
of pia ; with the scissors snip at either side of the fold so 
as to raise it a little ; then carry the forceps, held in the 
same way, more deeply into the fissure, not more than one 
centimetre deep, and attempt to draw out the intra-fissural 
fold of pia. If successful, continue to pull lengthwise of the 
fissure, cutting the pia at either side w henever necessary. 
Most of the other fissures may be dealt with in the 
same way ; but some, notably the occipital and calcarine, 
are very deep, and arteries traverse them which must 
usually be cut more than once. 
The Sylvian fissure is not only deep, but spreads lat- 
erad over the insula, and there are several arteries. 
Rather than run the risk of tearing the adjoining gyres 
it is better to remove only so much pia as easily sepa- 
rates, leaving the rest and the arteries until one of the 
operculums can be cut off and afterward replaced. 
While removing the pia or studying the lateral fissures 
of young or foetal brains, breaking is avoided and divari- 
cation of the gyres facilitated if the hemicerebrum is 
placed on its meson on a piece of thick Manila paper 
(such as is used for the portfolios), which is sufficiently 
firm to support the organ and yet yields so as to permit 
the exposure of the fissural depths. When the mesal 
surface is studied the specimen should rest in a thick bed 
of cotton. 
§ 40. Prevention of Drying.-The strong alcohol in 
which brains are preserved (eighty per cent, and upward) 
evaporates rapidly while the brain is exposed, as in ex- 
amination or dissectidn ; it may be dipped in the alcohol 
occasionally, or-which is preferable with delicate speci- 
mens-the alcohol may be allowed to drip gently upon 
it from a pledget of absorbent cotton. When a specimen 
only partly submerged in alcohol has to be left for a 
short time, drying may be prevented by covering it with 
a thin layer of cotton, one end of which dips into the 
liquid. 
§ 41. Labelling Specimens.-Much of the real value of 
a specimen depends upon its identification as being a cer- 
tain part of a certain brain, taken from an individual of 
a certain age, sex, and nationality, and preserved in a 
certain way. Even if the possessor has so few specimens 
that he feels sure of remembering the entire history of 
♦ It is understood that this includes the arachnoid, which on most 
parts of the cerebrum adheres closely to the pia ; Vol. VIII., Fig. 4687. 
117 Brain. 
Brain. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
each, his death would abolish the source of information. 
Hence every specimen should be labelled in some way. 
In Vol. VIIL, p. 198, §§ 55, 56, the method was 
briefly indicated. Since that volume appeared the writer 
has observed surprisihg instances of carelessness in this 
regard, even upon the part of some who should set an ex- 
ample of scientific accuracy. 
Were the specimen never to be removed from the jar 
in which it alone is kept, the object could be accom- 
.plished by inserting the label in the jar or attaching it 
thereto; but this is rarely an adequate precaution, 
neither is it often possible to state all the desirable data 
upon a label attached to the specimen itself. The most 
satisfactory plan tried by the writer is the adoption of a 
serial number for each brain. This number corresponds 
to a list or catalogue (Vol. VIIL, p. 198, § 56), and is af- 
fixed to each brain and to every separated part thereof ; 
that is, the first brain obtained or prepared is numbered 1, 
and all its parts, when separated, bear the same number, 
with the addition of letters a, b, c, etc., when there is 
(which is very seldom) any chance of non-recognition of 
the nature of a fragment. These numbers may be writ- 
ten with lead pencil (not common ink), and last for some 
time if not handled ; but if written with India ink (or- 
dinary drawing ink, with an equal volume of water), on 
good paper or parchment, they are permanent. The 
label may be affixed by one or two small pins.* 
For purposes of dissection, photographing, or drawing 
it may sometimes be necessary to remove the label, but 
ordinarily it should be affixed to some other region, so 
that there may be no possibility of misplacement. 
§ 42. Distinctive Labels.-The ready recognition of 
brains belonging to groups may be provided for as fol- 
lows : 
A. The sexes are distinguished by using quadrangular 
labels for males and circular ones for females. 
B. Presumed normal white brains have white labels ; 
Africans (of all shades), gray; murderers and other 
criminals, red ; insane and idiots, blue. 
§ 43. Dissection of the Brain.-As commonly practised 
this contrasts strongly with the examination of the rest 
of the body. With the latter, dissection is universal, and 
sections are seldom made or even studied ;f but with the 
former, sections, macroscopic or microscopic, are the rule, 
and dissections, careful, prolonged, and thorough, are 
nearly unknown in medical schools. Like the prepon- 
derance of osteology over neurology, the difference is 
due to the "nature of things;'' but like many other 
natural conditions it may need modification. 
The advantages of sections for surgical, pathological, 
and regional study are obvious ; they are easily made, 
even with the fresh adult human brain, especially by 
means of the apparatus devised by Professor Dalton, t 
If the human brain were like that of the frog or opos- 
sum, with the several segments of approximately equal 
size, and nearly upon the same plane, the common 
method would be more appropriate for macroscopic 
study. But, in view of the extreme cranial flexure and 
the overlapping of certain segments by others, the objec- 
tions to sections are as follows : 
1. They present plane surfaces which do not naturally 
exist in the brain. 
2. They are almost invariably oblique with respect to 
the axis. 
3. They always include more than one encephalic seg- 
ment, and are therefore, so far as the beginner is con- 
cerned, apt to be more confusing than instructive. 
4. They present the parts in contiguity rather than 
continuity. § 
The foregoing objections apply to all sections. A 
macroscopic section, especially of a brain which has had 
the cavities alinjected, presents the advantage of exhibit- 
ing in perspective enough of the natural contours of parts 
to facilitate their recognition and comparison. 
Admitting, then, that sectionshave their uses, what is 
urged is, not that section-making be practised less, but 
dissection more. 
§ 44. Preliminary Dissection of Alcoholic Brains.-In 
the article in Volume VIII., § 34, this is recommended in 
a single line. The writer is yearly more convinced of its 
importance on three grounds : 
A. The brain is a complex organ and at the best per- 
plexing ; the simpler features of form, location, and 
relation to cavities are morphological, while color, like 
histological composition, has a physiological significance. 
B. The fresh brain is less easy to dissect neatly, and 
requires constant support against its own weight, whereas 
the alcoholic may be held in any position and carved like 
cheese. 
C. The beginner should advance cautiously, and there- 
fore slowly, and the medical student is especially liable 
to interruption. The fresh brain remains fresh but a 
very short time, while the alcoholic is in itself imperish- 
able. Leisure means not only more carefid dissection, 
but also the taking of notes and the making of drawings ; 
hence all the arguments which the writer has advanced 
("Anatomical Technology," pp. 55, 56), in favor of pre- 
liminary anatomical work upon a small animal, which 
may be kept in alcohol for an indefinite time at slight ex- 
pense, apply to all alcoholic brains in general, and to those 
of moderate size in particular. 
D. After repeated dissection of alcoholic preparations, 
the anatomist is better qualified to manipulate the fresh 
brain and to appreciate its beauty. The last word is used 
advisedly, for, however unattractive may be "subjects"' 
and pathological "cases," the most exacting artistic sense 
can hardly fail of satisfaction with the soft white and 
gray and pink of the newly extracted brain. Resting 
securely in its calva, for him who has been disciplined 
by prolonged experience with the "pickled" organ, 
there are few more attractive, stimulating, or nourishing 
articles of intellectual pabulum than a fresh brain " upon 
the half shell." 
§ 45. Dissection.-Whether fresh or hardened, the 
writer believes the first step should be to slice off the 
dorsal parts of the cerebrum to near the level of the callo- 
sum and the next the exposure of the paracoeles as de- 
scribed in connection with Fig. 61 ; compare Vol. V., p. 
790. 
The occipital lobes may then be cut off opposite the 
splenium and one or both medicornus followed to the tip 
of the temporal lobe. 
The next object should be to remove the overlapping 
parts of the cerebrum from the subjacent diencephal (and 
so much as may remain of the other segments) so as to 
obtain a view of the ventral aspect of the splenium and 
fornix. These may be transected a little caudad of the 
portas. 
There will then appear the velum, with the conarium. 
If the velum be lifted carefully there will be recognized 
the attachments along the dorso-mesal curvature of the 
thalami which are commonly ignored but insisted upon 
in Vol. VIII., Fig. 4751. 
A transection through the portas will give a view of 
their boundaries, of the cephalic aspect of the medicom- 
missure, and of the caudal surface of the fornix and the 
precommissure; most of the other features are more easily 
examined upon the mesal aspect of the medisected brain. 
Somewhat full directions for dissection are given by 
Edinger, in the first part of Leet. III. Complete direc- 
tions are desirable, accompanied by figures indicating 
the appearances presented at each stage, such as the writer 
has framed for the brains of the cat (" Anatomical Tech- 
nology") and sheep (" Physiology Practicums "). 
* The ordinary pins are apt to corrode, more or less, and discolor the 
brain, or tear it when removed. It is to be hoped that pins of alumin- 
ium may ere long be available. 
+ Notwithstanding the example and opportunity offered by works like 
Braune's " Atlas of Topographical Anatomy " and Dwight's " Frozen 
Sections of a Child " and " Anatomy of the Head." 
t Topographical Anatomy of the Brain. Philadelphia. 1885, vol. i., pp. 
4-10; abstracts in N. Y. Med. Record. February 15, 1879 ; July 31, 1880. 
§ Solly's vigorous reprobation refers particularly to horizontal slicing: 
"It is unfortunate indeed that candidates for the medical diploma are 
still very generally required to describe the appearances presented by the 
brain dissected, or rather destroyed, by the old method of slicing-a 
method most unphilosophical in its conception, and totally inadequate to 
impart any real information in regard to the structure of the brain." 
118 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Brain. 
Brain. 
(SUPPLEMENT.) 
§ 46. Methods of Representing the Brain*-The follow- 
ing considerations and suggestions f apply more or less 
directly to all natural history illustrations, but with 
especial force to the human brain, on account of its soft- 
ness when fresh, the difficulty of preserving it, the great 
size of the entire organ, the minuteness of certain por- 
tions, the large number of recognizable parts within a 
small area, the continuity of all, the contiguity of some 
which are otherwise associated but remotely, the inter- 
mixture of two differently colored substances, the com- 
plicated relations of the meninges to each other, to the 
vessels, and to the cavities, and the preponderance of 
curved and oblique contours over straight lines and 
planes. 
§ 47. Importance of Orientation.-With all organs, 
but especially with the brain, it is essential that the loca- 
tion of the region represented be easily recognized ; other- 
wise details may be unappreciated or even misappre- 
hended. So far as possible, therefore, less familiar parts 
should be accompanied by such as are unmistakable. It 
might seem that useless expense was incurred by the 
publishers of Bourgery and Jacob's magnificent plates 
in the introduction of faces artistically drawn and col- 
ored ; but even the expert neurologist is guided in the 
comprehension of the relative position of brain parts by 
reference to the apparently superfluous facial outlines. 
§ 48. Enlargement of Complex Regions.-It often hap- 
pens that the same section or dissection includes regions 
that are comparatively simple, and others that are very 
complex ; shown upon a single scale, either the com- 
plex parts are unintelligible, or the total is undesira- 
bly and needlessly large. Hence, just as the histologist 
aims first to obtain a general view of all the parts in their 
gross relations, and then focuses a higher power upon a 
selected region, so the representer of encephalic struct- 
ures should give first a view of the whole, if only an 
outline, and then an enlargement of complex parts to 
any extent required for their complete elucidation ; he 
can hardly make this enlargement excessive. Compare, 
e.g., Quain's figures, 258 and 290, and Figs. 4740 and 
4742 in Vol. Vtll. of this work. 
§ 49. Terminal and limiting parts, membranes, and ap- 
parently atelic (functionless) parts and conditions should 
be distinctly shown, or the insufficiency of their represen- 
tation admitted. " The little things of the brain " might 
well form the subject of an entire article. From the 
stand-points of physiology and medical practice such 
parts as the terma, valvula, crista, conarium, hypophy- 
sis, and habena, and such conditions as the reflection of 
the endyma upon the plexuses, and the dorsal limitation 
of the porta, are of comparatively slight importance ; but 
their morphological significance is, at least in some cases, 
inversely to their functional activity, and they cannot be 
ignored without endangering the success of any attempt 
to understand or explain the structure of the brain. 
Anatomical figures should be something more than pict- 
ures conveying a general and vague idea. Where is 
there an adequate representation of the relation of the di- 
atela to the habeme, and of the cephalic end of the latter ? 
From the published figures could any student be ex- 
pected to comprehend the locations and boundaries of 
the " foramina of Monro " or of " Magendie ? " The tenia 
is easily enough shown as a white band throughout most 
of its course, but where are its extremities accurately de- 
lineated ? Anyone can see the caudate prolongation of 
the striatum, but representations of its termination at the 
tip of the medicornu are as nye as are figures of the ex- 
tremity of the filum terminale. Even so considerable a 
part as the flocculus is' seldom figured in such a way as 
to display either its form or its attachment. 
The avoidance of the morphological incongruities and 
deficiencies which are to be detected in nearly every por- 
trayal of encephalic anatomy demands the admission of 
three propositions, which are mere truisms in them- 
selves, but radical affirmations when contrasted with 
their almost universal non-recognition in anatomical 
works : 
1. Every part, organ, membrane,* or surface is either 
limited or continuous with some other part. If limited, 
its limits must be defined ; if not, its extension must be 
indicated. 
2. Every cavity is either open or closed. If closed, the 
continuity of its parietes must be demonstrated ; if open, 
its communications must be shown. 
3. Every elongated part has a middle and two extrem- 
ities ; not only the former but the latter must be repre- 
sented. 
§ 50. Figures - original ones especially - should be ■ 
multiplied and descriptions reduced. In descriptive 
anatomy, whether human or comparative, the text 
should be subordinate to the illustrations. Some treatises 
(Charles Bell, Meckel, Milne-Edwards, etc.) seem to 
have been prepared upon the idea that the description is 
essential and the figures merely supplementary ; chi the 
contrary, words should be employed only when pictures 
will not suffice-that is, for explanation, commentary, 
generalization, hypothesis, and manipulative directions. 
The arguments for the multiplication of figures may 
be summarized as follows : 
1. A figure is usually a guarantee that something like 
the object represented has been seen, at least by the artist, 
and that a certain amount of time has been devoted to its 
contemplation. 
2. The information conveyed by a figure is more real, 
and likely to be more lasting than that which is expressed 
in words. In respect to reality and impressiveness, the 
sources of knowledge may be ranked as follows, in an 
ascending scale : (1) Description ; (2) picture ; (3) model; 
(4) object seen ; (5) object handled ; (6) object personally 
prepared. The picture is thus intermediate in value be- 
tween the thing itself and a description thereof. 
3. A figure, if clear and properly placed, is more read- 
ily understood than a description, and a saving of time 
is thus effected. It may be easier for the author to write 
than to draw, or even than to supervise a drawing, but 
his personal inconvenience or loss of time should not out- 
weigh the gain to his readers. This applies particularly 
to dictionaries, cyclopaedias, and journals, which are 
commonly read or consulted in haste. Editors and pub- 
lishers would find eventual profit in offering to authors 
the fullest encouragement to employ illustrations so far 
as possible, and curtail their descriptions in proportion. 
That it is rather the exception than the rule for such en- 
couragement to be offered is probably due to several 
causes : a, Publishing houses have usually a staff of print- 
ers who must be employed, whereas the various pro- 
cesses involved in the making of pictures are common- 
ly done outside at extra expense; b, authors too often 
content themselves with carelessly made copies of "stock 
figures'' instead of insisting upon original representations 
of objects prepared by themselves. Hence, on the one 
hand, the exceptionally liberal publisher is liable to get 
a poor return for any allowance made for drawings, and, 
on the other, the exceptionally painstaking author is apt 
to be told that, at best, the engraving will be done if he 
will furnish the drawings ; and, if he cannot draw him- 
self, their cost is likely to deter him from their introduc- 
tion.! In short, all the existing conditions work to the 
disadvantage of the reader, who gets but a " penny- 
worth of [pictorial] bread to a monstrous deal of [verbal] 
sack." 
Before this state of things can be amended the au- 
* Every student of any branch of Natural History should compel him- 
self to learn to draw, however slight may be his inherited artistic capac- 
ity ; not merely the laboratory students in Cornell University, but the 
members of the large general classes in Physiology and Zoology are 
required to make drawings of entire animals, and of the parts exposed 
in their dissections. 
t The treatment of this subject is based upon the writer's " Cartwright 
Lecture," III., as reported, with illustrations, in the N. Y. Medical Jour- 
nal, June 14 and August 2, 1884. 
* So essential is the exemplification of coelian circumscription and en- 
dymal continuity, that the endyma should be represented by a distinct 
and rather heavy line, continuous excepting at the metapore; see Vol. 
VIII., Fig. 4711. 
t The liberal provision of the publishers of the Reference Handbook 
for original illustrations of the writer's articles in Vol. VIII. has been ac- 
knowledged therein on p. 107 ; they have since manifested what might 
almost be called an unbusiness-like generosity in furnishing the writer 
with electrotypes of many of the cuts for the use of his students. 
119 Brain. 
Brain. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
thors of books and papers must see clearly the impor- 
tance of illustration ; to paraphrase a witty saying as to 
the making of an index, the drawings should be made or 
personally superintended by the author, even if some one 
else has to write the text. 
4. Figures usually occupy less space than descriptions 
conveying an equal amount of information. This means 
condensation, convenience, and economy in the present, 
and a due consideration for our successors in the not 
far distant future. Exact data are not accessible, but 
no thoughtful and public-spirited person (unless he be a 
publisher or printer) can contemplate without concern 
the logical results of the present rate of book-making 
activity. 
§ 51. Borrowed figures should be fully credited, and 
all modifications, whether of size or features, explicitly 
• stated. To copy is to compliment, but unacknowledged 
copying is theft, and unspecified change is misrepresen- 
tation. 
The ill-effects of omitting to state the source of a figure 
are two: 1, The originator loses credit to which he is 
justly entitled ; 2, the reader may be seriously misled 
by the apparent duplication of some really unique feature 
or the confirmation of an error. For example, in the 
representations of the meson of the cat's brain by Leuret 
(Leuret et Gratiolet, Pl. V., Fig. 2), the pseudocode 
(" fifth ventricle") is made even more extensive than in 
man, reaching almost to the splenium. The figure is 
reproduced, without credit or correction, in Mivart's 
"The Cat" (Fig. 129). Whoever remarks the coinci- 
dence in respect to the pseudocode, but fails to note that 
one figure is simply a copy of the other, may naturally 
infer that the feature in question is normal, or at least 
not anomalous. 
On the other hand, if informed that three of Mivart's 
figures (125, 126,- 129) were copied from Leuret, the 
student might conclude that the representation of the 
base of the brain (Fig. 128) was derived from the same 
source ; this would be most injurious to the reputation of 
Leuret, for the figure in question displays several feat- 
ures (the size and direction of the hypophysis, the dis- 
connected fissure on the temporal lobe, the relations of 
the pons to the trigeminus and abducens nerves) which it 
is safe to say never were observed in a feline brain. 
Nor is it enough to give the sources of figures in a list, 
or in the preface, as in Huxley's " Vertebrated Ani- 
mals ; " so great is the labor of preparing an original fig- 
ure that the acknowledgement of it should be equally as 
explicit as that of a verbal quotation. 
Finally, in the case of modified figures, it needs but a 
moment's reflection to see that nothing short of an accu- 
rate statement of the nature and extent of the alteration 
can insure full justice to the originator. 
§ 52. Drawings should be made as notes. In many 
cases an outline * drawing, even if hastily made, would 
convey to the maker, or any one else, at a future time 
more prompt and complete information than could be 
embodied in writing covering the same space. But the 
general employment of sketches, in addition to words, or 
in place of them, can hardly be looked for until children 
are taught to draw the intelligible objects about them 
before they are drilled in the making of the-to them- 
unmeaning pot-hooks of the alphabet. 
§ 53. Figures should be more frequently employed in 
preliminary or incomplete publication. Probably one of 
the reasons for the comparative infrequency of pictorial 
representations of normal, abnormal, and pathological 
structures, especially in journals, is the difficulty, often 
the impossibility, of preparing a detailed figure in time 
for publication. But this need not prevent the early ap- 
pearance of a figure, if only in outline, illustrating one 
or more points of greatest importance. 
§ 54. Figures should be based upon photographs. 
Photography enables the anatomist to (a) record the ap- 
pearances of perishable specimens, or of such as are in 
course of dissection ; (b) insure the proper perspective; 
(c) save time and labor upon the part of the draughtsman, 
and thus either reduce the cost of the drawings or render 
a larger number attainable. 
It is seldom that a single anatomical preparation is so 
perfect as to display all that is needed, and yet present no 
superfluous parts; often, too, certain points are to be 
brought out with "diagrammatic clearness," others be- 
ing subordinated or omitted altogether. Hence, as a 
rule, the photograph forms rather the basis for the com- 
pleted figure, and two or more similar preparations may 
be required for the elucidation of all the desired feat- 
ures. * 
§ 55. Figures should be placed so as to be most 
readily understood and instructively compared. In 
comparing pictures of two or more houses, ships, 
or stoves, the architect, shipbuilder, or dealer places 
them in such positions with regard to one another and 
his own eyes as may minimize the effort at mental trans- 
position. If asked the principle on which he acts, he 
will probably say that no principle is needed, that he 
simply follows nature, experience, and common sense. 
With few exceptions it seems to be reserved for those 
whose business is the contemplation of natural objects, 
who are credited with more than the average degree of 
intelligence, and who have at command the recorded ex- 
perience of centuries, to disregard a matter whose sim- 
plicity is equalled only by its importance. In most works 
there is an utter absence of system. Seldom, indeed, 
are symmetrical figures placed otherwise than with the 
meson coinciding with that of the observer, but even 
this would be less likely to confuse than the apposition 
of transections of a subeylindrieal mass like the myel 
with the dorsum above in one case and below in another.f 
The prevalent carelessness in this regard may be as- 
cribed to three sources: a, The still too common idea 
that illustrations are of secondary importance ; b, the 
fact that most figures have been copied and thus placed 
without regularity, as in the original ; c, some time and 
trouble are required to reverse them. 
§ 56. General Rules for the Placing of Figures.- 
These rules are based upon a consideration of the whole 
subject ; there is probably no one of them to which 
exceptions may not exist ; but such exceptions should 
always have a well-defined reason and not occur through 
inadvertence. 
1. Figures should he coadjusted so as to facilitate 
comparison with each other and with typical structures 
in normal positions. 
2. The dorsal side should bb above. 
3. Direct views are to be preferred to oblique, though 
the latter are at times indispensable ; e.g., Vol. VIII., 
Figs. 4740, 4776. 
4. Symmetrical figures, or parts thereof, should be so 
placed that the meson is vertical, e.g,. Figs. 4688, 4689, 
4698, 4770, 4772. 
5. When there is no choice between the right and 
left sides, the latter should be represented; e.g., Figs. 
4767, 4713. 
6. Of medisected organs, unless there is special rea- 
son for choice, the mesal aspect of the right half is to be 
shoWn ; e.g., Figs. 4684, 47114 
* A chief obstacle to the employment of photographs as a basis for fig- 
ures of brains and embryos has been the difficulty of supporting such 
delicate objects within range of the camera in its usual horizontal, or 
nearly horizontal, position. This obstacle is wholly removed by the pho- 
tographic table devised by Professor Gage and used in the Anatomical 
Laboratory of Cornell University since 1878. With this the camera may 
be readily adjusted to any angle, and brought into a vertical position so 
as to cover an object lying upon cotton, or in alcohol, or even alive in 
water. The apparatus is described and figured in Science. April 11. 1884. 
+ The common disregard of uniformity in this respect was made the 
subject of a communication by a medical professor to the Association 
of American Anatomists at its meeting in December. 1892. 
J if the fuller discussion of this subject in the New York Medical 
Journal. August 2, 1884. be consulted, the following corrections should 
be made : 
Explanation of Fig. 57, last line, transpose antimesal and symmesal. 
Fig. 59. for antimesal read symmesal. 
Fig. 64, for symmesal read antimesal. 
* There is a general and almost unconquerable predilection for shaded 
drawings. However advantageous shading mav be in ordinary art as an 
element of finished pictures, and when merely a general effect is desired, 
in anatomical figures correct outlines are essential, and shading should 
be deferred until the last; otherwise it is too apt to " cover a multitude " 
of inaccuracies. 
120 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Brain. 
Brain. 
§ 57. Designation of Parts upon Figures.-The full 
technical names of parts should be given if possible.* 
From the purely artistic point of view, of course, any 
■extraneous line upon a picture is a disfigurement. But if 
it be once admitted that the primary object of an ana- 
tomical drawing is to convey accurate information, then, 
unless the shaded figure can be duplicated in an outline 
(as in Tiedemann, Vicq d'Azyr and Dalton), there should 
be no sacrifice of the essential to the accessory. 
It may be a question whether the names should be 
upon the parts (as in Gray) or at the sides of the figure, 
and connected with the parts by lines (Gegenbaur). 
Upon the whole the latter method seems preferable, 
especially if the technical names are used. 
§ 58. Abbreviations should represent technical terms ; 
they should be uniform throughout the work, and be 
placed at the sides of the figure. 
Four methods of designating parts by abbreviations 
have been employed: 1, By numbers and unsignificant 
and ununiform letters, which may or may not be ex- 
plained in the text (Owen) ; 2, by unsignificant characters, 
uniform only in part, and explained at a distance from 
the figure (Reichert) ; 3, by uniform and significant, but 
partly vernacular, abbreviations (Parker): 4, by uniform 
technical abbreviations (" Anatomical Technology"). 
The advantages of uniformity in the use of abbrevia- 
tions are obvious, but it is by no means easy to avoid the 
charge of ambiguity. Where uniformity is not attempt- 
ed, care should at least be taken to avoid the use of the 
same abbreviation for the names of parts which are liable 
to be taken for one another. For example, in Schwalbe's 
two representations of the lateral aspect of the crura and 
adjacent parts (Figs. 280, 281) not only are opposite sides 
shown for no good reason, with some differences of 
•detail which are puzzling rather than instructive, not 
only is the pons designated in one by p and in the other 
by po, and the tractus opticus by to in one and tr.o in 
the other, but the letters tp stand for the taenia pontis in 
Fig. 280, and in Fig. 281 for the tractus peduncularis 
transversus [cimbia]. Since these parts are similar in 
general appearance and direction, and only one appears 
in each figure, it is doubtful whether any but the most 
expert anatomist, thoroughly familar with this somewhat 
obscure region, could escape at least a temporary mis- 
apprehension. 
§ 59. Abbreviations should be explained in alphabetical 
order. The ''practical " business man would exclaim, 
" Of course, how else should they be ?" An " unscien- 
tific" child would adopt the alphabetical order with 
letters as he would the order of notation with numbers. 
But the super-scientific writer, especially if he be a Ger- 
man, scruples not to save a few moments of his own 
time at the expense of others, by giving the verbal equiv- 
alents of ten (Huxley, Fig. 19), fifteen (Balfour, ii., Fig. 
271), twenty (Quain, Fig. 263), twenty-five (Schwalbe, 
Fig. 279), or even forty (Meynert [Stricker], Fig. 253) 
■abbreviations, either in no recognizable order at all, or as 
they occur upon the figure.} The time wasted by each 
■consulter of the figure (not to mention the effect of just 
indignation) would nearly equal what it would have cost 
the author to place the abbreviations in alphabetical 
sequence. Burt G. Wilder. 
BRAIN, TUMORS OF THE. The article on tumors 
of the brain published in Vol. I. of the Reference 
Handbook was completed on the very eve of an impor- 
tant epoch. It was in 1884, and this same year an Eng- 
lish surgeon, Mr. Godlee, performed the daring feat of 
opening the cranial cavity of a man affected with a tu- 
mor of the brain, and removing the neoplasm. The 
patient died at the end of a month ; nevertheless he sur- 
vived the immediate effects of the operation, and was 
also relieved of the headache, vomiting, and epileptic 
(SUPPLEMENT.) 
convulsions which had been the most distressing symp- 
toms of his disease (see Case 1 of table). 
Between this date, November 25,1884, and the present 
writing, January, 1893, the operation of trephining for 
brain tumor has been performed eighty-five times. 
These cases have been arranged in chronological order 
in the table commencing on next page : * 
The intellectual, philosophic, and even romantic inter- 
est attaching to the operations for brain tumors much 
exceeds their actual practical importance. The attempt 
has been made to estimate this from analysis, not only of 
the operations which have been performed, but also of 
the fatal cases of brain tumors on record, not operated, 
but submitted to post-mortem examination. The latter 
has shown that a very large proportion -would have been 
inoperable, either because a local diagnosis could not have 
been made, or because the locality, though diagnosed, 
was inaccessible ; or because the tumors were multiple 
or malignant; or, finally, because they were too large for 
extirpation. The last objection can often be met by the 
observation that an early operation might have proved 
successful, though by delay the tumor had grown be- 
yond the bounds of surgical possibilities. This observa- 
tion, however, holds good for tumors in any part of the 
body. 
Tubercular tumors-the most common variety by far 
in childhood-are frequently multiple, either at the time 
of operation or by recurrence shortly after ; and are 
then, of course, unfavorable for operation. For ex- 
tremely malignant tumors (carcinoma) the prognosis is 
naturally as hopeless when the growth is situated in the 
brain as when it exists in other organs. On the other 
hand, sarcomata, when primary, have not unfrequently 
been removed with success, f 
A table quoted by Keen, in the article on " Brain Sur- 
gery," in this Handbook, shows the relative proportion 
of different varieties of brain tumors in a total of five 
hundred and eighty cases collected by Hale White and 
Bernhardt. Nearly a quarter of all (twenty-three per 
cent.) were tubercular, only four per cent, were carci- 
nomatous. In twenty-two per cent of the cases cited the 
nature of the tumor is not stated. 
Hale White estimates that only nine of his one hun- 
dred cases could be considered as operable. No tumor, 
even the most benign, could be considered operable 
which is situated at the base of the brain, or in the cere- 
bral axis (Starr), which is widely infiltrated, or which, 
as already noted, is multiple. Out of three hundred 
brain tumors in children collected by Starr, one-third 
were in the cerebral axis. Tumors of the cerebellum 
are fairly accessible, but operations upon them have 
proved very much more dangerous than operations upon 
the cerebrum. The space for operation is much nar- 
rower ; precise localizing symptoms are much less dis- 
tinct, and frequently fail altogether. On the other hand, 
the general symptoms are especially severe, owing to the 
excessive intracranial pressure ; and this same condition 
endangers the operation by causing the brain to bulge 
through the opening. The close proximity of the affect- 
ed part to the most vital organs of the cerebro-spinal axis 
renders shock imminent. The tumor is very frequently 
tubercular, and finally optic neuritis has nearly always 
reached an advanced stage before the operation is under- 
taken, so that when, by exception, the patient has sur- 
vived the operation, he has remained blind.$ 
* Seventy-two cases were tabulated by Knapp more briefly in his mon- 
ograph on intracranial tumors in 1890. The table given in the text 
necessarily includes Knapp's cases, but has been compiled from the 
original sources, and contains more details than are given by Knapp. 
Horsley mentioned two more cases, at the International Medical Con- 
gress, of which he gives no details. Keen has two more cases, as yet un- 
published. 
+ In the case reported by Weir and Amidon the cerebral symptoms 
occurred after the patient had already been operated upon for sarcoma 
of the neck (Annals of Surgery, June, 1887). 
t The symptom of choked disk, when present, has long been consid- 
ered more nearly pathognomonic than any other of cerebral tumor. 
Seguin has, however, recently declared that many cases of enormous 
tumors do not present choked disk, and, on the other hand, this ocular 
lesion occurs in persons who have no intracranial disease. "Indeed, in 
my experience as regards tumors of the hemispheres, the rule is that the 
optic nerves are normal" (Bost. M. & S. Journal/February 5, 1891). 
* This need not preclude using, in place of Latin terms, the paronyms 
appropriate to the language in which the paper is written ; e.g., for 
hippocampus, hippocamp (Eng.), Hippokamp (Ger.), hippocampe (Fr.), 
or hippocampo (Itai.). See Vol. VIII., pp. 530-531. 
+ Almost equally objectionable is the omission of the original pagina- 
tion in reprints from periodicals. 
121 Brain. 
Brain. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
No.of case. 
Operator, 
date, 
reference. 
1 
Time be- 
tween 
trauma 
and first 
symptoms 
or dura- 
tion. 
General symptoms. 
Localizing symptoms. 
Diagnosis. 
Operation. 
Situation and nat- 
ure of tumor. 
First result. 
Final result. 
Sex and 
age. 
Trauma 
or not. 
1. 
Bennett and 
Godlee (Ltncet, 
Dec. 20, 1884). 
Macewen (Lan- 
cet, May 16,1885). 
Sci am an n a 
(Hull. d. R. Ac- 
cad. Med. di 
Roma, xi., 1885 ; 
Quoted by 
Knapp, " I n - 
tra-cranial 
Growths "). 
Hirschfelder 
and Morse (Pa- 
cific Med. a n d 
Surg. Journal, 
April, 1886). 
Man, 25 
years. 
Male, 35 
years. 
Male, 46 
years. 
Man, 71 
years. 
Blow on head. 
One year. 
Violent headache, dif- 
fused, for some months; 
severe monthly convul- 
sions eighteen months 
after blow, ceased eigh- 
teen months before oi>- 
eration ; double optic 
neuritis (v i s io n nor- 
mal) ; vomiting. 
Paroxysmal twitching 
left side face and tongue, 
first symptom ; aura on 
left side precedes general 
convulsion, this for two 
and one-half years ; pro- 
gressive paresis left arm, 
then twitchings left leg, 
then slight paresis left 
side face ; paresis arm 
most marked at shoulder. 
Left hemiparesis; right 
facial paralysis. 
Left hemiplegia ; later. 
Tumor upper third 
fissure Rolando. 
November 25,1884. 
At first no tumor 
found ; incision inch 
long into anterior 
central convolution. 
Trephined over 
Glioma, size of wal- 
nut, middle upper 
third right ascending 
convolution. 
Tubercular mem- 
Temporary recov- 
ery ; diminished 
headache, vomiting, 
convulsions ; paresis 
increased. 
Development her- 
nia cerebri ; then 
septic meningitis; 
death in one month. 
Recovery. 
2. 
Injury to 
head in right 
frontal parie- 
tal region. 
Headache, vomiting, 
fainting, convulsions : 
slow pulse, somnolence. 
Dull, heavy pain, es 
pecially over occipital 
protuberance, vertigo ; 
increased tendon re- 
flexes ; optic neuritis 
both eyes, most on left, 
failure of vision in last 
three months; occasion- 
al convulsions, vomit- 
ing, hiccup ; totters on 
standing with closed 
right ascending fron- 
tal : mass removed. 
Trephined over scat 
of injury ; nothing 
found. 
February 15, 1886. 
Tumor excised,24 c.c. 
branous mass. 
Glioma right cen- 
Death in two days. 
3. 
4. 
right oculomotor and 
facial paralysis. 
Jerkings left face, arm; 
then paresis left arm ; 
drooping left side fore- 
head, corner mouth; left 
leg stiff and lame ; slight 
anaesthesia left trigem- 
inus. 
Tumor middle por- 
trum ovale, from 
right inferior cornu 
to corpora quadri- 
gemina. 
Soft infiltrating gli- 
oma middle portion 
right post, centralis 
gyrus. 
Death on eigh- 
teenth day of septic 
encephalitis. 
tion right post, cen- 
tralis gyrus ; pressure 
on parietal lobe (in- 
ferred from ancesthe- 
sia); posterior convol. 
also diagnosed, be- 
cause face, arm, and 
leg all involved. 
Fraser (Lan- 
cet, February 27, 
1884). 
Durante (Lan- 
cet, Oct. 1,1887). 
Graeme Ham- 
mond (Medical 
Retos, April 23, 
1887). 
Weir ("Annals 
of Surgery," St. 
Louis. 1887, with 
Amidon). 
Man, 44 
years. 
I n j u 
head. 
None. 
ry to 
Headache, vertigo, 
vomiting, stupidity. 
Impaired memory; 
severe vomiting; move- 
ments uncertain : me 
lancholia, taciturnity. 
D6but in sudden loss 
consciousness. At time 
of operation, double 
choked disk ; exagger- 
ated reflexes; four or 
five epileptic attacks; 
agonizing headache,an- 
terior, on left side. 
Precipitate micturi- 
tion and defecation ; 
frontal headache: slight 
optic neuritis, left side. 
Right hemiplegia, with 
contracture ; indistinct 
speech, amnesic aphasia, 
agraphia. 
Anosmia one year: left 
eye displaced downward. 
Convulsions limited to 
left side; paralysis left 
face; gradual paresis, 
then paralysis left arm ; 
gradual paresis left leg. 
Cramps left leg, paresis 
left knee ; cramps and 
numbness lefthand ; nar- 
rowing left palpebral fis- 
sure ; paralysis left upper 
arm ; left patellar reflex 
exaggerated. 
Tumor of left as- 
Trephined ; noth- 
ing found. 
May, 1884. Dura 
Glioma left tern- 
Death. 
6. 
7. 
8. 
cendir.g frontal con- 
volution. 
T u m o r anterior 
poral lobe, involving 
ascending convolu- 
tions ; second (?) tu- 
mor in middle right 
ascending parietal. 
Fibrosarcoma oc- 
Stitches removed 
Patient recovered 
35 years. 
Illness, 
two and 
o n e ha 1 f 
years. 
Two 
months 
d oration 
symptoms. 
lobe; paralysis olfac- 
tory nerve. 
Tumor cortical or 
here perforated by 
tumor; drainage tube 
through opening 
made into ethmoid; 
enucleated. 
Operation ; tumor 
not found. 
Trephining; notu 
mor found. 
cupied anterior fossa 
cranium ; weighed 70 
grins. 
Three cysts in a 
seventh day ; drain- 
age -tube fifteenth 
day. 
promptly ; still well 
four years after oper- 
ation. 
Death in twenty- 
29 years. 
Woman, 
26 years. 
Four pre.i- 
ous operations 
for sarcoma, 
neck. 
subcortical at motor 
centres. 
Tumor upper ex- 
tremity Rolandic fis- 
sure, one inch from 
median line. 
line in motor region 
of anterior central 
convolution, right 
side. 
Sarcomatous tu- 
mor from lower sur- 
face left lobe cere- 
bellum compressing 
medulla ; originated 
in pia, extended 
into spinal canal 10 
ctm.; not continuous 
with cerebellum, 
Disappearance of 
headacheand spasms; 
temporary recovery. 
Hernia cerebri which 
increased to size of 
hen's egg. 
one hours. 
Death in ten weeks. 
122 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Brain. 
Brain. 
9. 
Horsley (Am. 
Male, 20 
None. 
None described, ex- 
Cramps left thumb and 
Tumor at thumb 
Tumor removed 
Tubercular nodule 
Second 
day, pare- 
Comjilete recovery 
10. 
Journal Med. 
Sciences, April, 
1887). 
Horsley (Brit. 
Md. Jour., April 
23, 1887). 
Ibid. 
years. 
Male, 38 
years. 
Male, 37 
None. 
cept frequent head- 
ache. 
Epileptic convul- 
sions ; semi-comatose 
for ten days before op- 
eration. 
Constant headache. 
forefinger; clonic oppo- 
sition twice daily for 
three months; then epi- 
leptic fits, always begin- 
ning with same clonic 
spasms ; conjugate devi- 
ation head andeyesto left; 
left lower limb drawn up ; 
paralysis left leg after a 
fit ; reflexes exaggerated 
in left arm. 
Convulsions began in 
left shoulder, followed by 
left hemiplegia. 
Gradually increasing 
centre; i.e., junction 
lower and middle 
thirds ascending pa- 
rietal convolution. 
Tumor involving 
upper part of middle 
third of Rolandic re- 
gion. 
Tumor in leftmotor 
with excision of sur- 
rounding tissue, June 
21, 1886. 
at junction lower and 
middle thirds ascend- 
ing parietal convolu- 
tion. 
Infiltrating glioma, 
oz.. from shoulder 
centre as diagnosed. 
Tumor, 4 J oz.: sit- 
sis left buccal branch 
facial; paralysis left 
arm; fifth day, left 
hemianae s t h e s i a 
without analgesia; 
complete loss muscu- 
lar sense ; persistent 
exaggeration deep re- 
flexes. 
from epilepsy and 
paralysis. 
11. 
None. 
Removed Decem- 
sciousness; mental 
state, normal for 
three and one half 
months; diminution 
paralysis ; patient 
walking in two and 
one-half months; no 
fits. 
in three months. 
Death in six months. 
No more headaches 
12. 
Ibid. 
years. 
Male, 18 
None. 
Headache, vomiting; 
optic neuritis; increas- 
ing weakness all limbs; 
epileptoid attacks; one 
year in bed. 
Frontal headache ; 
right hemiplegia; fits be- 
ginning in right forefin- 
ger ; slight defect of 
speech ; no fits for three 
months before operation. 
Left arm and leg espe- 
cially weak ; in fit conju- 
gate deviation head and 
eyes to right. 
Gait reeling backward 
and to left. 
For nine months right 
hemiparesis; paresis both 
external recti; dilated 
left pupil; intentional 
tremor right arm ; stag- 
gering, tendency to fall 
forward ; mouth to left; 
left conjunctival reflex 
lost; paralysis left eyelid; 
diminished faradaic con- 
tractility for all left side 
face. 
Unsteadiness gait; 
numbness right leg, hand, 
and shoulder ; left lateral 
hemianopsia. 
Depression over left 
parietal. 
Pain and spasms in 
right great toe. Paresis 
right leg. 
Paresis right arm; 
spasm tongue, face pla- 
tysma. 
cortex, involving 
hand centre, pressing 
on Broca's convolu- 
tion. 
Tumor in right 
lobe of cerebellum. 
Cerebellar tumor. 
ber 7, 1886. 
Removed Decem- 
uated as diagnosed. 
Tubercular tumor ; 
7 drachms, as diag- 
nosed. 
Tubercle size of 
Died in nineteen 
or convulsions; hemi- 
plegia not cured, but 
progressed no fur- 
ther. 
13 
Bennett 'May 
(Lancet, April 
16, 1887). 
Suckling (Lan- 
cet, October 1, 
1887). 
Birdsall and 
years. 
Male, 7 
ber 17,1886. 
Removal tumor. 
hours from shock ; 
chronic general tu- 
berculosis of viscera. 
Shock. 
Death. 
14. 
years. 
Girl, 12 
vomiting; amblyopia ; 
optic neuritis; nystag- 
mus ; abolition knee- 
jerks. 
Headache, vomiting; 
dimness vision two 
years ; diplopia for two 
weeks ; vertigo; double 
optic neuritis; nystag- 
mus ; diminished knee- 
jerks. 
Since 1885 vomiting; 
moderate headache; 
drowsiness; beginning 
neuro-retinitis; diplo- 
pia, transitory. 
Convulsions; dull 
Tumor left lobe 
Curved incision. 
pigeon's egg. 
At post-mortem 
tumor found occupy- 
ing all left lobe and 
much of middle lobe. 
Sarcoma occupied 
Shock. 
Death in forty - 
eight hours. 
15. 
years. 
Male, 42 
None. 
cerebellum, growing 
down, compressing 
left facial and both 
sixth pair nerves. 
Tumor on mesial 
convexity down- 
ward to base of left 
mastoid process; two 
trephine openings on 
line from occipital 
protuberance to tip 
of mastoid ; cerebel- 
lum bulged ; tumor 
inaccessible. 
March 9, 1887. 
Death 
from hem- 
16. 
Weir ( Phil. Med. 
News, 1887). 
Markoe (Phil. 
Med. News, No- 
vember 5, 1887). 
Mace wen (Lan- 
cet, August 11, 
1888). 
Ibid. 
years. 
Man, 25 
years. 
Girl, 7 
Injury to 
head. 
No record. 
aspect right occipi- 
tal lobe, involving 
primarily the cuneus, 
and perhaps para- 
central lobule ; loco- 
motion impaired 
from pressure on ten- 
torium. 
Trephining one inch 
above occipital pro- 
tuberance, one inch 
from median line; 
tumor too large for 
removal ; incised, 
softened contents re- 
moved. 
Operation over de- 
pression ; cyst re- 
mo v e d containing 
brain substance. 
Removal tumor. 
tip of right occipital 
lobe. 
Cyst hemorrhagic. 
Tubercle size of 
orrhage 
hours. 
in a few 
Recovery. 
Recovery. 
Recovery. 
17. 
headache. 
Convulsions. 
18. 
years. 
Male, 22 
years. 
Injury to 
head. 
Removal. 
hazel-nut from top 
of left ascending pa- 
rietal ; tubercles in 
meninges. 
Cyst size of filbert 
removed from base 
of left ascending 
frontal. 
(SUPPLEMENT). 
123 Brain. 
Brain. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
No. of case. | 
Operator, 
date, 
reference. 
Sex and 
age. 
Trauma 
or not. 
Time be- 
tween 
trauma 
and first 
symptoms 
or dura- 
tion. 
Genera) symptoms 
Localizing symptoms. 
Diagnosis. 
Operation. 
Situation and nat- 
ure of tumor. 
First result. 
Final result. 
1!). 
Mace wen (Lan- 
cet, August 11, 
1888). 
Syphilis. 
Left hemiplegia. 
Trephined over 
right parietal region; 
removed degenerated 
gumma. 
Trephined over 
Yellow mass over 
Recovery. 
20. 
25 years. 
Male, 29 
years. 
Right hemiplegia; 
upper part right as- 
cend ing convolu- 
tions. 
Large hyperosto- 
sis. 
Recovery: still 
pionniere (Jour- 
nal de Med. et de 
Chir., lix., 1888). 
aphasia. 
left ascending fron- 
tal convolution ; re- 
moved tumor. 
partly paralyzed. 
21. 
Rannie (Brit. 
Med. Journal, 
May 19, 1888). 
Von Bergmann 
(" Surgical Dis- 
eases of Brain," 
Woo d's Mono- 
graphs). 
Seguin a n d 
Black 
woman, 35 
years. 
Man, 25 
years. 
Male, 39 
Syphilis, ter- 
tiary. 
Intense headache, 
Pain and tenderness 
Operation June 9, 
1888. over right as- 
cending frontal con- 
volution : growth re- 
moved with piece of 
dura and brain tis- 
sue. 
Chiselled piece of 
skull 7x74 ctm.; cyst 
evacuated, communi- 
cating with lateral 
ventricle. 
Trephined, re- 
Degenerating 
gumma. 
Paresis remained. 
Recovery. 
Death in four 
22. 
23. 
eighteen months ; buz- 
zing in ears,' visual 
hallucinations : gloomy 
dreams ; alternated ex- 
altation and depres- 
sion ; convulsions. 
June 1, 1887. 
Epileptic attacks; 
headache ; debut with 
sudden apoplexy. 
Memory impaired for 
right frontal and parie- 
tal region ; in fit left an- 
gle mouth retracted ; 
conjugate deviation to 
left side ; left upper ex- 
tremity adducted : fore- 
arm flexed, wrist and 
fingers flexed ; left leg 
extended stiffly, clonic 
convulsions left arm and 
face, then left hemipa- 
resis face and limbs. 
Right hemiplegia and 
contraction motor apha- 
sia ; loss of muscle sense. 
Five years before oper- 
Tumor in Rolandic 
but steadily dimin- 
ished ; headache and 
fits ceased. 
None. 
region. 
Tumor, probably 
subcortical, in left 
hemisphere, involv- 
ing centre for face 
and partly for arm. 
Tumor pressing on 
anterior lobe, left 
hemisphere, involv- 
ing third frontal con- 
volution ; fibroma. 
Operation Decern- 
ber!5,1887. Incision 
through tender scar; 
enucleated tumor 
from fossa behind 
squamous bone. 
Sarcoma size of 
Temporary com- 
weeks from meningi- 
tis. 
Six months after 
24. 
Weir (Am. Jour. 
Med. Sciences, 
1888). 
Keen (" Trans. 
Am.Surg.Ass'n," 
vol. vi., 1888). 
years. 
Male, 26 
years. 
Injury to 
head when 
three years old. 
Twenty 
years. 
two years ; no optic 
neuritis; mental ac- 
tion slow but accurate ; 
headache only recent- 
ly. 
General neuralgic 
pains, 1884 : violent 
epilepsy twice weekly, 
1885 : severe pain in 
head ; pulse 60°. irreg- 
ular; anorexia; insom- 
nia ; two years before 
operation temporary 
blindness, first in right 
eye, then left; moder- 
ate headache; optic 
neuritis. 
ation spasm drawing 
right cheek and neck : 
epileptic attack three 
years later, preceded by 
twitching right forearm, 
hand: eight months be- 
fore operation paresis 
right arm : speech thick 
and slow : paresis lower 
facial; slight anaesthesia 
right cheek; numbness 
over right arm. 
Painful scar on left 
side head; paralysis 
right arm, then right leg, 
then right face ; right 
pupil dilated, insensitive; 
vision right eye imper- 
fect ; marked aphasia ; 
in fit. right hand closes 
tightly, first finger, then 
thumb; right deviates 
upward and outward; 
paresis right internus 
right eye, and of left in- 
ferior and superior recti; 
paresis inferior fibres or- 
bicularis on both sides ; 
vision right eye much re- 
duced : left, homonymous 
hemianopsia ; clonic con- 
vulsions, chiefly in right 
limbs; slight paresis right 
hand. 
moved tumor. 
Fibroma presented 
at opening; extend- 
ed from base third 
frontal convolution 
backward 2| inches 
to fissure Rolando, 
upward into external 
part, first frontal in- 
ternally to corpus 
striatum ; weighed 3 
oz.; measured 74 in. 
in circumference. 
large almond within 
white substance, one 
inch below posterior 
edge second frontal 
and anterior edge 
precentral gyri; i.e., 
in fasciculus for face. 
First week, increased 
aphasia ; large clot 
f onn d in wound ; 
then disintegrated ; 
then aphasia dimin- 
ished. Second week, 
temperature. 104° F.; 
hernia; diarrhoea; 
abundant discharge 
cerebro-spinal fluid ; 
temperature normal 
by third week. 
p 1 e t e hemiplegia ; 
nearly complete 
aphasia; eight 
weeks after operation 
epileptic attack be- 
gun with twitching 
right side face ; 
aphasia diminished 
then increased again. 
operation in perfect 
health : slight hemi- 
paresis right side ; 
walk normal, knee- 
jerks normal both 
sides; sensibility 
normal : aphasia al- 
most gone. 
Recovery eighty- 
fourth day ; mind 
clearer; paralysis 
gone ; one epileptic 
attack in five weeks. 
(SUPPLEMENT.) 
124 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Brain. 
Brain. 
25. 
26. 
27. 
28. 
29. 
30. 
Wille (Allgem. 
Wiener M cl. Zei- 
lung. December 
18, 1888). 
Fitzgerald 
("Sajous's An- 
nuare," Vol. 11., 
1888, p. 36). 
Heath and 
lloss (Lancet, 
April 7, 1888). 
Mace wen (Br. 
Med. Journal, 
August 11, 1888). 
Pean (G nette 
den Hopitaux, 
February 21, 
1889). 
Fischer (Ver- 
Woman, 
4" yeai s. 
Girl, 16 
years. 
Male, 20 
years. 
Female. 
Man, 28 
years. 
Male, 37 
Dementia; difficult 
deglutition; inconti- 
nence urine and fueces ; 
disturbance speech; 
later, convulsions. 
Convulsions. 
Headache; optic neu- 
ritis. 
Headache ; dulness. 
Epileptic attacks six 
years, extremely fre- 
quent; temperature, 
104° F. ; night before 
operation thirty-seven 
attacks status epilepti- 
cus. 
Vertigo, convulsions. 
Swelling over left pari- 
etal bone. After incision, 
paresis right leg, right 
facial, right mm. 
Amaurosis right eye ; 
partial paralysis (?). 
Left hemispasm ; left 
hemiparesis: tenderness 
of lower right ascending 
frontal. 
Orbital growth; nodule 
on skull half way between 
ascending frontal and 
anterior aspect ; spasm 
right face and arm ; myo- 
sis left pupil. 
Painful spasm right 
great toe ; stiffness right 
lower limb ; tonic, then 
clonic convulsions same 
limb; extension these 
to arm and face; not al- 
ways loss of conscious- 
ness. 
Paresis, then paralysis 
Tumor 
lobe. 
Tumor 
tie right 
tremity. 
parietal 
motor cen- 
lower ex- 
First operation, in- 
cised swelling ; no 
pus; later necrosis 
bone trephined; sub- 
dural pus evacuated ; 
no tumor found. 
Left temple tre 
pinned : contents of 
cyst evacuated. 
Trephined over 
tender spot; large 
adherent growth 
found; could not be 
removed. 
Trephined over no- 
dule ;t u m o r dura 
one-half inch thick 
removed. 
Operation December 
7, 1888. Trephined 
at upper part left as- 
cending frontal and 
parietal convolu- 
tions; trephine just 
outside sagittal 
suture. Enucleated 
tumor without injury 
to brain. 
First operation 
Tumor, size pigeon 
egg, in front part left 
paracentral lobule, 
extending into up|ier 
part ascending pari- 
etal convolution; sec- 
ond smaller tumor in 
middle of ascending 
parietal convolution, 
both gliomata. 
Echinococcus. 
Tumorat post, half 
of opening; grows 
from dura over left 
ascending convolu- 
tions : fibro-lipoma 
(Pean): endothelioma 
(Cornil). 
Sarcoma pressing 
Death. 
Relief of headache. 
Recovery. 
Day after, only six 
fits. 
Afler first trephin- 
Recovery. 
Recovery. 
Died eight years 
later of nephritis. 
Two months after 
operation no more 
attacks. 
Death two months 
81. 
32. 
33. 
34. 
35. 
handl. d.deuta'h 
Gesell. f. Chir- 
urg., 18th Con- 
gress ; also, "An- 
nals Surgery," 
St. Louis, 1889). 
Pilcher and 
Dana ("Annals 
S u r g e r y," St. 
Louis, 1889). 
Wood and Ag- 
new (Univ. Med. 
Magazine, April, 
1889). 
Parker (Brit. 
Med. Journal, 
Nov. 30, 1889). 
Thomas 
("Trans. Amer. 
Inst. Homreop.," 
1889, p. 46 i). 
Lirnont and 
years. 
Man. 33 
years. 
Man. 
Mm, 38 
years. 
Woman. 
Woman, 
Thrown from 
carriage, 
-truck head, in 
1882. 
Confinement. 
One year 
to first 
general 
symptoms 
Fourteen 
Irritable, childish ; 
apathetic after one 
year; general convul- 
sions, 1884. then petit 
mal ; severe frontal 
headache: mental im- 
pairment; double optic 
neuritis ; exaggerated 
reflexes. 
Vertigo, severe head- 
ache ; loss mental pow- 
er ; optic neuritis; loss 
equilibrium. 
Long-standing head- 
ache ; mental dulness. 
Headache; thick 
"neech ; no optic neu- 
ritis. 
Sudden unconscious- 
right arm; diminished 
sensibility ; paresis leg ; 
slight aphasia. 
In abortive attack, con- 
jugatedeviation head and 
eyes to left ; tonic spasm 
right arm and leg. 
Left hemianopsia. 
Total paralysis left arm: 
paresis left leg ; puffy 
swelling of scalp over 
right parietal eminence. 
Spasm left hand ; loss 
of consciousness; paresis 
left leg and face : paraly- 
sis and rigidity left arm. 
Spasms right arm ; 
nothing found; sec- 
ond, removed tumor 
piecemeal. 
Operation over seat 
of injury, angular 
gyrus ; no t u m o r 
found. 
Trephined over 
right cuneus; found 
and evacuated hem- 
orrhagic cyst. 
Trephining over 
swelling. Tumor re- 
moved with adherent 
dura. Suppuration 
on nineteenth day ; 
hernia cerebri re 
duced by mechanical 
pressure. 
Removed tumor 
weighing 3 oz. 
Portion large gli- 
on left central convo- 
lutions. 
Glioma in left oc- 
cipital lobe, extends 
to tip of left frontal, 
reaches lateral ven- 
tricle, island of Reil 
softened. Cicatrix 
had misled. 
Tumor right tem- 
poro-sphcnoidal lobe. 
Rounded gttmmous 
tumor size walnut 
under right parietal 
eminence. 
Middle Rolandic re- 
gion, pressing on but 
not involving convo- 
lutions. 
ing, convulsion, 
headache ceased; 
paralysis less; apha- 
sia increased after 
second operation; 
also recovery. 
Death from respir- 
atory failure. 
Total hemiplegia 
one day after first 
operation. Ten days 
afterward, second for 
suppuration. Total 
loss headache. 
Temporary recov- 
later from recurrence 
growth in dura. 
Death from hem- 
orrhage. 
Recovery on eigh- 
tieth day. 
Death in three 
days. 
Growth recurred. 
Page (Brit. Med. 
Journal, Oct. 26. 
1889). 
32 years. 
days. 
ness ; numerous con- 
vulsions. 
speech affected. 
oma removed (from 
lower part ascending 
frontal?) 
ery. 
(SUPPLEMENT.) 
125 Brain. 
Brain. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
No of case. 
Operator, 
date, 
reference. 
Sex and 
age. 
Trauma 
or not. 
Time be- 
tween 
trauma 
and first 
symptoms 
or dura- 
tion. 
General symptoms. 
Localizing symptoms. 
Diagnosis. 
Operation. 
Situation and nat- 
ure of tumor. 
First result. 
Final result. 
■ 
36. 
Maunsell (New 
Man, 18 
Headache ; vertigo ; 
Staggering to right; 
Trephined over 
Cyst of cerebellum 
Recovery,but blind- 
Zealand Medical 
Journal, 1889). 
years. 
vomiting; reeling gait; 
blindness:anosmia : 
convulsions; dilatation 
pupils; incontinence 
urine and fseees ; head 
and neck much swol- 
len ; eyes prominent : 
head retracted. 
convulsions begin with 
retraction head ; involve 
right arm and leg. 
cerebellum ; evacuat- 
ed subtentorial cyst. 
four inches long, two 
inches broad. 
ness persists. 
37. 
Verco (Inter- 
colonial Medical 
Congress, A u s - 
tralasia, 1889). 
Boy, 11 
years. 
Fall fr 
tree. 
o in 
Eight 
months. 
Pains in head ; 
screaming at night 
from pain ; tired sigh- 
ing ; three convulsions 
three weeks ago ; occa- 
sional vomiting; incon- 
tinence urine and fasces: 
tenderness head : dim- 
ness vision : pupils di- 
lated : sluggish ; double 
optic neuritis; head 
very large, 24 inches 
in circumference. 
Left palpebral fissure 
smaller; paresis left lower 
facial: hyperaesthesia 
right front chest: paresis 
left hand ; slight bulging 
right temporal and an- 
terior parietal region. 
Hydatid cyst from 
size of head, unilat- 
eral bulging, and 
paresis. 
Trephined over 
bulging region, 
inches above right 
meatus, 41 inches be- 
hind angular process. 
3| inches from sagit- 
tal suture. 
Cyst over area 4x2; 
adherent to temporo- 
sphenoidal lobe; cen- 
tral convolutions dis- 
placed upward. 
Death from men- 
ingitis ; temperature 
104° Fahr. 
38. 
Mercanton and 
Coinbc (Revue 
M e d. de la 
Suisee, Aug. 30, 
1889). 
Girl, 12 
years. 
Blow by 
teacher's ruler 
over nose and 
forehead. 
Fifteen 
months. 
Headache first symp- 
tom : diminished vis- 
ion ; in two years atro- 
phy optic disks. 
Jacksonian epilepsy 
right arm ; no aura, no 
loss of consciousness ; 
temporary paralysis arm 
after attack: later right 
f we, then right leg in- 
volved, then aphasia af- 
ter attacks ; intentional 
tremor ; rotation head 
to right, no deviation 
eyes, tender point near 
bregma to right of sagit- 
tal suture. 
Tumor in middle 
left ascending fron- 
tal convolution, 
reaching superior 
third above, inferior 
third below, also to 
island Reil (from 
aphasia of transmis- 
sibility). 
No record. 
No record. 
39. 
Kocher (Brit. 
Med. Journal. 
September. 1889, 
Correspondc ace 
from Berne). 
Choked disk ; ambly 
opia : headache ; stag- 
gering. 
Tumor of cerebel- 
lum. 
Operation to re- 
lieve pressure ; one 
opening posterior 
right side below ten- 
torium, one ante- 
rior on left side; ex- 
treme tension dura ; 
hernia cerebellum, 
removed with sharp 
spoon. 
In four days con- 
gestion disks disap- 
peared ; no improve- 
ment of sight. 
40. 
Keen (Refer- 
encehandbook 
Med. Sciences. 
Art. " Brain Sur- 
gery," 1889). 
Boy, 4 
years. 
Enlargement head ; 
double optic neuritis; 
amblyopia. 
None. 
Tumor cerebellum 
pressing on straight 
sinus, causing inter- 
nal hydrocephalus. 
Tapping ventri- 
tricles ; trephined 11 
inch behind external 
auditory meatus 
(side not recorded), 
11 inch above Reid's 
base line ; hollow 
needle and horse- 
hair 'drain intro 
dUced; drainage fifty- 
two days ; repeated 
probing brain ; irri- 
gation ventricles. 
Tumor cerebellum, 
with density same as 
brain. 
Diminution choked 
disks from day to 
day, but atrophy be- 
ginning. 
Death fifty-two 
days after first oper- 
ation. 
(SUPPLEMENT.) 
126 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Rraiu. 
Brain. 
41. 
Keetley (Lan- 
cet, 1889, vol. ii., 
p. 593). 
Child, 7 
years. 
Fall. 
Fourteen 
days. 
Giddiness; stagger- 
ing ; vomiting ; knee- 
jerks exaggerated ; 
attack of collapse, fol- 
lowed by subnormal 
temperature. 
Slight internal strabis- 
mus left eye. 
insensibility; rigid- 
ity limbs, especially 
left arm ; ptosis right 
upper eyelid : vomit- 
ing one-half pint 
black fluid ; temper- 
ature 105.6° F. 
beath in two dayL 
tion through left 
squamous bone ; 
nothing found. 
three times natural 
size by infiltrating 
glioma ; no inflam- 
mation or abscess ; 
pons uniformly yel- 
lowish. 
42. 
Maudsley and 
Fitzgerald 
(•'Trans. Inter- 
col. Med. Con- 
gress, 1889 "). 
Male, 28 
yea: s. 
Headache; vomiting; 
vertigo, staggering; 
dim vision, blindness 
later; optic atrophy. 
Awkwardness, left side; 
anosmia, left side; dila- 
tation right pupil; slight 
paresis right facial ; ab- 
sence left knee-jerk; 
deafness left ear. 
Tumor left lobe 
Trephined over left 
lobe cerebellum; solid 
nodule found, not re- 
moved ; loss of much 
brain substance. 
Solid nodule fixed 
Recovery, with 
persistent blindness 
am! deafness. 
cerebellum compress- 
ing left facial and 
auditory nerves. 
to temporal bone. 
43. 
Barton ("Ann. 
Snrg.,"St. Louis, 
1889). 
Lampiasi 
(IFirn. Jfed. ,Mav 
19, 1889; from 
Knapp, loc. cit.). 
Horsley (Brit. 
Med. Journal, 
December 6, 
1890). [Paper 
read at Interna- 
tional Med. Con- 
gress, Berlin.] 
Ibid. (Three 
cases mentioned 
without details 
for record.) 
Knapp and 
Bradford (Bost on 
Md. and Burg. 
Journal, April, 
1890). 
Woman, 
Syphilis; ne- 
crosis os fron 
tis ; a b s c e s s 
opened. 
S y m p - 
toms brain 
pressure 
developed 
after oper- 
ation on 
abscess. 
Lethargy; confusion; 
anxiety. 
Convulsions; optic 
neuritis; exophthal- 
mos. 
Epipleptic convul- 
sions ; attacks dysp- 
noea. 
Vomiting three 
months in 1886 ; paresis 
both hands 1887, then 
convulsions ; in 1888, 
headache; double optic 
neuritis. 
Incomplete right hemi- 
plegia ; failure to find 
words for thoughts. 
Trephined through 
necrosed bone ; re- 
move 1 softening 
syphilitic gumma. 
Trephining over 
cerebellum. 
Removed first one- 
Immediate im- 
Recurrence of 
44. 
30 years. 
Child, 2 
Tubercle size of 
provement in paraly- 
sis and speech. 
Death in four days. 
Abolition of dysp- 
noea, headache, and 
rotatory convulsion. 
Death from shock 
in three-quarters of 
an hour. 
drowsiness in three 
w< eks ; death in 
month, encephalitis. 
45. 
yeafs. 
No rec- 
None. 
In fits, body rotated 
violently to left around 
central axis. 
Left hemiplegia and 
contraction left arm : ex- 
aggerated reflexes on left; 
operation advised, March, 
1887 ; tactile left hemian 
ajsthesia ; loss muscular 
sense and paralysis left 
arm ; paresis left leg; 
sensory aura in left wrist ; 
clonic spasm left hand. 
Tumor in middle 
egg in cerebellum. 
Life prolonged in 
46. 
ord. 
Male 32 
lobe cerebellum. 
Tumor ascending 
frontal convolution 
below level first fron- 
tal sulcus, extending 
back and upward. 
half occipital bone ; 
later, the other half. 
1889. Removed tu- 
mor; operation lasted 
fifty minutes. 
Tubercle.35] grms., 
middle right ascend- 
ing frontal convolu- 
tion. 
comfort for two 
years. 
years. 
47. 
48. 
Springthorpe 
(Austral. Med. 
J our nal, Novem- 
ber 15, 1890). 
Oppenheim 
(t eulsch Med. 
IVoch ensch rift, 
1896). 
Boy, 13 
years. 
Woman, 
Fall off five 
foot fence on 
right forehead. 
Never 
well after 
fall; opera- 
tion three 
years later 
Severe headaches; 
gradual loss of sight ; 
attacks vomiting; con- 
vulsions ; vertigo; epis- 
taxis ; tottering gait; 
atrophy both optic 
disks; diminished knee- 
jerks. 
Convulsions daily ; 
headache; loss mental 
power; no choked disk; 
salivation ; vomiting ; 
six months pregnant. 
Conjugate deviation 
head and eyes to right 
in fits ; aura of formica- 
tion in both hands; hear- 
ing right ear dull; falling 
toward right side and 
backward. 
Pain in right half of 
forehead ; mouth drawn 
to right : paralysis left 
eyelid ; total paralysis left 
arm ; contracture ; slight 
pare-is left leg ; sensibil- 
ity blunted face and arm. 
Cerebellar tumor. 
Cortical tumor low- 
Trephined o v e r 
right lobe cerebel 
him; clear, serous 
fluid escaped ; no tu- 
mor found. 
Trephined : no pul- 
A t post-mortem, 
found glioma middle 
lobe cerebellum, with 
decomposing cavity 
in centre; numerous 
hemorrhages; all 
channels to lateral 
ventricles dilated; 
ventricles full of 
blood-stained fluid; 
cranial bones 
thinned ; main press- 
ure on right side. 
Glioma, with cystic 
degeneration. 
Death. 
Sensory and motor 
Fairly complete re- 
36 years. 
er part right ascend- 
ing convolution. 
sation ; incised dura ; 
anterior convolu- 
tions deep bluish 
red and swollen ; 
opened into cyst ; 
abundant serous 
fluid evacuated ; no 
response to electric- 
ity over convolutions. 
paralysis diminished 
next day. 
covery. 
127 Brain, 
Brain, 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
No. of case. 
Operator, 
date, 
reference. 
Sex and 
age. 
Trauma 
or n t. 
Time be- 
tween 
trauma 
and first 
symptoms 
or dura- 
tion. 
General symptoms. 
Localizing symptoms. 
Diagnosis. 
Operation. 
Situation and nat- 
ure of tumor. 
First result. 
Final result. 
49. 
Graham (Aux- 
Bo , 16 
Fall over 
Unco n- 
Severe frontal head- 
Amaurosis left eye ; 
Trephined over up- 
per portion fissure 
Rolando. Entered 
cyst, evacuated, re- 
moved by traction. 
Trephined over arm 
centre on left side. 
Area brain equal to 
silver dollar of cen- 
tral and frontal 
gyres decorticated 
to depth one-quarter 
inch. 
Trephined over 
these centres ; found 
nothing : operation 
relieved pressure. 
Trephined ; noth- 
ing found. 
Trephined frontal 
bone above supra-or 
bital ridge on right 
side; probe passed 
along orbital plate ; 
nothing found. 
Trephined over 
upper p a r t fissure 
Rolnndo, close to 
mesial line of skull ; 
dura opaque, no pul- 
sation ; dense subdu- 
ral growth, one-half 
inch thick ; partial 
removal on account 
of proximity to sinus. 
Exploratory opera- 
tion over left ascend- 
ing frontal; negative 
result. 
Hydatid cyst; pia 
intact ; motor area 
depressed; cyst had 
grown from arach- 
noid ; capacity cyst, 
19 oz. 
Spider-shaped new 
growth, with long 
filaments on surface 
of convolution. 
Small spindle-celled 
sarcoma in parietal 
lobe, behind leg cen- 
tre ; s a m e consist- 
ency as brain, remote 
from arm centre, yet 
arm engaged. 
Tumor found on 
Seventh day began 
to take interest; vicis- 
situdes till fourteenth 
day ; thence steady 
improvement. 
Next day aphasia, 
right motory and sen- 
sory hemiplegia: then 
twitchings in limbs 
preceded restoration 
functions ; rise of 
temperature; a month 
later small abscess at 
wound. 
. 
Recovery con- 
sciousness, and dim- 
inution paralysis. 
Recovery, but with 
blindness. 
Recovery, but cor- 
vulsions recurred in 
two months. 
Death in three 
weeks. 
Death second day. 
50. 
51. 
52. 
tral. Mcdicil Ga- 
a tie, June, 1890). 
Church (N. 
American Prac- 
titioner, 1890, p. 
433). 
Stokes (Brit. 
Med. Journal, 
1890). 
Beach (Boston 
Med. and Surg. 
Journal, April, 
1890). 
Wyman (Med. 
News, February 
8, 1890). 
years. 
Man, 38 
years. 
Man, 4 2 
years. 
Man, 51 
rock, ten feet. 
scions two 
days: first 
symptoms 
five years 
later. 
ache ; giddiness ; nau- 
sea; attack vomiting, 
four days: blindness ; 
post, neuritic atrophy ; 
attacks drowsiness, 
etc.; coma begins just 
before operation. 
Apoplectic seizure ; 
afterward convulsions; 
constant frontal head- 
ache. 
Coma at time of op- 
eration; absence choked 
disk; fixed headache 
and vomiting. 
Severe frontal and 
leans to right side in 
walking; paresis right 
leg ; protrusion eyes. ' 
Fits begin with pain and 
spasm in r.ght index fin- 
ger, then other fingers, 
wrist, elbow, shoulder in- 
vaded by pain and clonic 
spasm ; then loss con- 
sciousness and general 
convulsions ; p a i n and 
contraction persist in 
right hand. 
Tonic spasms left side, 
beginning in leg, invad- 
ing trunk, arm, face; 
then paralysis in same 
order. 
Short attacks of apha- 
sia, without agraphia or 
loss of consciousness; tre- 
mor right hand; jierrna- 
nent hesitancy speech ; 
twitching right hand and 
right eyelid ; then paresis 
extensors right hand. 
Divergent squint after 
convulsion ; slight move- 
ment rotation ; anosmia. 
Initial paralysis, then 
paresis right leg ; aura of 
torsion in right leg. then 
leg forcibly flexed ; hemi- 
spasm: pal esis right arm; 
recurrent twitchings and 
numbness right limbs : 
face drawn to right in fits; 
speech affected afterward, 
then slight motor aphasia 
Hesitation in speech, 
then aphasia; hemor- 
rhage right ear and 
mouth ; offensive dis- 
charge right ear ; series 
spasms left side ; com- 
plete left hemiplegia 
(not left-handed); con- 
tracture ; exaggeration 
left tendon reflex ; hemi- 
anopsia not tested. 
Tumor at leg and 
arm centres. 
Tumor anterior 
53. 
54. 
55. 
years. 
Young 
man. 
Man, 47 
years. 
Boy, 14 
years. 
occi pital headache; 
mental dulness; double 
optic neuritis. 
Frontal headache a 
year ; fever several 
weeks' duration; dimin- 
ished vision ; double 
choked disk; vomiting: 
epileptic attacks; great 
muscular weakness. 
lobe, pressing on 
lower part central 
convolutions. 
Tumor in region 
of sella turcica. 
supposed level, but 
behind motor area ; 
posterior edge limited 
by post, ascending 
branch of Sylvian fis- 
sure ; anterior by 
small sulcus ; motor 
and frontal convolu- 
tions healthy ; optic 
tracts compressed. 
Tumor inches 
long, contained in a 
cavity in left hemi- 
sphere cerebellum ; 
all ventricles distend- 
ed with fluid. 
Very chronic 
syphilitic neoplasm 
growing from dura 
and falx cerebri. 
Cystic mass at left 
of sella turcica 
springing from apex 
petrous bone. 
Syphilis 
Fall against 
tree in coast- 
ing. 
Thirty 
years be- 
fore symp- 
toms. 
Eighteen 
month s 
iiefore ad- 
mission; 
first syrnp- 
t o m s in 
three 
weeks af 
ter a c c i- 
dent. 
Twitchings in foot 
for two days, did not 
spread ; abscess 
formed in wound. 
Death in few 
hours. 
Death from septi- 
camiia on nineteenth 
day. 
ct, March 1, 
1S90). 
Walker (Brit. 
Med. Jou-nal, 
Aug. 23. 1890). 
1 
1 
side ; several weeks ; 
convulsions; uncon- 
scious three hour s, 
then repeatedly ; exag- 
geration reflexes both 
sides. 
Dizziness, then pare- 
sis hands ; staggering ; 
mental power failed 
with speech; vomiting. 
Tumor with de- 
scending sclerosis. 
(SUPPLEMENT.) 
128 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Brain. 
Brain. 
56. 
Dumin (Neu- 
rol. Central- 
blatt, August 15, 
1890; quoted 
by Knapp, loc. 
cit.). 
Bremer and 
Hemiplegia ; aphasia 
Jacksonian epilepsy. 
Spasm left arm and 
Trephined ; re- 
moved tumor. 
Trephined over 
right fissure Rolan- 
do ; tumor removed. 
Trephined over 
scar ; nothing found. 
Trephined, Feb. 
25, 1890 ; tumor too 
large for removal. 
Operation Novem- 
Tumor of ante- 
Recovery. 
Sudden death four 
months after opera- 
tion. 
Recovery. 
Death. 
Death in eight 
days. 
Entire recovery; 
•'marvellous expan- 
sion of intelligence ; '' 
disappearance of pa- 
ralysis. 
Recovery ; no fur- 
ther attacks three 
and one-half months 
after operation. 
Perfect recovery. 
Death. 
57. 
ord. 
Male, 23 
years. 
Male, 35 
years. 
Morning vomiting; 
peculiar gait; begin- 
ning choked disk ; ab- 
sence mental initiative. 
Cerebral tumor; 
rior central convolu- 
tion. 
Cavernous angio- 
ma. 
Glioma left corpus 
striatum and optic 
thalamus. 
Glioma, 3|x4 in., 
in left frontal lobe, 
reaching beyond fis- 
sure Rolando. 
Congenital serous 
cyst in locality diag- 
nosed. 
58. 
Carson (Am. 
Jour. Med. Sci- 
ences, Septem- 
ber, 1890). 
Kerr (Occident. 
Med. Times, 
1890; from 
Knapp). 
Eskridge 
(from Knapp). 
Doyen (Con- 
gres Franyais de 
Chirurgie, 1891). 
Blocq and Rey- 
mer (C o n g r e s 
Franyais de Chi- 
rurgie, 1891). 
McCall Ander- 
son (Brit. Med. 
Journal, 1891). 
Seguin (Boston 
Med. and Surg. 
Journal, Febru- 
ary, 1891; from 
Knapp). 
Bullard and 
Bradford (Bosto n 
Med. and Surg. 
Journal, April 
30, 1891). 
Injury 
head. 
neck; temporary apha- 
sia ; left hemiparesis with 
contraction in left foot; 
contractions platysma al- 
ways begin spasm. 
Right hemiparesis and 
spasm ; scar over upper 
part fissure Rolando. 
Right hemiparesis, 
then hemiplegia. 
Left hemiparesis; 
slow growth in or 
beneath Rolandic re- 
gion near centres 
for wrist and platys- 
ma. 
59. 
Loss of strength. 
60. 
32 years. 
Boy, 16 
years. 
Boy, 10i 
years. 
Boy, 16 
years. 
I 
Sy m p- 
memory,mental power; 
headache. 
Torpor of intelli- 
Tumor of meninges 
or brain behind bulg- 
ing bone compressing 
central convolutions. 
Partial sensitive- 
Drain withdrawn 
61. 
toms sev- 
en years 
before op- 
eration. 
First 
gence, gradually deep- 
ening to imbecility; 
vertigo, absences ; epi- 
leptic attacks of in- 
creasing severity. 
Crises, beginning at 
five years in prickling 
of facial mucous sur- 
faces and increased 
secretion from conjunc- 
tiva. nose, and mouth ; 
at eight years, falls ; at 
nine, convulsive at- 
tacks. growing more 
intense; intelligence 
intact. 
Sudden epileptic at- 
tack ; second fit eigh- 
teen months ago, then 
others ; at first arrested 
by bromides, then 
eighty-nine attacks in 
ten weeks ; double optic 
neuritis; increased ex- 
cretion earthy phos- 
phates. 
No record. 
diminution visual field 
on right side, then blind- 
ness and optic neuritis 
on this side; bulging right 
squamous bone. 
Attacks -five to six 
ber 5,1889, over bulg- 
ing bone ; very large 
cyst found ; opened ; 
drained. 
Operation, August 
second day because 
causing bleeding; re- 
placed sixth day, 360 
c.c. albuminous 
liquid evacuated ; 
then every three or 
four days till 50 c.c. 
left; permanent drain 
in six weeks; cure in 
two months. 
Attacks returned in 
62. 
63. 
64. 
symptoms 
five years 
before op- 
eration. 
Four 
and one- 
half years 
before ad- 
mission. 
times a day; mouth 
dragged to right, associ- 
ated with prickling sen- 
sation at mouth and 
tongue; deviation tongue 
on right side, and bitten 
on right side ; eyes fixed ; 
head turned to right, then 
loss consciousness; right 
arm raised in flexion and 
adduction, then leg, then 
general convulsion after 
attack ; right hemianes- 
thesia ; temporary paraly- 
sis right arm. 
Exaggerated reflexes 
wrist and knee on left 
side; slight left facial 
paralysis; numbness and 
pain left thumb and in- 
dex ; acute pain above 
right ear, tenderness two 
inches behind ; paresis 
left arm and leg. 
motrice epilepsy ; ne- 
oplasm at inferior 
and middle third cen- 
tral convolutions. 
Tumor at Horsley's 
thumb centre, junc- 
tion middle lower 
third right parietal 
convolution. 
Tumor under mo- 
19, 1890. Localiza- 
tion according to 
Poirier ; cyst found 
extending toward 
frontal convolutions; 
wall excised ; drain- 
age. Second opera- 
tion . removed cyst, 
volume of large wal- 
nut, December 13th. 
Trephined just be- 
hind line for Rolan- 
dic fissure, three 
inches from upper 
extremity; at first 
found nothing; sec- 
ond trephine higher 
up ; then brain sub- 
stance bulged at first 
opening; tumor size 
of plum rolled out. 
Trephined ; noth- 
• 
sixteen days; after 
second operation pa- 
tient well for six 
days, then attack 
followed by aphasia 
for two hours. 
No epileptic attack 
for eight weeks ; still 
some spastic con- 
traction muscles fin- 
gers. wrist, elbow, but 
power to move arm. 
Glioma, one-half 
Female, 
6f years. 
Vomiting; vertigo; 
staggering; weakness 
all four limbs ; incoor- 
dination ; blindness ; 
optic neuritis; head- 
ache. 
tor centre for left 
leg. 
ing found. 
Trephined over 
torula; opening made 
into sinus. 
inch in diameter, 
found at autopsy at 
point diagnosed in 
medullary substance 
below cortex; same 
consistency as brain. 
Cheesy tubercle in 
cerebellum. 
Death from hem- 
orrhage. 
129 Brain. 
Brain. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Q 
O 
6 
Z 
Operator, 
date, 
reference. 
Sex and 
age. 
Trauma 
or not. 
Time be- 
tween 
trauma 
and first 
symptoms 
or dura- 
tion. 
General symptoms. 
Localizing symptoms. 
Diagnosis. 
Operation. 
Situation and nat- 
ure of tumor. 
First result. 
Final result. 
Knapp and 
Bradford (Case 
xxix. of ''Essay," 
1891). 
Mills and Keen 
Male, 28 
Headache: vomiting: 
optic neuritis; blind- 
n e s s ; paraesthesia 
mouth and hands; 
deafness; anosmia. 
No optic neuritis ; no 
general symptoms. 
Epileptic attacks; 
Tenderness in right 
temporal region; absence 
left knee-jerk; slight pa- 
resis left hand. 
Left hemiparaesthesia 
for few moments; attacks 
at intervals weeks or 
months; in four years 
complicated by spasm left 
limbs, then passing to 
right; most marked in 
arm : prickling sensation 
left arm ; cry ; extension 
left arm, this leg; head 
twists to right. 
Incomplete left paresis; 
Trephined over 
tender spot; nothing 
found; operation only 
to relieve intracrani- 
al pressure. 
Trephined 1.75 inch 
to right of median 
line, in line of fissure 
Rolando; cranial in- 
dex =0.75; tumor 
removed. 
Operation while pa 
tient six months 
pregnant: trephined 
over lower part right 
parietal convolu- 
tions ; dura did not 
pulsate; no reaction 
to electricity ; swol- 
len convolution over 
cyst; evacuated, an- 
terior part removed. 
Trephined 1.3 ctm. 
behind parieto-occip- 
ital fissure, 3.2 ctm. 
to left of median line; 
dura bulged; no pul- 
sation ; no response 
to Faradic current; 
elastic hard body 6.3 
ctm. below surface ; 
some pieces removed. 
Trephined over fis- 
s u r e Rolando; re- 
moved tumor. 
Removal tumor 
Tumor involving 
left lateral lobe of 
cerebellum. 
Small growth, orig- 
inating in pia, had 
bored through dura 
and formed nest in 
skull, one-sixteenth 
inch in front of tre- 
phine ; Faradisation 
just behind fissure 
elevated shoulder ; 
above opening Fara- 
disation gave same, 
also flexion leg and 
thigh; growth looked 
like hypertrophied 
Pacchionian body, 
but proved sarcoma. 
Cyst size of hen's 
egg ; cystic degener- 
ated sarcoma. 
Relief from head- 
Death from en- 
66. 
67. 
years. 
Female, 
27 years. 
Woman, 
First symp- 
toms ten years 
before admis- 
sion. 
A ttaek apo- 
ache ; cerebral her- 
nia ; left hemiplegia 
and left anaesthesia. 
Movement left 
cephalitis about ten 
weeks later. 
Same attacks con- 
(Amer. -Journal 
M e d . Sciences, 
1891). 
Koehler and 
Lesion right motor 
zone. 
Tumor parieto- 
occipital lobe in an- 
gular gyrus, with 
pressure on left 
cuneus. 
shoulder paralyzed; 
all paralysis disap- 
peared on thirty- 
third day, though 
limbs weak. 
Headache ceased ; 
tinned, but less se- 
vere. 
Typical epileptic 
attack four months 
after. Death. 
Death in fourteen 
68. 
69. 
0 ppenheimer 
(Berlin A lin. 
Wochen., 1891). 
Keen (Amer. 
36 years. 
Man, 56 
plexy one year 
before admis- 
sion. 
Injury to 
head. 
Five months. 
Eighteen 
years: first 
symptoms 
two years 
before ad- 
mission. 
loss of memory; irrita- 
bility ; headache; ver- 
tigo ; no optic neuritis. 
Headache; nausea ; 
then paralysis left arm: 
paresis left leg; knee-jerk 
exaggerated on left side; 
attack begins with draw- 
ing mouth to left; draw- 
ing in left arm, thumb, 
and index; then clonic 
convulsion arm ; paraly- 
sis left half face. 
Aphasia : right lateral 
hemianopsia ; lesion left 
side brain; right hemi- 
paresis ; apraxia. 
Atrophy right leg and 
arn; reflexes exagger- 
ated on left; pain on left 
side head. 
Jacksonian epilepsy. 
Anosmia on left side; 
paralysis left facial; 
paresis left leg disap- 
peared ; arm recov- 
ered ; normal deliv- 
ery. At autopsy 
several months later 
softened tumor found 
size of apple in cortex 
and medullary sub- 
stance of lower part 
central convolutions; 
interstitial encepha- 
litis. 
Journal Medical 
Sciences, Sept., 
1891). 
Castro ("Ann. 
Surgery," St. 
Louis, 1891), 
Poirier (Rev. 
years. 
Boy, 14 
years. 
Man, 32 
vertigo; diminished 
vision ; vomiting at- 
tacks ; double optic 
neuritis. 
Headache ; vomiting. 
bert, 5 ctm. from end 
of occipital lobe, 2.5 
ctm. from median 
line ; angular gyrus 
removed at opera- 
tion ; infiltrating gli- 
oma. 
Blackish tumor size 
Bulging wound on 
seventh day; on 
twelfth day cicatrix 
opened ; cyst, 7 ctm. 
ejected. 
hours. 
Death, from diph- 
theria of wound. 
Recovery; freedom 
from attacks. 
Recovery. 
u 
Epilep- 
tic attacks 
twelve 
years, ev- 
ery f o r t- 
night. 
of walnut. 
Tumor; central 
71. 
de Chir., 1892). 
Booth and Cur- 
years. 
General epileptic con- 
vulsions ; marked psy- 
chic changes; choked 
disk, bilateral. 
through hole made 
by mallet and chisel. 
Trephined over 
eroded bone ; tumor 
removed. 
gyri vascular. 
Tumor, tubercu- 
lous. 
t i s (Neurologi- 
cal Society, New 
York. December 
6, 1892). 
bone eroded at angular 
process left frontal bone. 
(SUPPLEMENT.) 
130 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Krain. 
Krain. 
72. 
Llobet (Revue 
d e Chirurgie, 
December, 1892). 
Boy, 
years. 
13 
.. 
l1 W 0 
yrs.; head- 
ache. 
Headache violent: 
abolition intelligence 
and memory; crying 
and anger ; exagger- 
ated patellar reflexes ; 
pulse slow ; respiration 
slow and irregular. 
Jacksonian epilepsy 
two months after head- 
ache ; total hemiplegia 
right side; contracture 
in flexion forearm and 
fingers ; right leg in flex- 
ion ; foot in equinus 
varus; diminution vision 
right eye ; mydriasis. 
Tumor in psycho- 
motor centre left 
hemisphere. 
Resection temporal 
bone : flap 8x10 ctm.; 
no pulsation brain ; 
fluctuation ; evacua- 
ted 260 grms. fluid ; 
extracted cyst. 
Hydatid cyst. 
Disappearan ce 
headache, epilepsy, 
hemiplegia, contract- 
ure, aphasia; re- 
flexes became nor- 
mal, also pulse and 
respiration. 
Recovery, but 
memory not returned 
in three months. 
73. 
Girl, 
years. 
18 
Ten 
Cerebral vomiting; 
pain in forehead; blind- 
ness six weeks: intense 
double optic neuritis. 
Twitching attacks in 
left arm, beginning in 
thumb and first finger ; 
sensory aura in s a m e 
parts. 
Trephined over 
Rolandic fissure ; 
nothing found. 
Multiple cerebral 
tubercles in right 
hemisphere ; dissem- 
inated tuberculosis. 
Hernia cerebri. 
Death in a 
month. 
son (Lancet, 
May 14, 1892). 
weeks. 
74. 
Hitzig (Berlin, 
k I i n. Worhen- 
schrift, July 18, 
1892). 
Man, 
years. 
29 
Blow 
head. 
o n 
Headache ; incipient 
dementia, choked disk; 
narrowed visual fields ; 
paresis both legs ; ex- 
aggerated both patella 
reflexes ; mental symp- 
toms preceded motor. 
Paresis left hand in 
repeated attacks; dimin- 
ished vision of right eye ; 
paresis left facial ; head 
inclined to left; paresis 
left arm ; swelling soft 
tissues : over right tem- 
poral region of head, ten- 
derness. 
Tumor posterior 
part frontal lobe, 
adjacent to middle 
and lower part as- 
cending frontal con- 
volution on right 
side. 
Trepanned at point 
indicated; high 
grade hyperostosis ; 
skull one centimetre 
thick ; tumor found ; 
opening enlarged to 
16 ctm. long and 9 
ctm. broad ; success- 
ful removal. 
Tumor, 280 grms., 
equal to weight of 
half a hemisphere ; 
sarcoma. 
Facial paresis and 
deviation tongue 
persist; paralysis 
arm increased. 
Recovery. 
75. 
Ibid. 
Man, 
years. 
4* 
Blow on right 
Eighteen 
months 
before ad- 
mission; 
first symp- 
toms in 
ten days 
after blow. 
Consciousness intact; 
Paresis index finger, 
then thumb and middle 
finger ; later, convulsion 
left side, then paralysis 
hand, arm ; paresis left 
facial left vocal cord; 
tongue pushed to left; 
ankle-clonus left side. 
Trephining d i s - 
covered cyst size of 
goose egg, proved 
to be an encapsulated 
cysto-sarcoma ; r e - 
moved in second op- 
eration. 
- - . 
Recovery. 
side head. 
no general symptoms; 
paresis both lower ex- 
tremities ; increase pa- 
tellar reflexes. 
76. 
Von Bram- 
Fall on head. 
Eighteen 
Paresis three fingers 
left hand, arm, and left 
half face ; twitchings. 
Tumor 
at 
fissure 
Trephined ; bluish 
cystic tumor per- 
ceived through dura ; 
30 grms. clear serum 
withdrawn ; drain- 
age. 
Round-celled sar- 
Recovery after first 
o)>eration; recurrence 
in three weeks; sec- 
ond and third opera- 
tion ; at last tumor 
removed. 
Recovery persists 
three months after 
operations. 
maim (Wien. 
Med. Wochens., 
1892). 
ord. 
months 
previous to 
admission. 
Rolando. 
coma. 
77. 
Ibid. 
Blow on head 
Persistent headache; 
Sudden weakness in 
Tu m o 
Trephined ; tumor 
extirpated; tempo- 
rary collapse. 
Operation over ex- 
posed bone; neoplasm 
incompletely re- 
moved. 
Eyeball removed ; 
inside, spindle-cell 
sarcoma surrounding 
optic nerve ; second 
operation three 
months later; tre- 
phined over speech 
area; no tumor dis- 
covered ; threatened 
collapse. 
Trephine over up- 
per part right ascend- 
ing parietal; no bulg- 
ing, but after needle 
3 ij. straw - colored 
fluid ; no tumor 
found. 
Spindle-cell sar- 
coma ; small cyst. 
Hard cartilaginous 
neoplasm adherent to 
superior longitudinal 
sinus. 
Recovery. 
Death fift 
78. 
Nixon (Med. 
Press and Circu- 
lar, 1892). 
Clegg (Liver- 
pool Med. Chir. 
Journal, 1892). 
Twynam (Aus- 
tralasian Medi- 
cal Gaeette, May, 
1892). 
ord. 
Man, 
years. 
Man, 
years. 
Man. 
28 
in former years 
Histnrv n f 
diminished vision: 
diminished mental 
power. 
Giddiness ; vomit- 
left hand ; gradual pa 
ralysis left arm and left 
face ; neuritis left eye. 
Left hemiplegia ; sup- 
purating sebaceous cyst; 
exposed bone over right 
parietal eminence. 
Aphasia and right hemi- 
plegia ; temperature one 
degree higher on left side; 
eye suppurates; after first 
operation epileptic at- 
tacks, beginning in right 
side face, right arm; 
rarely right leg. 
Parekis left hand and 
area. 
Marked improve- 
ment ; disap]H?arance 
pain, paralysis, and 
sphincter paralysis. 
Jacksonian epilepsy 
continued ; temi>o- 
rary recovery after 
second operation. 
Bronchitic rides; 
Ii week, 
try hem- 
wound. 
of pain 
in four 
79. 
31 
syphilis. 
ing ; amnesia ; defect- 
ive vision; intense 
headache; double optic 
neuritis ; dulness; pa- 
resis sphincters. (These 
symptoms all sudden.) 
Exophthalmos, 
double optic neuritis: 
severe amblyopia; con- 
vulsion after temporary 
aphasia. 
Giddiness five min- 
from seconds 
orrhage fron 
Return 
80. 
Six weeks. 
Tumor occupying 
whole medullary cen- 
tre right parietal 
lobe, 68 by 57 mm. ; 
extends from Roland- 
ic fissure to parieto- 
occipital, bulging into 
roof lateral ventricle. 
and attacks 
months. 
tocks. 
utes after fall ; head- 
ache in six weeks. 
leg ; some loss sensation ; 
pain in right temporo- 
frontal region. 
death on fourth day. 
(SUPPLEMENT.) 
131 Brain. 
Brain. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Final result. 
Death sudden in 
few days. 
Death in few days. 
Death third day 
after; temperature, 
108° F. for an hour. 
1 
Out of the 300 cases of tumor in children, 96 were situ- 
ated in the cerebellum. This single fact suffices to es- 
tablish a relatively unfavorable prognosis for brain tu- 
mors in childhood. 
In this same list were found 56 cases of tumor of the 
cortex and centrum ovale, localities favorable for opera- 
tion ; 16 of these, however, were not correctly diagnosed, 
therefore could not have been operated, even if the oper- 
ation had been suggested. 
Out of the 40 which remain, localizing diagnosis 
would have been impossible in 21, though the autopsy 
showed that in some of them an operation would have 
been possible. In 19 cases the tumors were in the cen- 
tral convolutions, or subjacent centrum ovale, and in 13 
of these local spasm followed by paresis made the pre- 
cise diagnosis sufficiently clear. In the remaining 6 the 
locality was established by the symptom hemianopsia. 
The author estimates, however, that in only 16 of these 
cases could an operation have been undertaken with 
much hope of success, and as 10 of these were tubercu- 
lar, the number of cases where even this new and heroic 
remedy offered hope of complete recovery was reduced 
to 6 out of a total of 300. 
The statistics for adults, as regards localization, differ 
somewhat from the above. A table of 649 cases, com- 
piled from the cases of Ladame and Bernhardt, has al- 
ready been given in the article on " Brain Tumor " in the 
main body of this Handbook. It may be worth while 
to reproduce this table. The tumor was situated in the : 
Per 
cent. 
Centrum ovale in; 192 cases = 29 
Cerebellum in 132 " = 27 
Cortex in 74 " =11 
Pons in 53 " = 8 
Basal ganglia in 36 " = 5 
Medulla in 30 •* = 4 
Corpora quadrigemina in 13 " = 2 
Cerebral peduncle in 10 *• = 1 
Extra cerebral in 71 " =11 
This table can be compared with Starr's as follows : 
Situation and nat- . .. 
ure of trauma. r,r8t result- 
Shock; death in 
few hours. 
Relief from head- 
ache. 
Recovery, but slight 
symptoms recurrence 
Tumor in middle 
lobe cerebellum. 
Cystosarcoma 
middle lobe. 
Round-cqjled sar- 
coma size of hickory 
nut in ascending pari 
etal convolution, one- 
quarter of an inch 
beneath surface, at 
junction of upper and 
middle third; had 
been penetrated by 
exploring needle. 
Diagnosis. Operation. 
Trephined; re- 
moved very large glio- 
sarcoma. (Operation 
proposed eleven 
months before finally 
performed.) 
Trephined with 
apex of flap on supe- 
rior curved line ; no 
tumor found. 
Trephined between 
curved lines ; cystic 
tumor tapped ; could 
not be removed. 
Operation Novem- 
ber 14, 1890. Laid 
bare ascending fron- 
tal, ascending parie- 
tal, bases 2d and 3d 
frontal, anterior 3d, 
1st and 2d parietal 
convolutions; dura 
tense and bulging ; 
examination by need- 
les : no tumor found. 
Opening over left 
Rolandic area ; cyst 
Tumor frontal lobe 
impinging on motor 
centres. 
Tumor right lobe 
cerebellum. 
Tumor middle lobe 
cerebellum. 
Tumor left centrum 
ovale (Subcortical. 
because no convul- 
sion) beneath upper 
part ascending parie- 
tal convolution. 
Tumor arm centre. 
Localizing symptoms. 
Tenderness on percus- 
sion left side head ; right 
side hemiparesis. 
Exaggerated reflexes 
on right side ; some right 
anaesthesia of face. 
No local symptoms. 
Paralysis right leg ; pa- 
resis right arm ; muscu- 
lar sense greatly im- 
paired ; other sensibility 
!preserved; exaggeration 
। right knee-jerks. 
Twitching, then pare- 
1 sis right arm; loss of 
Tumors situated in 
Children. 
All cases. 
Cerebellum 
Cortex and centrum ovale 
96 cases = 32% 
56 " = 18% 
162 cases = 27% 
266 " =41% 
Thus consideration of the prevailing situation of brain 
tumors alone, would seem to justify Bergmann's dictum,1 
that the field for successful operation is very narrow, the 
reverse of what can be now affirmed of trephining for 
brain abscess. On the other hand, examination of the 
85 cases in which operations have been performed gives 
a more favorable view. At this date (January, 1893) there 
is a record of 39 successful operations against 46 unsuc- 
cessful cases, and one trephining to relieve intracranial 
pressure.2 These have been performed in all parts of 
the world, even British Guiana having contributed a suc- 
cessful case in 1888 (Rannie, British Medical Journal, 
1888). The following table summarizes these results. 
"Successful" implies that the tumor was found and re- 
moved, that the serious symptoms subsided and the pa- 
tient lived more than two months, or even recovered com- 
pletely. " Unsuccessful " refers, not only to the death of 
the patient from the immediate consequences of the oper- 
ation, but also to the impossibility of completing this, 
either because the tumor was not found at the locality 
supposed, or proved too large or too deeply seated to be 
completely removed ; finally to the speedy recurrence of 
the tumor so as to cause the death of the patient in a 
short time, notwithstanding the immediate success of the 
operation. 
Successful 39 
Unsuccessful: 
Tumor not found 20 
Tumor not removed 10 
Death from operation or speedy recurrence of 
neoplasm 16-46 
85 
General symptoms. 
Marked psychic symp- 
toms ; sluggish thought 
and speech ; headache ; 
double optic neuritis; 
no failure vision ; mo- 
tor symptoms devel- 
oped later; exagger- 
ated reflexes both sides. 
Optic neuritis; 
blindness ; staggering ; 
severe headache. 
Vomiting; headache; 
blindness; choked disk; 
staggering. 
Headache; insomnia; 
cremaster reflex slug- 
gish on both sides; 
somnolence before op- 
eration. 
Time between 
trauma and 
first symptoms 
or duration. 
Sym p t o m s 
one month be- 
fore operation; 
hard growth in 
Scarpa's t r i - 
angle. 
Trauma 
or not. 
Sex and 
age. 
Man. 
Man. 
Child, 12 
years. 
Man, 38 
years. 
Operator, 
date, 
reference. 
Starr and 
McBurney (New 
York Academy 
Medicine, Janu- 
ary 5, 1893). 
Ibid. 
Ibid. 
Gray and 
Wyeth (Brain, 
1892-93). 
Stieglitz & Ger- 
ster (Neurolog. 
•ox 03U3 
19 
GO 00 00 GO 00 
132 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Brain. 
Brain. 
In 1888 Dr. Keen wrote (Reference Handbook, 
" Brain Surgery ") that the percentage of mortality was 
thirty-five per cent. This calculation was based upon the 
17 operations which had then been performed, with six re- 
coveries, and included among them one case (Heath, Lan- 
cet, 1888, Case 27 of table), which we have placed among 
the unsuccessful cases, because, although the patient sur- 
vived the operation and was relieved, the tumor was too 
large for removal. The percentage of successes (11 cases 
out of 17) was nearly sixty-five. To-day, the larger num- 
ber of cases yields as successful about forty-six per cent., 
as failures, nearly fifty-four per cent. The less favorable 
result is not surprising, for the operation has been at- 
tempted under a much greater variety of circumstances, 
so that a greater number of unfavorable conditions have 
been encountered. For this reason the estimate of the 
operation has varied in the same way as did that for 
tracheotomy. This operation on its first suggestion ex- 
cited unbounded enthusiasm, until experience showed 
how numerous conditions of failure were inherent in the 
disease for which the operation was performed, and which 
could not be overcome by any degree of perfection in its 
surgical technique. 
The precision is surprising with which small tumors 
have sometimes been localized for removal. In Seguin 
and Weir's case (No. 24) the neoplasm was only the size 
of an almond, and lay an inch below the surface. In 
another case, however, reported by Seguin, a glioma 
one-half inch in diameter escaped detection. It was 
found at the autopsy at the locality diagnosed, under 
the motor centre for the left leg, but its consistency so 
resembled that of the brain tissue that it could not be 
differentiated (Case 63). The writer remarks that an 
operation may be undertaken too early on the brain- 
i.e., before the tumor has grown sufficiently large to be 
appreciable, even although it may have occasioned pa- 
thognomonic symptoms. 
In 19 other cases where the tumor was not found, 
the reason for the failure was quite different. In Keet- 
ley's case (41) the pons was found enlarged to three times 
its natural size by an infiltrating glioma. The only lo- 
calizing symptom presented had been a slight internal 
strabismus of the left eye (paresis abducens). This fact 
should have suggested a pontine, and consequently 
inoperable tumor, as also the fact that the knee-jerks 
were exaggerated, while absence of paralysis, and ex- 
istence of vomiting, giddiness, and staggering pointed 
to a tumor of the cerebellum.* With the latter, how- 
ever, the knee-jerks are habitually diminished, and this 
special combination of negative and positive signs should 
suggest a lesion of the pons, in spite of the absence of 
many of its characteristic paralyses. The patient, a 
child of seven, who had had a fall fourteen days before 
the onset of the symptoms, had an attack of collapse fol- 
lowed by a subnormal temperature just before the op- 
eration, another circumstance pointing to the pons. An 
exploratory operation was made through the left squa- 
mous bone, but nothing found, and the child died two 
days later. 
In Pilcher's case (31) there was a scar after an injury 
situated over the left angular gyrus, and the skull was 
trephined at this point. The patient had marked men- 
tal impairment, epileptic attacks, beginning in a con jugate 
deviation of head and eyes to the left, and tonic hemi- 
spasm on the right side. Shafer {Brain, April, 1888) 
claims that excitation of the brain near the angular gyrus 
produces conjugate deviations of the eyes to the opposite 
side. The centre for such deviation is placed by Hors- 
ley at the posterior extremity of the middle frontal 
gyrus ; and the autopsy in this case would seem to con- 
firm that localization. A glioma was found on the left 
side, in the occipital lobe, but extending forward as far 
as the frontal lobe. The island of Reil was softened. 
The mental impairment, taken together with the conju- 
gate deviation of the eyes, pointed to the frontal lobes, 
(SUPPLEMENT.) 
where also the headache was situated. Nothing indicated 
the occipital lobe, and at the angular gyrus nothing was 
found. In Sciammana's case (3) also the patient was 
trephined, unsuccessfully, at the seat of an injury to 
the head in the right parietal region. The tumor was a 
glioma, lying in the right centrum ovale and extending 
from the right inferior cornu to the corpora quadri- 
gemina. Crossed paralysis had existed, left hemiplegia, 
followed by right oculo-motor and facial paralysis. This 
is not explained by the autopsy. 
Kerr's operation (58) is the third on the list misled by 
a scar. The indication was the more plausible because 
the scar was situated over the upper part of the left 
fissure of Rolando, in a patient suffering with hemispasm 
and hemiparesis. A glioma was found in the left corpus 
striatum and optic thalamus. This is the only case on 
the list where a tumor in this situation had simulated a 
cortical tumor. 
In Knapp's second case (65), the trephine was applied 
over a tender spot in the right temporal region, although 
there were well-marked symptoms of a cerebellar tumor. 
After death, ten weeks after the operation, the tumor was 
found in the left lateral lobe of the cerebellum. In this 
case the left knee-jerk was absent, and there was slight 
paresis of the left hand, symptoms which, together with 
the characteristic symptoms of tumor, might have suf- 
ficed to indicate the cerebellum. 
In seven other cases an erroneous diagnosis was made 
of tumor of the cortical motor centres (Fraser, Hammond. 
Amidon, Stokes, Walker, Dobson, Twynam), and in one 
(Beach) of tumor of the frontal lobe pressing on the cen- 
tral convolutions (Cases 5, 7, 8, 51, 55, 73, 80). 
In Fraser's case (5) the localizing symptoms were right 
hemiplegia and contracture, indistinct speech, amnesic 
aphasia, agraphia. The error depended on the duplicity 
of the lesion. There wTas a tumor in the middle of the 
right ascending parietal convolution, and another in the 
left temporal lobe involving the ascending convolutions. 
The amnesic character of the aphasia really pointed to 
the left temporal lobe rather than to the neighborhood of 
Broca's convolution. It is difficult to understand the fail- 
ure in Hammond's case (7), as the autopsy revealed three 
cysts in a line in the anterior central convolution pre- 
cisely where the lesion had been diagnosed. In Amidon 
and Weir's case (8) the tumor was found in the cerebellum 
at the autopsy, although the patient had had left hemi- 
spasm and paralysis of the left arm. Two circumstances, 
however, pointed to the cerebellum-with the left-sided 
paralysis co-existed a paresis of the right arm, thus a 
bilateral motor defect, and there was also optic neuritis on 
the left side. Stokes's case (51) shows, as the author re- 
marks, that the motor centre for the leg extends farther 
back than is usually assumed, or else that transmitted 
pressure from a distance may cause the same symptoms 
as a lesion at the centre. A spindle-celled sarcoma was 
found in the parietal lobe, just behind the leg centre, and 
being of the same consistency as the brain, could not be 
distinguished. 
In Walker's case (55) the symptoms were very confus- 
ing. Staggering seemed to indicate a cerebellar tumor, 
as also the vertigo and vomiting. But a marked mental 
defect pointed to the frontal lobes, and motor aphasia to 
a lesion on the left side. On the other hand, left hemi- 
spasm and hemiplegia were to be referred to the right 
side of the brain, and hemorrhage and an offensive dis- 
charge from the right ear seemed to localize the disease 
more precisely near the petrous bone. Paresis of both 
hands pointed to the cerebellum ; exaggeration of the 
left tendon reflex, on the contrary, confirmed the indica- 
tions offered by the left hemiplegia. An exploratory op- 
eration was performed over the left ascending frontal 
with negative result. At the autopsy a cystic mass was 
found at the left of the sella turcica, springing from the 
apex of the petrous bone. The record leaves unexplained 
why this should have been associated with discharge 
from the right ear. 
Dobson's case (73) exhibited an apparently exquisitely 
precise symptom, namely, twitching attacks in left arm, 
beginning in thumb and first finger, with sensory aura in 
* The knee-jerks are usually diminished in tumors of the cerebellum, 
whereas they are exageerated in tumors of the pons. This may be a 
useful detail in distinguishing between these two lesions, whose symp- 
toms often resemble each other. 
133 Brain. 
Brain. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
same parts. Horsley has located the thumb centre just 
behind the middle of the ascending parietal convolution, 
and a signal symptom in Jacksoniam epilepsy, initiated at 
this point, has several times guided to an exact diagnosis. 
But in this case the centre was evidently irritated by press- 
ure from a distance. There were multiple cerebral 
tubercles in the right hemisphere. This is the second 
case of multiple tumor on the list. 
In Twynam's case (80) the tumor seems to have escaped 
detection, partly because it lay too far below the surface 
in the medullary substance, partly because, as in Stokes's 
case, the tumor, though pressing on the central convolu- 
tions, lay behind them, in the parietal lobe. Besides the 
hemiparesis there was some loss of sensation, and this 
symptom, as well as the loss of muscular sense, seems to 
point to the parietal lobe rather than the central convolu- 
tions. Another fact in the same sense was the incomplete 
nature of the paralysis. The tumor found on autopsy 
was very large, 68 by 57 millimetres, extending from the 
Rolandic fissure to the parieto-occipital, and bulged into 
the roof of the lateral ventricle. 
In Beach's case (52), finally, a tumor was diagnosed in 
the left frontal lobe, pressing on the lower part of the cen- 
tral convolutions. The first local symptom had been a 
motor aphasia, followed by tremor, then twitching of 
right hand and eyelid, then paresis of right hand. The 
tumor was found at the supposed level, but, as in Cases 
51 and 80 (Stokes and Twynam), it lay in the parietal lobe 
behind the motor convolutions and between the posterior 
ascending branch of the Sylvian fissure and a small sulcus 
anteriorly which separated it from the ascending parietal 
convolution. There were no sensory symptoms to aid 
the diagnosis. 
In Wille's case (25) a tumor of the left parietal lobe 
(SUPPLEMENT.) 
was diagnosed, but the diagnosis was guided by the ex- 
istence of a swelling over the left parietal bone. Only 
after this had been incised did right hemiparesis appear, 
including the facial nerve. In a second operation sub- 
dural pus was evacuated but no tumor was found. At 
the autopsy was discovered a tumor the size of a pigeon's 
egg in the posterior part of the left paracentral lobule, 
extending into the upper part of the ascending parietal 
convolution. Also, and this makes the third case of mul- 
tiplicity, a second tumor was found in the middle of the 
ascending parietal convolution. In two other cases on 
this list the tumor lay in the cerebellum. In Wyman's 
case (53) it had been diagnosed in the sella turcica, be- 
cause, in addition to the general symptoms, the patient 
had a divergent squint (paralysis motor oculi), anosmia, 
and slight movement of rotation at the beginning of the 
convulsive attacks. There was great muscular weakness, 
but neither hemiplegia nor staggering. A tumor three- 
quarters of an inch long was found in a cavity hollowed 
out in the left hemisphere of the cerebellum. All the ven- 
tricles were distended with fluid. The great frequency 
of cerebellar tumors might, it would seem, have decided 
the surgeon to operate, if at all, in their locality. But 
instead of this he trephined the frontal bone above the 
supra-orbital ridge and passed a probe over the orbital 
plate to the sella turcica with necessarily negative result. 
In Springthorpe's case (47) a cerebellar tumor was cor- 
rectly diagnosed, and several symptoms pointed to press- 
ure on the right lobe of the cerebellum. In the tits 
there was conjugate deviation of the head and eyes to the 
right side ; the right ear was moderately deaf, arid the 
patient fell backward and to the right side. An opening 
was made over the right lobe of the cerebellum, clear 
serous fluid escaped, but no tumor was found. At the 
Table II.-Twenty Cases of Operation where Tumor was not Found. 
No. 
Name. 
Diagnosis. 
Real locality. 
Result. 
Remarks. 
68 
Seguin. 
Tumor under motor centre 
for left leg. 
Locality diagnosed. 
Death. 
Tumor very small, half inch in diameter, and 
of same consistency as brain. 
41 
Keetley. 
No record. 
Infiltrating glioma of 
pons. 
Death in two days. 
Symptoms pointed to cerebellar tumor, but 
exaggerated knee jerks, attack of collapse, 
and subnormal temperature. 
3 
Sciammana. 
Trephined over a scar or 
tender point. 
Right centrum ovale. 
Death in two days. 
Symptoms not explained by autopsy. 
31 
Pilcher. 
Trephined over a scar or 
tender point. 
Occipital lobe. 
Death. 
Conjugate deviation eyes, pointed either to 
angular gyrus or upper part frontal lobe; 
latter affected by pressure. 
58 
Kerr. 
Trephined over a scar or 
tender point. 
Basal ganglia. 
Death. 
Hemispasm and hemiparesis fully simulated 
a cortical tumor. 
65 
Knapp and Brad- 
ford. 
Trephined over a scar or 
tender point. 
Cerebellum. 
Death. 
Symptoms indicated a cerebellar tumor, be- 
cause general symptoms marked, left knee- 
jerk absent, and paresis left hand. 
84 
Gray and Wyeth. 
Tumor in Rolandic convo- 
lutions. 
Tumor of centrum ovale 
one-fourth inch below 
surface of ascending 
parietal convolution. 
Death in three days; 
much e xp 1 o r a - 
tion of brain by 
needles. 
Failure due to identical consistency of neo- 
plasm and brain tissue. 
5 
Fraser. 
Tumor in Rolandic convo- 
lutions. 
Double lesion : first, as- 
cending parietal : sec- 
ond, temporal lobe. 
Death. 
Amnesic aphasia really indicated temporal lobe 
or island of Reil. 
Hammond. 
Tumor in Rolandic convo- 
lutions. 
Triple lesion, but all in 
motor convolution. 
Death in twenty-one 
hours. 
Failure to find three cysts is not explained. 
8 
Amidon and Weir. 
Tumor in Rolandic convo- 
lutions. 
Cerebellum. 
Death in ten weeks. 
There was bilateral motor defect and left optic 
neuritis, which might have suggested cere- 
bellar lesion. 
51 
Stokes. 
Tumor in Rolandic convo- 
lutions. 
Parietal lobe, just be- 
hind leg centre. 
Death in three 
weeks. 
Symptoms very confusing, but included dis- 
charge from ear. 
55 
Walker. 
Tumor in Rolandic convo- 
lutions. 
Apex petrous bone. 
Death in few hours. 
73 
Dobson. 
Tumor in Rolandic convo- 
lutions. 
Multiple tubercles in 
hemisphere. 
Death in one month. 
Apparently characteristic cortical epilepsy. 
80 
Twynam. 
Frontal lobe, pressing on 
motor convolutions. 
Parietal lobe. 
Death fourth day. 
Some loss of sensation might have suggested 
superior parietal lobule. 
52 
Beach. 
Frontal lobe, pressing on 
motor convolutions. 
Parietal lobe. 
Death second day. 
In this case no sensory symptoms, and motor 
aphasia had preceded hemispasm. 
25 
Wille. 
Parietal lobe (scalp swell- 
ing here). 
First, in paracentral 
lobule ; second, in as- 
cending parietal. 
Death. 
Many cerebellar symptoms, but also paralysis 
abducens and anosmia. 
53 
Wyman. 
Sella turcica. 
Left hemisphere of ce- 
rebellum. 
Death. 
47 
Springthorpe. 
Cerebellum, right hemi- 
sphere. 
Middle lobe cerebellum. 
Death. 
Pressure on right side localized the symptoms. 
82 
Starr and McBur- 
ney. 
Right lobe cerebellum. 
Middle lobe cerebellum. 
Sudden death in 
few days. 
40 
Keen (Reference 
Handbook Med- 
ical Sciences, 
1889). 
Tumor cerebellum. 
Cerebellum. 
Death in fifty-two 
days. 
Tumor diagnosed but not sought; ventricles 
tapped for internal hydrocephalus. 
134 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Brain. 
Brain. 
autopsy a glioma with a central cavity was found to oc- 
cupy the middle lobe of the cerebellum. All the ventri- 
cles were full of blood-stained fluid. The main pressure 
was upon the right side. 
The last case has just been reported by Gray and 
operated by Wyeth (84). The exact locality of the tumor 
was correctly diagnosed, but it lay one-quarter inch be- 
low the surface (as had been expected from the absence 
of convulsions), and the consistency so closely resembled 
that of the medullary brain-tissue in which it was em- 
bedded that an exploring needle passed through it without 
detecting its presence, and it was discovered at the autop- 
sy with difficulty, and by careful slicing of the brain. 
Nearly all the cases where the tumor was not found at 
the site of operation proved fatal, the operation seem- 
ing to accelerate the natural march of the disease. One 
case, however (Amidon and Weir), survived ten weeks, 
another (Dobson) a month. Four cases illustrate the now 
accepted rule, that a scar, and still less a tender point 
on percussion, must not be selected as a site of operation, 
unless focal symptoms point to the same locality. 
In the five cases of cerebellar tumor a retrospect of the 
symptoms, after the autopsy, makes them seem more 
significant than they had appeared before the operation. 
Cases 47 and 53, as do many other cases which have not 
been operated, show the impossibility of distinguishing 
with certainty whether a tumor of the cerebellum be situ- 
ated in its lateral or its middle lobe. Nothnagel's law of 
the frequent latency of tumors of the lateral lobes should 
always incline the diagnosis in favor of a central lesion, 
unless lateral symptoms are very well marked. The 
danger of hemorrhage, however, from trephining over 
the centre of the cerebellum, i.e., of the sinus, is very 
great, and, on the other hand, a tumor of the middle lobe 
is sometimes accessible from the side. 
(SUPPLEMENT.) 
where an inoperable tumor of the middle lobe of the cere- 
bellum existed. The patient had suffered for along time 
from epileptiform fits, with violent rotary movements, 
from severe headache and distressing attacks of dysp- 
noea. All these symptoms disappeared after the opera- 
tion, and the patient's life was prolonged in comfort for 
two years. 
In Heath's case (27), also, a large adherent growth was 
found over the right ascending frontal convolution, which 
could not be removed. Localized tenderness had existed 
over the site of the tumor. The patient was relieved 
of his headache by the operation, and, at the time of re- 
porting, had made a good recovery. In Case 35 (Limont 
and Page) a portion of a large glioma was removed, with 
temporary recovery, but the growth recurred. 
In Case 39 (Kocher) tumor of the cerebellum was diag- 
nosed from the four classical general symptoms, in the 
absence of focal symptoms. A double trephine opening 
was made to relieve intracranial pressure, one posteriorly 
on the right side below the tentorium, one anteriorly on 
the left side. In four days congestion of the optic disks 
had disappeared, but there was no improvement of vision. 
In Maudsley's case (42) a tumor had been diagnosed in 
the left lobe of the cerebellum, the trephine was applied at 
this locality and a tumor found, but it was a solid nod- 
ule, irremovably attached to the temporal bone. The 
patient recovered from the operation. Five other cases 
proved rapidly fatal. The entire list of ten cases is sum- 
marized in Tables III. and IV. 
Death occurred after removal of the tumor in sixteen 
other cases. The causes may be thus tabulated : 
1 
Bennett and 
Glioma upper third Rolan- 
Hernia cerebri ; septic 
God lee. 
die fissure. 
meningitis ; death in 
thirty days. 
4 
Hirschfelder 
and Morse. 
Infiltrating glioma post 
central gyrus. 
Death eighteenth day ; 
septic encephalitis. 
12 
Horsley. 
Tubercle right lobe cere- 
bellum, seven drachms. 
Death in nineteen 
hours from shock; 
general tuberculosis. 
13 
Bennett May. 
Tubercle size of pigeon's 
egg in cerebellum. 
Death from shock. 
14 
Suckling. 
Tumor left and middle 
lobes cerebellum. 
Death from shock in 
forty-eight hours. 
22 
Von Berg- 
mann. 
Cyst in Rolandic region 
communicating with 
lateral ventricle. 
Death in four weeks 
from meningitis. 
32 
Wood and 
Agnew. 
Right temporo-sphenoid- 
al lobe. 
Death from hemorrhage. 
34 
Thomas. 
Tumor, three ounces, mid- 
dle central convolutions. 
Death in three days. 
37 
Verco. 
Hydatid cyst adherent to 
temporo - sphenoidal 
lobe. 
Death from meningitis 
with temperature 
104° F. 
43 
Barton. 
Rolandic gyri syphilitic 
gumma with necrosed 
bone. 
Death in a month from 
encephalitis. 
44 
Lampiasi. 
Tubercle size of egg in 
cerebellum. 
Death in four days. 
46 
Knapp and 
Bradford. 
Tubercle, 35% grms., mid- 
dle ascending frontal 
convolution. 
Death from shock in 
three-quarters hour. 
64 
68 
Bullard and 
Bradford. 
Keen. 
Cheesy tubercle in cere- 
bellum. 
Tumor size of filbert five 
centimetres from end of 
occipital lobe. 
Sinus opened ; death 
from hemorrhage. 
Death in fourteen hours. 
6!) 
Castro. 
Tumor size of walnut 
over Rolandic fissure. 
Death from epidemic 
diphtheria affecting 
wound. 
81 
McBurney 
and Starr. 
Very large glio-sarcoma 
from frontal lobe. 
Death from shock in 
few hours. 
Table V.-Tumor Removed 
with Fatal Result. 
Table III.-Tumor not Removed, Temporary Recovery. 
45 
Horsley. 
Tumor middle lobe cere- 
Life prolonged in com- 
bellum; removal occipi- 
tal bone in two opera- 
tions. 
fort for two years. 
27 
Heath. 
Large adherent growth 
over ascending frontal 
convolution. 
Relief and prolonged re- 
covery. 
35 
Limont and 
Page. 
Temporary recovery; 
recurrence of growth. 
39 
Kocher. 
Tumor cerebellum diag- 
nosed. 
Double trephining re- 
lieved intracranial 
pressure, arrested op- 
tic neuritis. 
49 
Maudsley and 
Tumor a solid nodule fixed 
Recovery with persist- 
Fitzgerald. 
to temporal bone. 
ent blindness and 
deafness. 
15 
Birdsall and 
Sarcoma at tip of occipi- 
Death from hemorrhage 
Weir. 
tai lobe ; softened con- 
tents removed. 
in a few hours. 
54 
Clarke. 
Subdural growth over up- 
per end fissure Rolando 
adherent to longitudi- 
nal sinus; partial re- 
moval. 
Death from septicaemia 
on nineteenth day. 
59 
Eskridge. 
Glioma left frontal lobe 
reaching beyond fissure 
Rolando; too large for 
removal. 
Death in eight days. 
78 
Nixon. 
Bone necrosed over tu- 
mor ; operation at this 
point; neoplasm is com- 
pletely removed ; carti- 
laginous, adherent to 
longitudinal sinus. 
Death fifth week from 
secondary hemorrhage 
from wound. 
83 
Starr and 
McBurney. 
Cysto - sarcoma middle 
lobe cerebellum: tapped 
but could not be re- 
moved. 
Death in a few days. 
Table IV.-Tumor not Removed, Fatal Cases. 
Five out of these 16 cases are tumors of the cerebellum. 
Five cases on Table IL, one on Table III., and one on 
Table V., were also cerebellar; thus 12 out of the total 
number of 46 unsuccessful cases, or twenty-six per cent. 
The death from diphtheria (Castro) and that due to 
accidental opening of the cerebellar sinus (Bullard and 
Bradford) are theoretically avoidable. The case of 
glio-sarcoma removed by McBurney had been correctly 
diagnosed eleven months before, and the operation then 
advised. At that time it might have been successful, so 
that in this case the fatal issue may fairly have been at- 
tributed to the delay. It may perhaps be assumed that 
Operation on tumors too large for removal, when the 
cranial opening was really made over the seat of the le- 
sion, have not always proved so dangerous as in the 
class of cases just described. Thus, Horsley (Case 45) re- 
moved first one half of the occipital bone, then the other, 
135 Brain. 
Brain. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
the five deaths caused by septic meningo-encephalitis 
could have been avoided by more perfect antiseptic pre- 
cautions. 
The fatal issue is not clearly explained in the cases re- 
ported by Gray, Thomas, and Keen. The last case is 
particularly interesting, because the tumor had been cor- 
rectly localized in the cuneus on account of the symptom 
of hemianopsia. It is the only case in the entire collec- 
tion where this symptom was thus rendered available. 
In 39 cases the operation was successful. The situa- 
tion of the tumor in these cases is shown in the next 
table. 
Table VI.-Successful Cases. 
B u 
S 4> 
5-° 
Name. 
Diagnosis and Operation. 
Locality. 
Result. 
2 
Macewen. 
Tubercular membranous mass removed from right ascending 
frontal gyrus. 
Rolandic region. 
Recovery complete. 
10 
Horsley. 
Upper part middle third Rolandic region. 
Ibid. 
Recurrence tumor in three months; death 
in six months. 
9 
Ibid. 
Tumor thumb centre in ascending parietal gyrus. 
Ibid. 
Complete recovery ; disappearance of epilepsy 
and paralysis. 
11 
Ibid. 
Tumor hand centre pressing on Broca's convolution. 
Ibid. 
Recovery; persistence, but arrest of hemi- 
plegia. 
17 
Macewen. 
Tubercle size of hazel-nut top of ascending parietal. 
Ibid. 
Recovery. 
18 
Ibid. 
Cyst size of filbert base of left ascending frontal gyrus. 
Ibid. 
Recovery. 
19 
Ibid. 
Yellow mass over upper part right ascending convolutions. 
Ibid. 
Recovery. 
20 
Lucas Cham- 
pionniere. 
Large hyperostosis over left ascending frontal convolution. 
Ibid. 
Recovery, with persistent hemiplegia. 
21 
Rannie. 
Degenerating gumma from right ascending frontal. Piece of 
dura and brain removed. 
Ibid. 
Recovery, with cessation symptoms. 
23 
Seguin and 
Weir. 
Sarcoma size of almond one inch below posterior edge second 
frontal and anterior edge precentral gyrus. 
Ibid. 
Perfect health six months after operation ; 
signs of recurrence later. 
29 
Pean. 
Growth from dura over left ascending convolution ; fibro- 
lipoma. 
Ibid. 
No more epileptic attacks two months after 
operation. 
30 
Fisher. 
Sarcoma pressing on left central convolution. 
Ibid. 
Recurrence of tumor two months after oper- 
ation and death. 
38 
Mercanton. 
and Coinbe. 
Tumor middle left ascending frontal reaching to island of 
Reil. 
Ibid. 
No record, but presumed recovery. 
48 
Oppenheim. 
Glioma in cystic degeneration lower part ascending convolu- 
tion. 
Ibid. 
Complete recovery. 
49 
Graham. 
Hydatid cyst upper portion fissure Rolando. 
Ibid. 
Recovery, with blindness. 
50 
Church. 
Spider-shaped sarcoma over left arm centre ; decortication 
one-quarter inch. 
Ibid. 
Recovery ; recurrence epilepsy in two months. 
56 
Dumin. 
Anterior convolutions. 
Ibid. 
Recovery ; sudden death in four months after 
operation. 
57 
Bremer and 
Carson. 
Cavernous angioma at fissure Rolando. 
Ibid. 
Recovery. 
62 
McCall An- 
derson. 
Tumor at thumb centre right parietal convolution. 
Ibid. 
Perfect recovery ; no attack for eight weeks. 
66 
Mills and 
Keen. 
Small sarcoma from pia pressing upon central convolutions. 
Ibid. 
Recovery ; diminished severity attacks. 
72 
Llobet. 
Motor convolutions. Resected temporal bone. 
Ibid. 
Recovery, only memory not returned in 
three months. 
61 
Reynier and 
Blocq. 
Cyst over central convolutions extending to frontal gyri. 
Ibid. 
Cyst drained in first, removed in second 
operation; no attacks during three and 
one-half months. 
60 
Doyen. 
Very large cyst behind bulging bone. 
Ibid. 
Cyst drained for six weeks, 360 c.c. fluid 
at one time. 
70 
Poirier. 
Vascular tumor central gyri. 
Ibid. 
Recovery ; freedom from epilepsy. 
29 
Pean. 
Right leg centre. 
Ibid. 
Recovery ; cessation epilepsy at two months. 
75 
Hitzig. 
Cyst size of goose-egg. 
Ibid. 
Recovery. 
76 
Von Bram- 
mann. 
Cystic tumor at fissure Rolando. Drained twice ; removed at 
third operation. 
Ibid. 
Recovery. 
77 
Ibid. 
Spindle-ceiled cysto-sarcoma in Rolandic area. 
Ibid. 
Recovery. 
85 
Stieglitz and 
Gerster. 
Tumor arm centre. 
Ibid. 
Recovery, but symptoms recurrence six 
months later. 
16 
Markoe. 
Hemorrhage cyst over parietal lobe ; depression skull. 
Gummous tumor size of walnut under right parietal eminence. 
Parietal lobe. 
Recovery. 
33 
Parker. 
Ibid. 
Recovery on eightieth day. 
24 
Keen. 
Fibroma base third frontal convolution, reaching to fissure 
Rolando. 
Frontal lobe. 
Recovery eighty-fourth day; epileptic at- 
tack five weeks later. 
6 
Durante. 
Fibro-sarcoma, 70 grammes, in anterior fossa. 
Ibid. 
Prompt recovery, persisting four years after 
operation. 
74 
Hitzig. 
Tumor, 280 grammes, posterior part frontal lobe. 
Ibid. 
Recovery. 
79 
Clegg. 
Exophthalmos ; removal sarcoma with eyeball. 
Ibid. 
Return of pain and attacks in four months. 
26 
Fitzgerald. 
Echinococcus behind left temple. 
Ibid. 
Recovery. 
28 
Macewen. 
Nodule on skull between ascending convolution and frontal 
lobe. 
Tumor of dura at 
frontal lobe. 
Recovery for eight years. 
71 
Booth and 
Curtis. 
Erosion of bone at angular process frontal. 
Tubercle frontal 
lobe. 
Recovery. 
36 
Maunsell. 
Cyst four inches long, three inches broad. 
Cerebellum. 
Recovery; blindness persists. 
These cases of recovery include one, and only one, case 
of tumor of the cerebellum, and that was a cyst. This 
is to be reckoned against 12 fatal cases of cerebellum 
tumor, already noted. As might be expected, in the im- 
mense majority of successful cases the tumor is situated 
in the motor convolutions (29 out of 39 cases). This 
region unites all the conditions of success, facility of 
diagnosis, facility of operation, relative freedom from 
danger of shock. Among the unsuccessful cases the 
tumor was situated in the central convolutions only 7 
times, and in one of these the death was purely acciden- 
tal, due to an epidemic diphtheria. In all the others 
death was due to septic meningitis, in one case, also 
syphilitic. In one a communication existed between the 
tumor and the ventricle ; in another, there was an adhe- 
sion to the longitudinal sinus. 
The symptoms of lesion of the central convolutions 
are so well marked that when the tumor exists in this 
locality it cannot easily be overlooked. It sometimes 
happens, however, that tumors in other localities simu- 
late the symptoms proper to disease in the cortical motor 
centres. Thus : 1. The tumor may be situated in the 
subcortical region of the centrum ovale, as in Gray's case 
(84). The diagnosis in this case, notwithstanding the 
monoplegia, was correctly made as subcortical, on ac- 
count of the absence of spasm or convulsion. 2. The 
136 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Brain. 
Brain. 
tumor may lie in the frontal, parietal, or temporal lobes, 
and by transmitted pressure excite the symptoms proper 
to the motor area. The diagnosis, when possible, is made 
out by observing that lesions of intelligence, or speech, 
or sensibility, or vision, especially hemianopsia, have pre- 
ceded motor symptoms, and that the latter remain incom- 
plete- paresis, not paralysis. 3. Tumor of the basal 
ganglia may simulate cortical tumor. This occurred in 
Case 58 (Kerr). It is rather surprising that the mistake 
has not been made more frequently. That it has not, is 
due to the enormously valuable studies in "Jacksonian 
epilepsy," that may be ranked as the second link in the 
chain of investigation which, beginning with the re- 
searches of Hitzig and Ferrier on brain localization, have 
so rapidly led to brain surgery. Only one tumor of the 
occipital lobe has been operated at its site, the diagnosis 
having been guided by the remarkable symptom hemi- 
anopsia (Birdsall and Weir, 15). 
In Pilcher and Dana's case (31) the tumor occupied the 
left occipital lobe, but the operation was made at the site 
of a scar corresponding to the angular gyrus. The 
tumor, therefore, was not found. It is not stated 
whether the patient was examined for hemianopsia. 
It is claimed, especially by Starr, that an onset of 
symptoms with psychical changes is very characteristic 
of tumors of the frontal lobe. Such mental depression, 
however, is apt to occur with intracranial tumors in any 
locality, and cannot be considered a distinct indication 
of frontal lobe localization until, by extension backward, 
motor symptoms began to complicate the mental; or un- 
til conjugate deviation of head and eyes has become a 
signal symptom in convulsive attacks ; or until anosmia 
be discovered. In several of the frontal lobe tumors here 
recorded an external lesion coexisted and guided the 
operator to the exact locality. 
It seems to have become accepted that a fairly large 
opening through the skull is preferable to the small tre- 
phine openings originally chosen. With such large flaps 
much greater facility is offered for detecting a tumor, 
whose remote pressure symptoms had confused the pre- 
operative diagnosis (see Gray's case). 
From the foregoing record of cases we may deduce 
several propositions, which, collectively, contain the sum 
of new knowledge acquired in the treatment of brain 
tumors during the past decade. 
In the first place, it has been demonstrated that it is 
practicable to open the cavity of the cranium, to pene- 
trate the dura mater, to lay bare the brain, and even to 
excise portions of its tissue. The successful removal of 
brain tumors has restored to favor as a legitimate surgi- 
cal procedure the old operation of trephining, which 
had fallen into desuetude. * So far this surgical resto- 
ration has proved more useful in other cases of brain dis- 
ease than in that which is the subject of this chapter 
(see chapter on " Brain Surgery "). But the fact will al- 
ways remain interesting, that it was the greater exploit 
of excising a cerebral neoplasm, which has, in entirely 
modern times, encouraged surgeons to the lesser effort 
of trephining for cerebral abscess and traumatic hemor- 
rhage ; and revived the old rules of unhesitating trephin- 
ing in traumatic cases with depressed fracture. 
Again, when Hughlings-Jackson first began to study 
the precise order of development of the sensori motor 
phenomena in the class of convulsive attacks which now 
bears his name, their habitual dependence upon organic 
brain lesion had not yet been established. This has 
now been shown, and the cases of brain tumor attended 
by attacks of Jacksonian epilepsy have assumed the 
most favorable prognosis, because the fact of the at- 
tacks usually indicates that the tumor is situated in the 
cortex of the central convolutions, and from the details 
of the attack the exact motor centre may be inferred. 
Pursuing still further the line of thought, neurological 
surgeons have argued that if a tumor in the motor area de- 
termines a definite series of explosive symptoms-sensori- 
motor irritation, followed by sensori motor paralysis- 
(SUPPLEMENT.) 
the occurrence of such symptoms, apart from indications 
of intracranial tumor, implies that the same motor region 
is irritated, though in some other way than by a neoplasm. 
Many cases of epilepsy, hitherto considered a functional 
disease,* have therefore been trephined, and in many of 
these, organic lesions, as cicatrices, have been removed 
from the surface of the brain or meninges, with the result 
of allaying or arresting the convulsive attacks. Finally, 
even in the absence of all visible lesion, portions of cor- 
tical tissue have been excised containing the centres of 
motor representation corresponding to the limb seg- 
ments whose spasm initiates the attack. 
It is not within the province of this article to discuss 
this latest and most interesting development of surgical 
method, which began with removing the tangible organic 
causes of epilepsy. We may observe, however, that the 
signal symptom of the attack (the felicitous expression 
is Seguin's), which is held to localize the lesion, because 
indicating the point of earliest and most intense irrita- 
tion, does not necessarily show that the irritation origi- 
nates at this- point. It is quite as possible that the nerve- 
tissue has received an irritation propagated from some 
distant region, but not manifest until it has spent itself 
upon a motor centre and thence determined a nervous 
discharge. Excision of the motor centre, therefore, 
would not remove a cause of the spasm, but only the 
first effect, of some possibly inaccessible cause. 
From the frequent failure of the operation as a cure for 
epilepsy one may suspect that some such condition of 
things often exists. The difficulty in these non-organic 
cases is paralleled in cases of tumor, where, though the 
convulsions are immediately initiated by irritation of the 
cortical motor area, the causal lesion is situated in some 
other part of the brain and cannot be found. 
Another parallel has a more hopeful aspect. It has 
been sometimes found in cases of inoperable tumor 
that the symptoms due to pressure-vomiting, headache, 
and convulsions-could all be relieved when the pressure 
was lessened by trephining or removal of large pieces of 
cranial bones.f It seems therefore possible that in cases 
of epilepsy without gross or focal lesion, and before irre- 
mediable degeneration had set in, similarly afforded relief 
of intracranial pressure might arrest the disease. 
Traumatism, even when not more severe than that of a 
fall on the head, has always been recognized as an impor- 
tant factor in the etiology of brain tumors. Out of the 85 
cases of operation on record, there is a history of a fall or 
a blow in 204 Morbid symptoms rarely develop very 
soon after the accident : months, sometimes years, inter- 
vene. In the light of the experience now accumulated, 
it is indicated to operate very early after the appear- 
ance of symptoms indicative of intracranial neoplasm ; 
and the indication is especially formal if there is a his- 
tory of previous traumatism. It is possible, as Seguin's 
case shows, to operate so early that the tumor has not 
yet grown large enough to be found at the operation. 
This is, however, the only case on the list where the oper- 
ation failed from this cause ; only when the tumor is situ- 
ated entirely on the surface of the cortex is it liable to 
excite convulsive twitchings while yet very small; but 
in such a situation the tumor should be easily found.§ 
The danger of delay in operating is well shown in the 
first case of Starr and McBurney (Case 81). Eleven 
months intervened between the establishment of the 
diagnosis (when the operation was first proposed) and 
the time when the patient's consent to the operation was 
secured. In that time the tumor grew to such a size that 
its removal was followed by death from shock in a few 
hours. 
* According to the present view, non-local izable, i.e.. generalized epi- 
lepsy depends upon a diffused microscopic sclerosis (Fere, Les Epilep- 
sies) or a degeneration and vacuolation of ganglion cells (Dana, Treat- 
ise on Nervous Diseases). 
t Horsley (see Case 45) removed first one half, then the other half of 
the occipital bone, "and the patient lived in comfort two years." 
t Cases 1, 3, 5, 16, 18, 24. 31, 37, 38. 41. 49, 55, 58, 68, 74, 76. 76, 80. 82. 
Case 38 is particularly interesting. It is that of a little girl in a Swiss 
school who was struck on the head with a ruler by her teacher. 
§ In Case 50 (Church) the tumor was a spider-like, filiform growth, ex- 
tended on the surface of the central and frontal gyri. 
* Horsley, in a learned lecture, claims to have found evidence of 
operative trephining on the skulls of prehistoric men. 
137 Brain. 
Brain. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
The development of optic neuritis is not always pro- 
portioned to the size of the tumor, but much more to its 
situation. Hence, as has long been known, optic neuritis 
appears early and advances rapidly with tumors of the 
cerebellum, where the intracranial pressure is at its maxi- 
mum. An early operation is often indicated to relieve 
this pressure before the optic nerves should have atro- 
phied, in which case the patient would remain blind, 
even though be survived the operation and were re- 
lieved of other urgent symptoms.* 
An important decision formulated by Horsley is that 
syphilitic tumors should be operated on, and not left to 
the uncertain influence of internal treatment. Bergmann, 
on the other hand, maintains the sufficiency of this treat- 
ment, and the superfluous risk of the operation. 
If it be assumed that all tumors of the cortex and cen- 
trum ovale are conceivably operable, the proportion of 
operations to cases would be forty-one per cent., since 
266 out of 649 cases of tumor are situated in these two 
localities. If to these be added 162 cases of the cere- 
bellum the proportion would rise to sixty-five per cent, 
(table quoted on p. 132). 
The special difficulties surrounding tumor of the cere- 
bellum have already been emphasized. The general 
diagnosis is relatively easy, that is, it is usually easy to 
diagnose a tumor of the posterior cranial fossa and sub- 
tentorial. It is often difficult to distinguish between the 
middle lobe of the cerebellum and a lateral lobe ; and 
usually impossible to distinguish between tumor of the 
bone compressing the cerebellum and tumor of the organ 
itself. A precious aid in diagnosticating tumors of the 
occipital lobe from those of the cerebellum is the exist- 
ence of hemianopsia in the former, as against optic neuri- 
tis in the latter. Case 41 (Keetley) shows how a tumor 
of the pons may be mistaken for a cerebellar tumor, when 
by exception the paralyses of cranial nerves, so character- 
istic of pontine tumors, are lacking. The prognosis in 
cerebellar tumors, however, is rendered bad, far less by 
the difficulties of diagnosis, than by the special dangers of 
the operation which have already been mentioned. In the 
centrum ovale and cortex, on the contrary, the dangers 
of the operation are at the minimum, provided the tumor 
can be found. The difficulty of finding it depends upon : 
1st, whether it lie in a latent zone or in one whose symp- 
tomatology has been determined : 2d, upon its proximity 
to the surface ; 3d, upon the differentiation of its con- 
sistency with that of the brain. 
The accessible regions of the cerebrum whose lesions 
have so far been connected with sufficiently definite differ- 
ential symptoms, are as follows : 
Parietal lobe: 
Anterior convolutions or 
superior parietal lobule. 
Posterior convolutions: 
Angular gyrus. 
Occipital lobe: 
Cuneus. 
Temporal lobe : 
First convolution. 
Tip of lobe. 
Island of Reil. 
Incomplete symptoms of irritation or 
paresis of motor symptoms, usually de- 
veloped after general symptoms of brain 
tumor ; diminished sensibility; loss of 
muscular sense. 
Apraxia (?). 
Homonymous hemianopsia. Stagger- 
ing. ataxia, from pressure on cerebellum 
(sometimes). 
Sensory aphasia : motor spasm and pa- 
resis as tumor grows upward. 
Combination of motor aphasia from 
pressure on Broca's convolution, with sen- 
sory aphasia. 
Aphasia of transmissibility. 
Tumors of the centrum ovale are always latent, un- 
less they become very large, or are near enough to the 
surface to affect the cortex. By lesion of the motor 
tracts they cause paralysis unpreceded by spasm. Two 
cases are recorded (cases of Sciammana and Gray) where 
tumors of the centrum ovale escaped detection at opera- 
tion. 
In Sciammana's case (3) the locality was not diagnosed, 
and the trephine applied over a misleading scar. In 
Gray's case (86) the position was made out with great 
precision, but the failure was due to the third operative 
difficulty which has been mentioned, namely, the soft 
consistency of the tumor. 
This difficulty can never be foreseen in advance, and 
seems to be as great with large as with small tumors. 
Possibly some future therapeutic resource will enable the 
surgeon to prepare his patient for operation by the in- 
gestion of some food or drug which should change the 
consistency of the tumor. 
For details of cranio-topography, operative procedure, 
and technique, and the special dangers incident to the 
operation for brain tumor, the reader is referred to the 
article on " Brain Surgery," by Dr. Keen, in Vol. VIII. 
of the Reference Handbook? 
Mary Putnam-Jacobi. 
1 Surgical Treatment Diseases of Brain, translation from Beilin 
edition, in Wood's Medical and Surgical Monographs, 1890, New York. 
2 Horsley, British Medical Journal, 1890, reports without detail several 
such cases of similar trephining. 
BRAIN, VESSELS OF THE. Arteries, Medidural.- 
The furrows of the medidural artery on the entocranial 
wall deepen with years, and in old age the artery sinks 
quite into them. It has two primary branches, a larger 
cephalic and a caudal, the former again soon (at the 
sphenoidal angle of the parietal bone) separating into 
two secondary rami. The anterior ramus runs up behind 
the coronal suture, though a little more obliquely, being, 
according to Marchant, pretty constantly from 0. to 13 
mm. (averaging 5 to 6 mm.) away at the foot of the sut- 
ure, about 1 ctm. at its middle, and 15 mm. at its dorsal 
part. The second ramus starts on the entotemporal sur- 
face 4 ctm. behind the pterion, on an average. At its 
middle, on the entoparietal surface, it averages 54 mm. 
behind the coronal suture. Farther dorsad, the distance 
is very variable, 30 mm., more or less. 
The primitive caudal branch leaves the temporal 
squama 58 mm. behind the pterion, then goes toward, 
and becomes parallel with, the lambdoidal suture. 
The relations of these vessels to the subjacent cortex, 
important clinically, Duchaine sums up thus : 1. The 
cephalic branch runs up opposite the frontal lobe some 
ctm. before the central fissure, rather nearer the coro- 
nal suture. 2. The mid-ramus starts almost opposite 
the fissure, then runs up some ctm. behind it. 3. The 
caudal branch is always a ctm. or more distant from 
the fissure, and is still further separated above. 
Variations in the Basal Arteries.-Dercum offers "A 
Collection of Anomalies of the Circle of Willis" (Jour, 
of Nerv. and M. Dis., 1889, Jan.), and J. II. Lloyd (Ibid., 
1890, p. 225) gives such a case of a type described by Duret 
(right vertebral absent, both precerebrals from left caro- 
tid, etc.). St. John Bullen (Jour. Mnt. Sei., 1890, Jan., p. 
Frontal lobes : t 
Posterior and second 
frontal convolution. 
Left third frontal convolu- 
tion. 
Central convolutions. 
Marked and primary impairment of in- 
telligence. 
Spasmodic conjugate deviation head 
and eyes to side opposite lesion at begin- 
ning of epileptic attack : agraphia (?). 
Motor aphasia ; anosmia on side of 
lesion (sometimes); secondary incomplete 
irritative or paralytic motor symptoms ns 
tumor extends backward ; exophthalmos, 
unilateral (sometimes). 
Spasm, followed by paresis or paralysis, 
both permanent or intermittent, and oc- 
curring in attacks of Jacksonian epilepsy 
or as signal symptoms in general con- 
vulsion, in one or more segments of face 
or limbs innervated from the known motor- 
centres. 
* See Case 49 (Graham). In the article on Brain Tumor in the 
Refebence Handbook it has been noted that choked disk is some- 
times due to neuritis from diffused cerebritis, sometimes also to direct 
pressure on the optic tract. 
+ The following case illustrates the possible latency of a tumor of the 
frontal lobe: Boy, aged eight. Extensive joint disease right elbow and 
left tarsus. Thirty hours before death convulsion for the first time. 
Began on left side, with spasmodic closure eyelid, twitching in face, 
neck, arm, leg. Wave of convulsion then passed rapidly to right limbs. 
Examination, then made for first time, discovered double optic neuritis 
and anosmia. Death. Tumor. 3| inches long, 2| inches thick, at base of 
right frontal lobe, extended from one half inch of tip of frontal lobe to 
point corresponding to section through bases of first and second frontal 
convolutions, one inch anterior to fissure of Rolando. Came to surface 
at junction of third frontal with orbital gyrus. The tumor lay imme- 
diately behind and external to the root of the olfactory nerve. 
138 Reference Handbook 
OF THE 
Medical Sciences 
Plate XXXV. 
Fiy 1. 
Fig 2. 
Fig 3. 
Arterial Supply of Oblongata (from Adamkiewicz.) REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Brain. 
Brain. 
33) bases the following statements on the examination of 
1,565 brains (from the insane), but holds statistics too un- 
certain. Arterial variations occur much oftener in gen- 
eral paralytics than in those dying of other forms-this 
applying equally to all segments of the circle of Willis. 
However, such anomalies are more common in the post- 
communicants than in all the others. Of these vessels : 
1, Either may be absent ; 2, may be replaced by a branch 
from the subcerebellar, internal carotid, postcerebral, or 
two small nutrient branches respectively from the last 
two vessels ; 3, may supply unusual regions ; or, 4, may 
be unconnected with the carotid system. 
The precommunicant may be absent, or merely rudi- 
mentary, or double. Either of the postcerebrals may, 
1, be absent; 2, be a branch of the carotid system ; 3, be 
replaced by a large postcommunicant; or 4, by two 
thread-like vessels from the basilar. 
Either precerebral may, 1, be replaced by two small 
trunks; or 2, be absent, its region being supplied by branch- 
es of the opposite artery. Only occasional variations 
are attributed to the vertebrals : 1, absence of one, the 
existing vessel being joined by a branch from the oppo- 
site carotid ; 2, both may join the basilar on the same 
side ; 3, or one may be represented by two or three branch- 
es before entering the formation of the basilar trunk. 
Prechoroid Artery.-In general Kolisko's work corrob- 
orates that of Heubner. In a large number of examina- 
tions this vessel was never absent. It has a pretty con- 
stant diameter of | mm. In the foetus it is relatively 
very large. In animals (dogs, cats, rabbits) it was regu- 
larly present, but arose from the Sylvian. The branch to 
the uncus was always present, but has free anastomoses 
in the pia. The branches in plexus and tela also anasto- 
mose freely with others near ; but those to the brain- 
substance are terminal. 
The prechoroid supplies the following parts : The pos- 
terior arm of the internal capsule, with the lamina med- 
ullaris externa of the thalamus to the level of the upper 
angle of the mid-lenticular segment-usually only the 
posterior two-thirds ; the white substance back of the 
internal capsule as far as the roof of the medicornu ; the 
inner lenticular segment ; the uncus ; the optic tract (in 
its posterior half) ; the lateral choroid plexus ; the en- 
dyma of the posterior and lower parts of the paracoele ; 
the greater part of the tail of the caudatum ; exception- 
ally the external parts of the upper half of the thalamus. 
But the posterior arm of the internal capsule is also in 
part supplied by the medicerebral and postcommunicant 
(the anterior third of this part by the latter vessel), the 
deeper parts by the prechoroid and postcommunicant, 
and the upper parts (above apex of mid-lenticular seg- 
ment) by the Sylvian (lenticulo-optic ramus of Duret). 
Circulatory disturbances in the supply-territory of the 
prechoroid cause opposite hemiplegia by softening in the 
posterior segment of the internal capsule, involving the 
pyramidal and cranial-motor tracts. 
Hemianaesthesia, hemianopsia, and hemianosmia may 
likewise follow closure of the prechoroid, but are usu- 
ally headed off by collateral supply. 
Where the postcommunicant is large, its blocking may 
cause opposite facial and hypoglossal paralysis, since these 
tracts traverse the front part of the posterior arm of the 
capsule. 
Arteries of Oblongata.-The recurrent spinals from the 
vertebrals are given as follows by Kadyi. Immediately 
after the vertebrals traverse the dura there arises from 
each a 1 mm. thick branch (dorso-myelic), which, after 
giving up twigs to the restiform body, descends along the 
dorsal border of the lateral columns of the cord. This 
is homologous with other branches entering by the dorsal 
nerve-roots. Sometimes this arises from the vertebral in 
common with the postcerebellar. 
Near the union of the vertebral to the basilar there 
arises-usually one on each side, though unequal-the 
myelic branch for the ventro-myel. These two, how- 
ever, either soon or oftener after entering the spinal 
canal, combine to form the azygoid ventri-myelic artery. 
They are thus continuous and homologous with the other 
myelic arterioles coming in along the ventral nerve-roots. 
(SUPPLEMENT.) 
A full consideration of the minute details of the arterial 
distribution in the oblongata is given by Adamkiewicz. 
These vessels come wholly from the upper (intra-cranial) 
part of the vertebrals as they cross the ventral surface of 
the oblongata. 
The main facts regarding the three classes of secondary 
or nutrient arterioles (external or surface vessels) he 
accepts from Duret: 1. The radicals, direct from the ver- 
tebrals, supply the outgoing nerve-roots (facial, acoustic, 
glosso-pharyngeal, vagus, accessorius, and hypoglossus). 
2. The nuclears, at right angles from the one or two dorso- 
inyelics in an extent of 3 to 4 ctm. These penetrate the 
median fissure, at the bottom of which they form a kind 
of sagittal leader, and end beneath the floor of the metepi- 
coele (fourth ventricle). 3. Arteries for the other por- 
tions of the oblongata (olivary bodies, pyramids, corpora 
restiformia), in part at least from the myelics. 
Moreover, on the oblongatal surface is a rich net-work 
of vessels. The ventro-myelics opposite the oblongata 
give off a multitude of twigs that take a very sinuous 
course and soon settle into the furrows. For the dorsal 
surface of the oblongata there is no external supply until 
below the calamus-upper end of myel. Its source is the 
dorso-myelics. These latter, at the first cervical roots, 
turn caudad between the accessory nerve-roots (nearer 
the dorsal), and when at the level of the fourth or fifth 
cervical roots, they end by also anastomosing with ves- 
sels of louver origin. 
From the middle portion of the vertebrals, between the 
ventro- and dorso-myelics, arise the largest branches (sub- 
cerebellars), but these dodge the oblongata and are 
wholly for the cerebellum. 
Topographically, he distinguishes three sets of finer or 
nutrient arterioles (internal or substantial vessels) after 
the manner of the myelic supply. 1'. Ventro-fissurals, 
relatively large, dividing in the ventral commissure into 
two branches, one to each side for the corresponding 
ventro-mesal cinerea. In the oblongata these supply 
principally the pyramidal tracts and decussation, lem- 
niscus, interolivary tract, raphe, and the following nuclei 
-gray dorsal columna, n. pyramidalis, n. arciformis, 
oliva, and hypoglossus. 
2'. Dorso-fissurals, of course only caudad of the cala- 
mus. These divide at the dorsal commissure into two 
border vessels, and are for the substance of the dorsal 
columns, nucleus gracilis, accessorius centre, and casu- 
ally the hypoglossus. 
3'. Coronal, radial, or lateral system. These are very 
numerous, penetrate the alba from all sides (excepting 
of course the metepicoele), and in part reach the subjacent 
cinerea to then help form its mass of capillaries. A sub- 
class here-nuclear arteries-consists of 6 to 8 relatively 
large twigs entering the angulus restiformia olivaris and 
running parallel toward the middle of the floor of the me- 
tepicoele, to supply principally the centres for glosso-phar- 
yngeus, vagus, hypoglossus, and acusticus. The follow- 
ing parts receive these radial or lateral affluents-the 
ventral columns, lateral nuclei, lateral cornu, caput of 
substantia gelatinosa, nuclei cuneati gracilis, arciformis 
et pyramidalis, and the oliva itself. 
Width of Brain-arteries.-To make a relative estimate 
of the capacity of the arteries at the base, Bevan Lewis 
(" Examination of Brain," 1882, pp. 20-22) determined 
their average diameters in 45 cases (insane). That of the 
vertebral was, r. 3.147 mm., 1. 3.42 ; of basilar, 3.82 ; of 
postcerebral, r. 2.658,1. 2.56 ; of carotid, r. 3.951, 1. 4.02 ; 
of inedicerebral, r. 3.133, 1. 3.55 ; and of precerebral, 
r. 2.73, 1. 2.66. The sectional areas are of course pro- 
portional to the squares of these diameters. As a rule, 
the united areas of branches equal very nearly the area 
of the parent trunk-excepting the preponderance of the 
vertebrals over the basilar (22.4 to 14.8). 
Lowenfeld has found that the relation of the artery- 
width to the brain-weight is, even normally, somewhat 
variable, and that often, though not by any means in all 
cases, the width of the brain-vessels rises and falls with 
the width of the aorta; moreover, that not rarely 
abnormally small brain-arteries occur in otherwise well- 
developed arterial systems. He also made out a difference 
139 Brain. 
Bride8-les*Bains. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
in the two sides, the left carotid being usually wider than 
the right. 
Pressure in the Brain arteries.-A further matter, noted 
by St. John Bullen (I. c.) may partially indicate the relative 
pressures in the main brain-arteries. He remarked athe- 
roma of the basal vessels in 410 of 1,565 autopsies, or 26 per 
cent, of the total. It was present to a considerable extent, 
either generally dispersed, or in special trunks only, in 175 
cases, and to a less extent in 235. The relative frequency 
by location was : medicerebral, 38 per cent.; basilar, 30 
per cent.; postcerebral, 21 per cent.; carotid, 10 per cent. 
Mendel (1891) has found experimentally that the press- 
ure in the cortical arteries is materially less than that in 
the carotids, while that in the striatal arteries is not 
materially less. This he attributes 
to the fact that the latter are ter- 
minal vessels, though it is doubtless 
quite as much due to their less cir- 
cuitous supply. He further thus ex- 
plains the frequency of hemorrhage 
in the striatal region. 
Tedeschi's conclusions regarding 
the brain-arteries refer in part to 
moot points, but really contain noth- 
ing new and are deceptive in state- 
ment. 
Veins. - The careful work of 
Hedon traverses this field along ap- 
proved lines, and represents largely 
a verification of the work of others. 
Oblongata Region. - The ventro- 
rnesal chain of myelic veins is con- 
tinued cephalad on the ventral sur- 
face of the oblongata to the furrow 
between this and the pons, there 
connecting with a fine venous net- 
work over the surface of the latter 
(Kadyi). This plexus in turn also 
connects with the veins of the cere- 
bellum and of the base forward. 
Besides irregular smaller ones, 
there are in particular two constant 
and considerable veins passing from 
this plexus, one on either side along 
the trigeminal nerve to the sinus 
petrosus (or cavernosus). 
From the above-mentioned chain 
on the ventral surface of the oblon- 
gata, between the pyramids, there 
frequently arises a little trunk (up 
to | mm. or more thick) that joins 
one of the hypoglossal root-bundles 
and passes out with it through the 
precondyloid foramen-doubtless a 
part of Luschka's plexus venosus 
hypoglossi. 
The dorso-myelic chain of veins is 
continued cephalad over the oblon- 
gata. From a constant mesal vein 
here a small veinule traverses the 
arachnoid, covering the cisterna 
magna. Sometimes this adjoins the 
accessory nerve, and Kadyi thinks 
it probably empties into the sinus 
plexus about the foramen magnum. 
Among the cerebellar veins He- 
don, referring to Merkel, mentions 
one that " comes from the flocculus 
and empties into the superpetrosal sinus. An impor- 
tant branch of this vein rises from the interior of the 
cerebellum in the region of the dentatum, receives also 
veins from the cerebellar medi-peduncle, and emerges 
with the peduncle under the flocculus. The main trunk 
can acquire a very considerable size when it receives a 
branch of the basilar vein " (Precerebellar vein, Fig. 
67). 
Other Veins.-A point once described by the writer 
has recently (1889) been more carefully gone over by 
Mittpnzwpi c. In 900 phspu Iip fnnnd KQ in whinh thn 
(SUPPLEMENT.) 
pre-supracerebrals (to only 9 in which the post-supra- 
cerebrals) jumped over from the piarachnoid to the dura 
at 3 to 4 ctm. from the long sinus-thus favoring their 
rupture, as he thinks. 
The post-perforating veins come, according to Hedon, 
from the cinerea of the walls of the diaccele, and even 
from the mesal surface of the thalamus. He also claims 
that in the striate nuclei the perforating veins anastomose 
with those going toward the cavities and Galen's system. 
He further recognizes the communications in the medi- 
cornu between the choroidal and the infra-cornual veins. 
Developmental.-From various peculiarities in the vas- 
cular supply of the human brain, more especially the 
caudad displacement peripherally of the post-supracere- 
Fig. 67.-Veins of the Base (% nat. size). The two sides represent respectively the more common 
arrangements of these veins. Those of the myel and oblongata are largely after Kadyi. AA, 
supracerebrals; B. ramus to olfactory bulb; CC, subfrontals; D. precerebral; EE, Sylvian or 
insular; F, medicerebral (to cavernous sinus); F', post-medicerebral (per temporal sinus to 
superpetrosal); GG, preperforantes; H, postperforantes: I, subcerebral (to Galen's vein); I', 
subcerebral (when emptying at base); JJ, subcornuals ; KK, precerebellars ; LL, hypoglossals 
(to precondyloid emissary); M, postcerebral (to lateral sinus); N, paracerebellar (to lateral 
sinus); O, ventrimyelic (anterior spinal). 
bral veins, the writer has adduced evidence favorable in 
a general way to Hill's theory, and showing further that 
in any such rotation the brain and pia have glided caudad 
upon the dura and brain-case. 
Here may be added a casual observation of a persistent 
foetal form, made at the autopsy of a child of 22 months, 
dead of tubercular meningitis. The large left inedicere- 
bral vein took the temporal course in a deep groove (per 
temporal sinus, intradural), and passed out at the fora- 
men jugulare spurium instead of passing to the supra- 
petrosal sinus, first, however, connecting with a much 
140 Reference Handbook 
OF THE 
Medical Sciences. 
Plate XXXVI 
Fig / 
Fig 3. 
Ficj 4 
Brain-Vessels (Iide expl atudioi/ at end of article). REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Brain. 
BrideM-les-BainN. 
smaller prepetrosal sinus. No such appearance on the 
right. 
Sinuses. Occlusion.-By experimental blocking of the 
dural sinuses in the dog, Ferrari (1888) has shown that 
a large part of the whole sinus system, e.g., all the si- 
nuses of the calvarium may be rendered impermeable 
without injury to the functions of the brain. However, 
occlusion of the collective blood-efferents from the skull 
is of course quickly fatal, being usually preceded by an 
epileptic attack. But all this and more had been already 
determined by clinical experience in man. 
Lateral Sinus.-Korner (1889) has shown that intracra- 
nial disease from caries of the petrous is more frequent 
on the right, and from a study of 449 skulls he attributes 
this to the fact that the lateral sinus at its sigmoid flex- 
ure enters deeper into the mastoid and the petrous pyra- 
mid on the right than on the left, and thus on the right 
approaches nearer the primary focus of disease. In 22 
cases on the right and 8 on the left, there were gaps in 
the bony partition. He also holds that in the brachy- 
cephali the sigmoid excavation goes lower and deeper 
than in the dolichocephali, and that hence in the former 
such encranial sequelae follow more readily; but this 
has been disputed by Schiilzke. 
Birmingham, of Dublin (Brit. Med. Journ., 1890, ii., 683) 
from an examination of 100 recent dry specimens, points 
out that the relations of the lateral sinus to the surface 
are extremely uncertain, owing both to variations in the 
sinus curves and to irregularities in the bones. It begins 
opposite the external occipital protuberance in fifty per 
cent. ; lower (by never more than | inch) in thirty-three 
per cent. ; and higher in seventeen per cent. It does not 
run forward horizontally, but is distinctly arched. The 
bend of the sinus where it turns down at the asterion may 
vary, within wide limits, from a gentle to a very sharp 
curve. It then runs down in front of the post-mastoid 
margin, about 1 inch behind the meatus, and turns into 
the jugular foramen about J inch below the level of the 
meatus floor. Occasionally the sinus is only q'j inch from 
the surface. 
Venous Outlets.-Possibly a couple should be added 
from Hedon. Small rami accompany the olfactory bun 
dies through the cribriform plate of the ethmoid, of 
course connecting above with the vein of the olfactory 
bulb. " A vein leaves the aqueduct of Fallopius by the 
stylo-mastoid foramen to anastomose with the external 
jugular or post-auricular (Sperino). It joins, according 
to Blandin, a small dural ramus traversing the hiatus of 
Fallopius.'' 
Lymphatics.-The previous recorded results of Ross- 
bach and Sehrwald, regarding lymphatics in the brain- 
substance, are evidently discredited by Frommann (Centbl. 
f. med. Wissc., 1888, pp. 881-2). As regards the hypophy- 
sis, Pisentiand Viola (Ibid., 1890, pp. 451-2) believe that 
certain structures observed by them represent lymph- 
spaces. A cortical lymph-connective system has been 
studied by Bevan Lewis. 
Little evidence of lymphatics in the myel is found by 
Kadyi. The perivascular spaces of His occur, but are 
likely of artificial origin. From the results of one injec- 
tion he figures a net-work of voluminous canals running 
longitudinally beside the central canal, and that possibly 
represent a lymphatic system. 
Bibliography. 
Des Ruptures de 1'Artere miningee moyenne, par le Dr. F. Duchaine. 
Paris, 1890, pp. 115. 
Die Arterien des verlangerten Markes vom Uebergang bis zur Briicke. 
Von Prof. Dr. A. Adamkiewicz. Vienna, 1890. [Reprint.] 
Ueber die Beziehung der Art. choroidea anterior zum hintern Schenkel 
der innern Kapsol des Gehirns. Dr. A. Kolisko. Vienna, 1891, pp. 56. 
Ueber die Blutgefasse des menscblichen Riickenmarkes. Von Prof. Dr. 
H. Kadyi. Lemberg, 1889, pp. 152. 
Etude anatomique sur la Circulation veineuse de 1'Encephale, par Dr. E. 
Hedon. Paris, 1888, pp. 96. 
The Arrangement of the Supra-cerebral Veins in Man, as bearing on 
Hill's Theory of a developmental Rotation of the Brain, by William 
Browning. Journal of Nervous and Mental Disease. 1891, November. 
[Anatomy of Veins of Posterior Part of Head, of Neck, and Base of 
Skull], by Grigor Svijachenitioff. 1889, St. Petersburg. (Treats of ex- 
tra-cranial veins, emissaries, etc.) 
William Browning. 
(SUPPLEMENT.) 
EXPLANATION OF PLATES. 
Plate XXXV. 
Arterial Supply ok Oblongata (from Adamkiewicz), Enlarged & 
Diameters. 
Fig. 1. At Decussation of Pyramids. 
Hs, Dorsal Column. g, Boundary between Py and Vr. 
Ng, Nucleus gracilis. S, Arteria sulci. 
Nc, " cuneatus. Sa, A. sulci (at deeper layers). 
Sgc, Substantia gelatinosa cen- Acc, Aa. centrales cornuuni ante- 
tralis. riorum. 
Cep, Caput cornu posterioris Aca, Aa. cornu anterioris. 
(aut Tuberculum Rolando). Anl, A. nuclei lateralis. 
XII, Root of hypoglossus. As R, A. tuberculi Rolando. 
Vr, Remnant of ventral column. Anc, A. nuclei cuneati. 
Prk, Decussation eminence. Ang, Aa. nuclei gracilis. 
Py, Pyramid. F, A. fissur®. 
Fig. 2. Opposite Middle of Metepiccele. 
H. Hypoglossus nucleus. Na, Nucleus arciformis. 
Va, Post. Vagus nucleus. S, Arteria sulci. 
Po, Ponticulus (velum nredullare See, Affluents to external nest-like 
posticum). capillary coils, from sulcus ar- 
Gl, Glossopharyngeus nucleus. tery. 
Ac, Acusticus nucleus. Sei, Affluents to inner same. 
Lb. Longitudinal bundle. Aoli, Sub-lateral olivary artery. 
(Krause's respiratory fasciculus.) Aso, Olivary ramus from sulcus ar- 
Cr, Corpus restiforme. tery. 
X, Ant. Vagus nucleus. Aoli, Sub-olivary arteries. 
IX, Root of Glossopharyngeus. Aolm, Medilateral olivary artery. 
Aro. Angulus restiformio-olivaris. Aois, Super-olivary artery. 
O, Oliva. An, Arteries of the nuclei (Glosso- 
No, Nucleus pyramidalis. pharyngeus, vagus, hypoglossus). 
Ozs, Interolivary tract. Vn, Nuclear vessels (glossopharyn- 
R, Raphe. geus, acusticus). 
Py, Pyramid. F, Arteria fissur®. 
Fig. 3. Longitudinal Section Through Olivary Body. 
O, Oliva. Aoli. Aa. oliv® laterales inferiores. 
Br, Pons. An, Aa. nucleari®. 
Plate XXXVI. 
Fig. 1. Sinus Cavernosi et Intercavernosi-Sinus Circularis of Ridley. 
Inferior aspect of a corrosion-preparation from a child, with aSerents 
and efferents (somewhat enlarged, and also arbitrary as to execution of 
smaller vessels). From Langer's " Der Sinus cavemosus der harten 
Hirnhaut," Sitzbr. d. k. Akad., 1885, Vienna (Fig. 5). 
Vo, Vena ophthalmica superior et inferior. 
Sic. Sinus intercavernosi. 
E, Emissary veins passing through the oval foramen to the pterygoid 
plexus. 
Spi, Sinus petrosus inferior. 
L, Space for the dorsum ephippii. 
Fig. 2. Fine anastomotic net work between three arterial twigs in the 
pia of the parietal region. (Lucas, 1879.) 
Fig. 3. Very perfectly injected vessels of a choroidal villus. Two hilus- 
vessels, a vein, and an artery. Loops, vascular nets, etc. Enlargement, 
50 diameters. (From Luschka's " Die Adergeflechte des mensch- 
lichen Gehirns." 1855, Taf. ii., Fig. 2.) 
Fig. 4. Lobule of a choroidal villus ; one portion bare of epithelium. 
Sinuous vascular loop. Enlargement, 500 diameters. (Also from 
Luschka.) 
a. = Portion covered by epithelium. 
b. = Fibrillary connective tissue. 
c. = Structureless connecting substance extending well beyond the cap- 
illaries. 
BRIDES-LES-BAINS. A watering-place in Savoy, 
near Moiitiers, France. 
Location.-Brides-les-Bains is situated in a beautiful 
valley, with picturesque surroundings, about 1,800 feet 
above the level of the sea. The climate is mild and in- 
vigorating. Facilities for interesting excursions are 
plentiful, although the place is somewhat difficult to 
reach. 
Access.-From Paris, by the Paris, Lyons & Aledi- 
terranean Railroad, vid Chambery, to Albertville ; thence 
by stage in about three hours to Brides. 
Analysis.-One litre of the water contains : 
Gramme. 
Chloride of magnesium 0.3071 
Chloride of sodium 1.3601 
Chloride of potassium 0.0670 
Chloride of lithium traces 
Sulphate of soda 1.6113 
Sulphate of magnesia 0.1941 
Sulphate of lime 1.8200 
Bicarbonate of lime 0.4380 
Carbonate of iron 0.0112 
Carbonic acid gas 0.0837 
The temperature of the springs varies from 85° F. to 
95° F. 
141 Brides-les- Hains. 
Bright's Diseases. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Indications.-These waters are employed in a great 
variety of affections, such as obesity, liver complaints, 
abdominal plethora, gastralgia, constipation, vesical ca- 
tarrh, affections of the prostate gland, haemorrhoids, cere- 
bral congestion, neuralgia, migraine, sterility, heart affec- 
tions, diabetes, gravel, and diseases of women. It is said 
that the waters, if taken in the morning before break- 
fast, in doses of from one to three glasses per day, are 
tonic and aperient in their effect ; in stronger doses, of 
from four to eight glasses per day, they become laxative 
and purgative. They have the advantage that they can 
be taken daily for a long period as a slight purgative 
without causing the irritation produced by other more 
active waters. Season, middle of May to end of Sep- 
tember. 
Accommodation.-The Grand Hotel des Thermes is 
modern and good. The Etablissement des Bains is 
equipped with the usual appliances for bathing, sprays, 
etc. There is a small Casino, and mild amusements are 
provided. The place is quiet, and devoid of fashionable 
life. Edmund C. Wendt. 
BRIGHT'S DISEASES OF THE KIDNEY, DELA- 
FIELD'S CLASSIFICATION OF. Since pathologists 
have learned to distinguish the various diseases of the 
kidneys, formerly grouped under the one designation of 
Bright's disease, there has been an effort made to do 
away with this name as one that is indefinite and even 
misleading ; yet so strong a hold has it acquired in the 
popular language that it is doubtful whether it will ever 
be supplanted. And, indeed, it is not necessarjr that it 
should cease to exist as a synonym for disease of the 
kidneys, for popular medical nosology knows as little of, 
as it cares for, pathological distinctions. It is, however, 
exceedingly desirable that the name should be dropped 
from scientific nomenclature, as its retention only serves 
to create confusion in the minds of students and to ob- 
scure the subject, at its best not a simple one, of the 
pathology of renal diseases. No modern writer would 
publish a work on pulmonary diseases and call it a 
treatise on " Consumption," yet it would be just as proper 
a term for diseases of the lungs as "Bright's disease" is 
for those of the kidney. 
Writers have of late come to realize the inconvenience 
of this term, and have endeavored, after freeing them- 
selves from the bondage of the name, to study renal 
diseases as distinct affections and group them scientifi- 
cally, for a proper classification is essential to a clear 
comprehension of these different affections. The favor- 
ite method of grouping these diseases has usually been 
according to the part of the kidney involved, and we 
have therefore had such terms as " parenchymatous 
nephritis," " arterio-sclerosis," " glomerulo-nephritis," 
etc.-unsatisfactory enough, since the same inflammatory 
process may involve widely different parts of the organ, 
or the same parts may undergo varied and dissimilar 
pathological changes. A much better classification of 
diseases of the kidneys is one according to the nature of 
the morbid process, such an one as was proposed a few 
years ago by Professor Francis Delafield, of New York, 
which has commended itself to many pathologists and 
clinicians by reason of its simplicity and reasonableness, 
and which has already been adopted by many teachers 
and writers on renal diseases. A request had been made 
of the editor of this Handbook that, in case a supple- 
mentary volume should be issued, place might there be 
given to an exposition of this mode of classification ; 
and although Dr. Delafield was unable to prepare such 
an article, he very kindly placed his material at the dis- 
posal of the present writer, with permission to draw 
therefrom freely. He has also revised the article, so 
that the views here expressed may be regarded as his 
own. No attempt at originality of composition has been 
made, since the object of the writer was simply to give 
a resume, as brief as might be consistent with clearness, 
of Dr. Delafield's published writings on the subject ; and 
therefore the author's arrangement has been closely fol- 
lowed throughout, and in many places his very words 
have been borrowed. Any long extract taken bodily 
(SUPPLEMENT.) 
from his article in the American Journal of the Medical 
Sciences for October, 1891, has been marked by inverted 
commas. 
There are three morbid processes concerned in the 
production of the various pathological changes in the 
kidneys formerly included under the term "Bright's 
disease," viz., congestion, degeneration, and inflamma- 
tion. These three processes may be further divided 
according as they are acute or chronic, or as the inflam- 
mation is exudative simply, productive, suppurative, or 
tubercular. The Bright's diseases of the kidneys may 
therefore be classified as follows : 
I. Congestion. 
Acute. 
Chronic. 
II. Degeneration. 
Acute. 
Chronic. 
III. Inflammation. 
Acute exudative. 
Acute productive or diffuse. 
Chronic productive or diffuse. 
Suppurative. 
Tubercular. 
With exudation. 
Without exudation. 
I. Congestion.-Acute congestion of the kidney is a 
transitory condition caused by the ingestion of certain 
poisons, by traumatism, by operations, especially those 
on the bladder or urethra, by extirpation of one kidney, 
by over-exertion, or by taking cold. 
There are no alterations in the renal tissues, the only 
change in the organ being the engorgement of the blood- 
vessels. Congestion may occur, however, not only in a 
normal kidney, but in one previously diseased, and in 
this case the lesions of the pre-existing disease will, of 
course, be present. 
The urine is diminished in quantity, or, at times, even 
suppressed. It may contain albumin and casts, and oc- 
casionally blood : the specific gravity is, as a rule, un- 
changed. Usually constitutional symptoms are slight or 
absent, but in cases following surgical operations on the 
urethra or bladder, or extirpation" of the other kidney, 
there may be considerable depression of the vital forces, 
ending in collapse, or a typhoid state with mild delirium 
may supervene. Acute renal congestion is usually re- 
covered from, though it may in rare instances cause 
death. Repeated attacks, however, may lead finally to 
inflammation of the kidney. 
The treatment consists in confinement to bed and in 
securing free action of the bowels and skin, the latter 
being accomplished by means of heat applied to the sur- 
face of the body. 
Chronic congestion of the kidney is a secondary condition 
of engorgement of the renal vessels, following long con- 
tinued interference with the venous circulation. It may 
be due to aortic or mitral disease, dilatation of the heart, 
excessive pleural effusions, pulmonary emphysema, or 
other obstructive diseases. 
The kidneys are smooth, with non-adherent capsule, 
and are usually enlarged, though exceptionally they may 
remain of normal size ; they are heavier than healthy 
kidneys and are also darker in color. The capillaries of 
the glomeruli are dilated and thickened ; the veins of the 
pyramids are always, those of the cortex rarely, distend- 
ed. There is commonly either swelling or flattening of 
the epithelium of the cortex tubes, although it occasion- 
ally appears to be unchanged. 
The urine varies in quantity, but is usually diminished, 
the proportion of urea, however, being commonly in- 
creased. The specific gravity is ordinarily about 1.020 
to 1.025, but may vary all the way from 1.010 to 1.035. 
There is little or no albumin, and casts are generally ab- 
sent, though both may at times be found. The general 
symptoms are those of the primary disease, and the treat- 
ment is to be directed to this almost entirely. 
The prognosis is grave, chiefly because of the tendency 
of chronic congestion to pass into chronic inflammation 
of the kidney. 
II. Degeneration.-Acute degeneration of the kidneys 
is a secondary condition caused by the action of arsenic, 
mercury, or phosphorus, or of one of the toxines formed 
142 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Brides-les>Bains. 
Bright's Diseases. 
in the body during the course of certain of the acute in- 
fectious diseases. 
The lesions are confined to the renal epithelium, being 
most marked in that of the convoluted tubes. Here we 
find the epithelial cells simply swollen and irregular in 
outline, infiltrated with granular matter, disintegrated, 
containing hyaline masses, or in a state of coagulation 
necrosis. The kidneys are usually somewhat enlarged, 
with smooth surface and non-adherent capsule. When 
the degenerative process has been very rapid the blood- 
vessels are irritated and we then have congestion and ex- 
udation of serum, and thus a secondary exudative in- 
flammation is added to the degeneration. 
The urinary changes and general symptoms are in pro- 
portion to the extent of the degenerative process. In 
mild cases, such as occur with the acute infectious dis- 
eases, there are no symptoms beyond a moderate amount 
of albumin and some casts in the urine. But in severe 
cases, such as accompany yellow fever, or follow poison- 
ing by arsenic, mercury, or phosphorus, albumin and 
casts are found in large quantities, white blood-cells are 
present, and the urine is scanty or even suppressed. The 
specific gravity of the urine is normal and there is no 
dropsy. In mild cases recovery is the rule, but in the 
more severe ones the kidney lesion is a direct menace to 
life. 
There is no treatment for the degenerative changes, 
but if secondary exudative inflammation occurs the indi- 
cation is to cause free movement of the bowels and dia- 
phoresis. 
Chronic degeneration of the kidneys, like the acute form, 
is a secondary process. It results from the same causes 
that may produce chronic congestion, or from alcohol- 
ism and vicious modes of life, or it may occur in the 
course of certain chronic diseases. 
The degenerative changes are confined to the epithe- 
lium of the convoluted tubes which is swollen and the 
seat of fatty infiltration. When chronic congestion co- 
exists the lesions of the glomeruli associated with that 
condition-dilatation and thickening of the capillaries- 
will be present. The kidneys are usually increased in 
size, though they may be normal or even smaller than in 
health ; the surface is smooth. The pyramids are red, 
while the cortex may be whitish, yellow; or pink in 
color. 
The urine may be increased in amount, scanty, or sup- 
pressed, the quantity varying in different cases and at 
different times in the same case. It frequently contains 
albumin and casts, but the specific gravity is not low- 
ered and the relative proportion of urea is not decreased. 
The health of the patients is impaired ; they fall away in 
flesh and strength, become anaemic, and finally pass 
into the typhoid state with delirium and stupor. Dropsy 
is not a symptom of chronic degeneration of the kidneys. 
Treatment is usually ineffective, and the disease pro- 
gresses steadily to a fatal termination, at best retarded 
only by the therapeutic measures employed. Of course, 
the exciting cause (alcoholism, irregular mode of life, 
etc.), should be removed or minimized as far as possible. 
III. Inflammation.-The varieties of inflammation 
of the kidneys are : 
Acute exudative nephritis. 
Acute productive or diffuse nephritis. 
Chronic productive or diffuse nephritis with exudation. 
Chronic productive or diffuse nephritis without exuda- 
tion. 
Suppurative nephritis. 
Tubercular nephritis. 
Acute Exudative Nephritis.-This is one of the forms 
of kidney disease known as acute Bright's disease, acute 
parenchymatous, tubal, or desquamative nephritis, etc. 
It is "an acute inflammation of the kidney, character- 
ized by congestion, exudation of the blood-plasma, an 
emigration of white blood-cells, and a diapedesis of red 
blood-cells from the vessels ; to which may be added 
swelling or necrosis of the renal epithelium and changes 
in the glomeruli." The disease occurs as a primary in- 
flammation or may complicate any of the acute infec- 
tious diseases or the puerperal state. 
In mild cases there are no marked changes in the kid- 
neys, the inflammatory products in the Malpighian bodies 
and tubes being discharged with the urine as fast as they 
are exuded. In more severe cases we find the red and 
white blood-cells, serum, and coagulable matter from the 
blood-plasma in the tubes, Malpighian bodies, and stroma, 
especially in the cortical portion. The kidneys are in- 
creased in size, smooth, and intensely congested. The 
epithelium of the cortex tubes is often flattened, as in the 
chronic congestion secondary to heart disease, or it may 
be swollen, or more rarely degenerated and detached. 
In some cases there is, in addition to the flattening of the 
cells, a uniform dilatation of all the convoluted tubes. 
Irregular masses, formed of coagulable matter from the 
blood-plasma, and hyaline casts are found in the tubes, 
the latter being more abundant in the straight tubes, the 
former in the convoluted ones. Red and white blood- 
cells may also be found in the tubes. When there is an 
excessive emigration of wdiite cells these are usually 
found collected in foci in the cortical portion, and not 
uniformly distributed throughout the kidney. 
In the glomeruli the capsular epithelium is swollen 
and there is also a swelling and growth of the cells cov- 
ering the capillaries. In consequence of this latter 
change, although the outlines of the main divisions of 
the tufts may be visible, those of the capillaries are lost. 
In some cases the walls of the branches of the renal ar- 
tery within the kidney are seen to be thickened, a result 
chiefly of the swelling of their muscle-cells. 
The urine in mild cases of acute exudative nephritis is 
somewhat diminished in quantity, of normal or high 
specific gravity, and contains albumin and hyaline, gran- 
ular, and epithelial casts in moderate numbers, and oc- 
casionally blood. The constitutional symptoms are often 
insignificant, consisting merely of a slight malaise, head- 
ache, and some aching in the back and limbs. The con- 
stitutional symptoms last from one to two weeks, the 
urinary changes from four to five. 
In severe cases the changes in the urine are much more 
pronounced. The quantity is greatly reduced, or it may 
even be suppressed ; the specific gravity is not lowered 
and may be raised ; there is a large amount of albumin, 
casts are abundant, and epithelium and white and red 
blood-cells are often present. The amount of albu- 
min and casts in the urine is usually, though not always, 
proportionate to the severity of the disease. The consti- 
tutional symptoms are also more marked. " A febrile 
movement with more or less prostration ; stupor, head- 
ache, sleeplessness, restlessness, muscular twitchings, 
and general convulsions ; dyspnoea, loss of appetite, nau- 
sea, and vomiting; a pulse of high tension with exag- 
gerated heart-action, or hypertrophy of the left ventricle, 
dropsy, and anaemia-these may be called the character- 
istic symptoms of acute exudative nephritis. Of these 
symptoms a certain number-the fever, the prostration, 
the loss of appetite and nausea, the anaemia, the diminu- 
tion in the quantity of urine, the albumin and casts in the 
urine-are such as would naturally accompany an acute 
inflammation of the kidney, and very often they are the 
only symptoms which do accompany it." 
In a certain number of cases there are, in addition to 
these features, cerebral symptoms, dropsy, and changes 
in the heart and circulation. That these do not, in all 
cases at least, depend upon the diminished excretion of 
urine is evidenced by the fact that they are often absent 
in patients who are passing very little urine, and are 
often present in persons who are passing an abundance 
of urine of normal or high specific gravity. It is not 
improbable that they depend upon some morbid state, 
whether spasmodic or inflammatory, of the arteries and 
capillaries, whereby the passage of blood through them 
is impeded. 
In cases in which there is an excessive production of 
pus-cells the symptoms not infrequently resemble very 
closely those of acute meningitis. " The invasion is 
sudden, with a high temperature and marked prostra- 
tion. Restlessness, delirium, headache, and stupor are 
soon developed and continue throughout the disease. 
The patients lose flesh and strength and pass into the 
143 Bright'* Diseases. 
Bright's Diseases. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
typhoid state. Dropsy is slight or absent altogether. 
The urine is not so much diminished in quantity as one 
would expect; its specific gravity is not changed ; albu- 
min, casts, and red and white blood-cells are present in 
considerable quantities, but not always early in the dis- 
ease, and may even be absent altogether." 
This form occurs in children or adults as a sequel of 
diphtheria, measles, or scarlatina, or it may be a primary 
inflammation. It is uniformly fatal, but fortunately 
is not of very common occurrence. 
The prime indication for treatment is to relieve the 
congestion of the kidneys, avoiding as a rule the use of 
diaphoretics or cathartics. This congestion is relieved 
partially and temporarily by means of the hot-air bath, 
dry or wet cups, hot applications to the lumbar region, 
or the exhibition of small doses of calomel or magnesium 
sulphate repeated at short intervals until the effect upon 
the bowels begins to be manifested. In order to prevent 
the cerebral symptoms the condition of the circulation 
should be closely watched. As soon as signs of increased 
tension of the arteries and labored action of the heart 
become evident, drugs to relieve this state should be 
given. These are aconite, nitro-glycerine, chloral hy- 
drate, and opium ; they should be given in small doses at 
regular intervals, but if the cerebral symptoms appear 
threatening then large doses by the rectum or subcutane- 
ously are'Called for. The patients are to be kept in bed 
and put on a fluid (milk) diet until the disease begins to 
subside ; then solid food may gradually replace the milk, 
and iron and oxygen will be indicated to overcome the 
anaemia. 
Acute Productive or Diffuse Nephritis.-This is an acute 
exudative inflammation of the kidneys, to the lesions of 
which are superadded certain characteristic changes in 
the glomeruli and a growth of connective tissue in the 
stroma ; its lesions are of a permanent character, and it 
is frequently associated with circulatory disturbances. 
It is very often met with as a primary disease, or it 
may complicate scarlatina, diphtheria, or the pregnant 
state. 
The kidneys are smooth in the early stages of the dis- 
ease, later roughened ; the pyramids are red, and the cor- 
tex is thickened, white, mottled with yellow and red, or 
congested. The lesions are those of exudative nephritis 
with the addition of a growth of connective tissue in the 
stroma and of an increase in the capsule cells of the Mal- 
pighian bodies. These additional changes, which are 
present from the first and are characteristic of this form 
of nephritis, are not uniformly distributed throughout 
the organ but are confined to strips or wedges following 
the line of the arteries. These wedges may be small, 
symmetrical, and few in number, or large, irregular, and 
numerous. Each wedge contains one or more arteries 
running up into the cortex and terminating in the tufts 
of the glomeruli ; the walls of these arteries are thick- 
ened, there is a growth of cells upon and in the capilla- 
ries forming the tufts, and the corresponding Malpighian 
bodies show an excessive growth of the capsule-cells ; in 
the stroma around these arteries, and parallel to them, 
is a growth of connective-tissue cells and basement 
substance. The growth of the cells lining the capsules 
is so great as to compress the tufts, the capillaries of 
which then become obliterated, and the glomeruli are 
finally changed into little balls of fibrous tissue. The 
new growth of connective tissue in the stroma leads to 
compression, and finally to atrophy, of the tubes around 
which it is formed. 
The urine is scanty or suppressed, of high specific grav- 
ity, and contains a large amount of albumin, many casts, 
and red and white blood-cells. Later, the urine becomes 
more abundant, of lower specific gravity, and contains 
fewer casts and less albumin ; or it may be that these 
less pronounced changes are present from the first. The 
general symptoms are headache, sleeplessness, muscular 
twitchings or general convulsions, anorexia, nausea and 
vomiting, dyspnoea, neuro-retinitis, diarrhoea, hyper- 
trophy of the left ventricle of the heart, increased arte- 
rial tension, loss of flesh and strength, dropsy often ex- 
treme, and finally delirium, stupor, and coma. These 
symptoms vary according to the intensity of the morbid 
process, and there are often remissions simulating com- 
plete recovery. The disease is, however, a progressive 
one, and although life may be prolonged for a consider- 
able period by appropriate treatment a fatal result comes 
sooner or later. 
The treatment is essentially a climatic one, residence in 
a warm, dry, equable climate being most important. In 
some cases, during the early stages, a measure of relief 
may be obtained by the plan of treatment followed in 
acute exudative nephritis. For the dropsy, diuretics, dia- 
phoretics, and cathartics are indicated ; sometimes punc- 
ture of the skin or tapping of the serous cavities becomes 
necessary; but occasionally this condition refuses to yield 
to any mode of treatment. The arteries should be 
watched, as in acute exudative nephritis, and if they be- 
gin to show signs of increasing tension the appropriate 
remedies mentioned above are called for. 
Chronic Productive or Diffuse Nephritis with Exudation. 
-This is a chronic inflammation attended with growth of 
connective tissue in the stroma, changes in the glomeruli, 
degeneration of the epithelium, exudation from the ves- 
sels, and sometimes changes in the walls of the arteries. 
The amount of exudation varies at different times, occa- 
sionally being so slight that little or no albumin is found 
in the urine. It should be remembered that the two 
forms of productive nephritis here described are essen- 
tially the same disease, differing only as there is or is not 
an exudation of serum from the blood-vessels in addition 
to the lesions of the productive inflammation. The disease 
may occur as a primary affection, may follow acute dif- 
fuse nephritis or chronic congestion or degeneration of 
the kidneys, or may complicate syphilis, tuberculosis of 
the lungs, bones, or joints, chronic endocarditis, or pro- 
longed suppuration. 
The kidneys are usually large, but may be small or of 
normal size, and are smooth, roughened, or nodular ; the 
cortex is the seat of an extensive growth of connective 
tissue, its tubes being atrophied in some places and di- 
lated in others; the straight tubes contain coagulated 
matter, cylinders, or blood ; the renal epithelium is 
swollen or flattened, broken, granular, or fatty. " The 
glomeruli are changed in several different ways : 1. 
There is a growth of the capsule-cells in such numbers 
that they compress the tufts. The cells covering the ca- 
pillaries are also increased in size and number. The cap- 
sule-cells may finally be changed into connective tissue 
and the tufts become atrophied. 2. The glomeruli are 
of large size, the cells covering the capillaries are increased 
in number so that the outlines of the capillaries are lost, 
but yet the capillaries are not compressed nor the glom- 
eruli atrophied. 3. There is a growth of the cells which 
cover the capillaries and of the cells within them. Of 
the cells which cover the capillaries the cell-bodies be- 
come very large, the capillaries are compressed, and the 
glomeruli eventually become atrophied. 4. The walls 
of the capillary vessels become the seat of waxy degen- 
eration, while the cells which cover them are increased in 
size and number. 5. If the nephritis follows chronic 
congestion, the capillaries are dilated and there is an in- 
crease in the size and number of the cells which cover 
the capillaries. The arteries remain unchanged, or they 
are the seat of obliterating endarteritis, or there is a 
symmetrical thickening of all the coats of the artery, or 
all the coats of the artery are thickened and converted 
into a uniform mass of dense connective tissue, or there 
is waxy degeneration of the walls of the artery." 
During the exacerbations of the disease the urine is 
generally diminished in quantity or suppressed, but dur- 
ing the quiescent periods it may be normal ; when the 
patients are doing badly, and often when they are drop- 
sical, the quantity is greatly increased. The specific 
gravity slowly diminishes as the growth of connective 
tissue in the stroma of the cortex increases or when the 
capillaries of the glomeruli become the seat of waxy de- 
generation. Albumin and casts are present, usually in 
large quantity, but varying according to the activity of 
the inflammatory process in the kidney. Dropsy is of 
very constant occurrence in this form of renal disease. 
144 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Bright's Diseases. 
Bright's Diseases. 
(SUPPLEMENT.) 
being either continuous or coming and going from time 
to time. Other symptoms are marked anaemia, headache, 
sleeplessness, neuro-retinitis, cough, anorexia, nausea and 
vomiting, and dyspnoea. The latter when due to contrac- 
tion of the arteries or to failure of the heart's action, is 
often the first thing that attracts attention to the kidney 
lesion ; it comes on in attacks, especially at night and 
when the patient is lying down. The most constant 
symptoms are anaemia, dropsy, and albumin in the 
urine. 
The course of the disease is almost infinite in its va- 
riety : "1. There are cases in which the symptoms are 
nearly continuous, the patients get steadily worse and 
die within one or two years. The anaemia, the dropsy, 
and the albumin are constantly present, and the patients 
die with dropsy or with chronic uraemia. 2. There are 
cases in which the anaemia, the dropsy, and the dyspnoea 
come on in attacks which last for weeks or months. 
Between the attacks the patients are comparatively well, 
often able to work, although the urine always contains 
albumin. 3. There are cases in which a number of years 
before death the patient has an attack of dropsy, etc., 
from which he apparently recovers and goes on able to 
work, but with urine of low specific gravity, which 
sometimes contains albumin. After an interval of many 
years comes the fatal attack, with all the characteristic 
symptoms. 4. There are cases which for years have no 
symptoms but pallor of the skin and urine of low specific 
gravity containing albumin. These patients often for a 
long time feel so well that they cannot understand that 
they have a serious disease. 5. There are cases in which 
the first symptom is the attack of spasmodic dyspnoea, 
the patients otherwise feeling well. It may be months 
or years before the other symptoms are developed. 6. 
There may be a history of chronic endocarditis lasting 
for years before the renal symptoms are developed. 7. 
There are cases which apparently recover from the dis- 
ease." 
The best results are obtained by sending these patients 
to a warm, dry climate where they can be much in the 
open air. As the urine contains a proportionately small 
amount of urea, its quantity must be maintained above 
the normal, if possible. The dyspnoea, convulsions, co- 
ma, and other symptoms due to arterial contraction will 
call for nitrite of amyl, nitro-glycerine, chloral hydrate, 
or opium. 
Chronic Productive or Diffuse Nephritis without Exu- 
dation.-This form of nephritis is usually secondary to 
alcoholism, chronic lead-poisoning, gout, chronic con- 
gestion of the kidneys, hydronephrosis, or chronic pye- 
litis, or is brought about by the same conditions as those 
which cause emphysema, endocarditis, endarteritis, and 
cirrhosis of the liver. 
The kidney is usually diminished in size, the two to- 
gether often weighing only about one-half as much as 
one normal kidney. The surface is roughened or nodu- 
lar, the cortex is thin and red or gray in color. In not 
a few cases there is no diminution in size, and there may 
even be an increase, but in all cases the capsule is adhe- 
rent and the surface roughened. There is a progressive 
formation of new connective tissue in the cortex and 
pyramids, compressing and finally obliterating the tubes. 
The tubes not involved in the new growth become dilated, 
sometimes forming cysts of considerable size ; the epithe- 
lium of these dilated tubes may be flattened, swollen, 
cuboidal, degenerated, or fatty. When the disease fol- 
lows chronic congestion the glomeruli are large and there 
is a marked growth of cells covering the capillaries of the 
tufts ; in other cases many of the tufts are compressed by 
the excessive growth of their cellsand of those lining the 
capsules, and finally become converted into little fibrous 
balls. The capillaries of the glomeruli may also become 
the seat of waxy degeneration. The changes in the ar- 
teries are the same as those described as occurring in 
chronic nephritis with exudation. 
Among the complicating lesions of this form of chronic 
nephritis we find hypertrophy of the heart, valvular dis- 
ease, pulmonary emphysema, cirrhosis of the liver, peri- 
carditis, bronchitis, or gastric catarrh. 
The urine is usually increased in quantity, of a specific 
gravity of about 1.010, with little or no albumin or casts, 
except during exacerbations of the nephritis, and con- 
taining a diminished amount of urea. This is the typi- 
cal urine of chronic non-exudative nephritis, but it is sub- 
ject to important modifications. The specific gravity 
may remain constantly as high as 1.023, or it may fall 
almost to 1.000. In some cases several quarts of urine 
may be passed in the twenty-four hours, in others the 
secretion may amount to only a few ounces, or may even 
be suppressed entirely. 
Dropsy is ordinarily absent except in cases complicated 
by chronic endocarditis or cirrhosis of the liver. Head- 
ache is sometimes a most distressing symptom, and neu- 
ralgic pains in various parts of the body are not uncom- 
mon. Sleeplessness is often complained of. Muscular 
twitchings and convulsions may appear early or late in 
the course of the nephritis. Hemiplegia may occur early 
and continue up to the end, or may disappear after a few 
hours or days ; there may be several such attacks accom- 
panied by aphasia or coma, or there may be periods of 
delirium with elevated temperature and contracted ar- 
teries-acute uraemia. Instead of these acute attacks the 
uraemic symptoms may come on gradually ; the tempera- 
ture is then usually low and the pulse rapid and feeble. 
Neuro-retinitis, bronchitis, emphysema, cardiac hyper- 
trophy, valvular disease, chronic gastritis, and vomiting, 
one or more, are observed with more or less frequency 
in cases of chronic non-exudative nephritis. 
" Dyspnoea is a very frequent symptom, often the first 
symptom noticed by the patient. It is a spasmodic dysp- 
noea coming on in attacks which last for minutes, hours, 
or days. It is regularly made worse by mental or bodily 
exertion, or by the recumbent position. It does not re- 
semble pulmonary asthma. It is apparently due to the 
association of changes in the arteries and in the heart. 
With contraction of the arteries alone, or with a feeble 
heart alone, no dyspnoea may exist; but if the contraction 
of the arteries is so great that the hypertrophied and 
laboring heart is unable to overcome the obstruction, or 
if with the contracted arteries the heart becomes dilated 
or feeble, then the attacks of dyspnoea begin. At first 
the attacks are not severe and are of short duration, 
but if the mechanical conditions which cause them can- 
not be controlled they become longer and more distress- 
ing. 
" Perhaps the most striking examples of this dyspnoea 
are in the patients in whom it is the first symptom of the 
nephritis. They are apt to be middle-aged or elderly 
men, often engaged in large financial or commercial en- 
terprises. They profess that they feel quite well and that 
they can attend to their affairs perfectly, but that they 
are very much annoyed because early every morning they 
have an attack of asthma. In spite of their professions 
of good health, it is evident that they are pale and that 
they have dyspnoea on exertion. • The heart is found to 
be enlarged, with or without a murmur ; its action is 
either labored or feeble. The pulse is tense. The urine 
is of a specific gravity of 1.010 to 1.030 ; it contains no 
albumin, or only a trace. In the earlier stages of the 
disease this dyspnoea can be controlled, but later on it is 
more distressing and difficult to remedy." 
While chronic diffuse nephritis, like the chronic pro- 
ductive inflammations of other organs, may be a serious 
and fatal disease, like them it may also exist as a lesion 
which does not interfere with general good health and a 
long life ; and it is not at all uncommon to find evidences 
of the disease in persons who have died from other causes. 
The subjects of this lesion are, however, in constant 
peril, for though they may appear to be in fair health 
they are liable to succumb speedily to an attack of pneu- 
monia or pericarditis, or to the shock of a severe in- 
jury. 
" A very common form for the disease to take is that 
of attacks which are repeated a number of times, each 
attack worse than the preceding,-and the general health 
more and more impaired between the attacks. During 
the attacks there are cerebral symptoms more or less se- 
vere-headache, sleeplessness, delirium, stupor, coma, 
145 Diseases. 
Caecum. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
convulsions. Dyspnoea may be present or absent. The 
arteries are contracted, with a tense pulse. There is loss 
of appetite, nausea, and vomiting. The urine is of low 
specific gravity and usually contains albumin. Between 
the attacks the patients at first seem to be fairly well, but 
later they gradually lose flesh and strength. The urine 
between the attacks is of low specific gravity and con- 
tains little or no albumin. They finally die in one of the 
attacks, feeble and emaciated. 
"In some of the patients spasmodic dyspnoea is the 
first symptom. This can often be controlled for months 
and years, and the patients then seem to be well. But 
after a time it is more difficult to manage, and other renal 
symptoms are added. In some cases there are no symp- 
toms for a long time, so that persons apparently in good 
health are attacked without warning by convulsions, 
coma, delirium, or hemiplegia. They may die in the 
first attacks or live to go through subsequent ones. In 
some cases the only symptoms up to the time of the 
patient's death are gradual loss of flesh and strength and 
disturbance of digestion, the patient dying feeble and 
emaciated. These cases are hard to make out, unless 
the specific gravity of the urine is low and a little albu- 
min is present. Otherwise there is nothing to draw 
attention to the kidneys as the cause of the illness. Loss 
of eyesight from nephritic neuro-retinitis may be the 
first symptom." 
The treatment consists mainly in a regulation of the 
diet and mode of life, and in change of climate. The use 
of alcohol and tobacco should be stopped, and starches 
and sugars should be removed as far as possible from the 
dietary, the ingestion of fats on the other hand being en- 
couraged. Residence in a climate that will permit of reg- 
ular out-door exercise is advisable, and a change of scene 
and air occasionally is most desirable. The condition of 
the heart and arteries should be most carefully watched, 
and any signs of beginning tension should be at once 
met by the exhibition of the arterial dilators. A weak 
heart calls for cardiac stimulants. The use of opium is 
apparently safe when the arteries are contracted, but if 
they are not, a very little opium may prove fatal. In 
general convulsions or sudden coma, hypodermic in- 
jections of from one-eighth to one-quarter of a grain of 
morphine may be of decided benefit; and in cases of 
restlessness or wakefulness, with persistent arterial con- 
traction, much relief may be obtained by an injection of 
one-eighth of a grain of morphine every three hours. 
The other forms of inflammation of the kidneys, 
namely, suppurative and tubercular, do not call for con- 
sideration here, as they are not properly included under 
the designation of " Bright's diseases." 
Thomas L. Stedman. 
BROMOFORM (Terbromide of formyl, CHBr3). In 
chemical composition it is analogous to chloroform, 
CHClg, and iodoform, CHI3. It is formed by the action 
of brominated lime on alcohol in the same way that 
chloroform is made from chlorinated lime and alcohol. 
It is a bright clear liquid, specific gravity 2.9, taste sweet, 
without causing any irritation to the mucous membrane 
of the mouth ; it has an ethereal odor, is almost insoluble 
in water, but is soluble in alcohol and ether. It is very 
volatile and is rapidly decomposed by light, bromine 
fumes being evolved which impart a pink color to the 
liquid. 
Bromoform possesses anaesthetic properties, but in a less 
degree than chloroform, the period of excitement is less 
pronounced, and the anaesthesia is of shorter duration. 
It is also a powerful antiseptic. 
A new application of this drug was brought to the no- 
tice of the profession in 1889 by Dr. Stepp, of Nuremberg, 
who advocated its use in whooping-cough. He claimed 
that the course of the disease was shortened in every in- 
stance, that the paroxysms were diminished in number 
and severity, and that complications were less frequent, 
and when present were benefited by the treatment. The 
dose he gave was as follows: From six months to one 
year, 2 minims three times a day ; from one to two years, 
3 minims ; from two to three, 4 minims ; from three to 
(SUPPLEMENT.) 
four, 5 minims ; and from four to seven, 6 or 7 minims. 
In prescribing the remedy its high specific gravity must 
be remembered, one minim being equal to five drops. 
When administered internally no deleterious effects have 
been observed beyond an occasional sense of depres- 
sion and lassitude. Two cases of poisoning have been 
recorded. In each instance the child had taken a 
large dose of the pure drug; it produced profound 
depression and collapse, from which both children re- 
covered. 
The drug is best given in a teaspoonful of water ; it 
forms a " bead " in the water which is easily swallowed. 
It may be given in solution in water to which a small 
amount of alcohol is added, but should always be freshly 
prepared on account of its instability. How the drug 
acts is uncertain-whether as a specific, or on account of 
its germicidal properties, has not been determined. Dr. 
Stepp thinks bromine is excreted by the lungs after the 
drug has been decomposed in the system. The reports 
of others who have used it for this purpose corroborate 
the views of Dr. Stepp as to its efficacy in whooping-cough 
and its freedom from bad effects. Beaumont Small. 
BROMOL (Tribromophenol). Is formed by adding 
bromine water to a solution of phenol. It is deposited 
in white crystals, taste is sweet and astringent, odor re- 
sembling bromine ; it is nearly insoluble in water, soluble 
in alcohol, ether, oils, and glycerine. 
It has been introduced as an antiseptic in the treatment 
of wounds, ulcers, etc. Applied in its pure state it has a 
slight caustic action and favors the removal of sloughs. 
As a dressing it is applied in solution in oil or as an oint- 
ment, one part in thirty. It has been used in diphtheria 
as a local application to disinfect the throat and remove 
the membrane. 
When administered internally it is not acted on by the 
gastric secretions, and in the intestines is but slowly de- 
composed. Its action is therefore slow and prolonged. 
It is given in doses of 3 to 5 grains a day, and has proved 
of service as an intestinal antiseptic in cholera infantum 
and typhoid fever. For infants 4 to £ grain may be given 
at each dose. Beaumont Small. 
BUSSANG. A watering-place in the Vosges Moun- 
tains, France, used chiefly for " after-cures," although 
it boasts of several mineral springs. 
Location.-The situation of Bussang in the Vosges 
Mountains, about two thousand feet above the level of 
the sea, is decidedly attractive, on account of the hills 
and tine forests in the immediate vicinity. The climate 
is, on the whole, bracing and tonic. The air is pure 
mountain air, as Bussang is right among the higher 
mountain peaks of the Vosges, at the foot of the Dru- 
mont and Rouge Gazon. The Moselle River rises near 
the principal hotel of the place. Near the German fron- 
tier is the Col de Bussang, " one of the most picturesque 
points of the entire Vosges." Nir. Wolff states (" The 
Watering-Places of the Vosges") that, as a watering-place, 
Bussang owes its reputation to three chalybeate springs, 
only two of which are at present worked. The principal 
is the Source de Salmade, which is used only for drink- 
ing. There is not very much bathing, but the baths are 
well organized and clean, and very refreshing. Massage 
is often combined with them. In fact it could not be 
spared for bathing, because in the busy time something 
like ten thousand litres is sometimes bottled in a day. 
The annual sale exceeds one million two hundred thou- 
sand bottles. The water is only slightly mineralized, con- 
taining about 1.5 gramme of solid matter in a litre. On 
the other hand, it is so strongly impregnated with car- 
bonic acid, that carbonic acid intoxication has been 
known to result from too free use. 
The Bussang water is not, like many other chalybeate 
springs, constipating, having, on the contrary, a mild 
aperient effect. 
Access.-The village is reached from Paris, by way 
of Epinal, thence by stage or carriage. 
Analysis.-Two springs are found, both almost iden- 
146 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Diseases. 
Creeuin. 
SUPPLEMENT.) 
tical in chemical composition. In one thousand parts 
there are found : 
are inferior to many French, German, and Swiss ones in 
point of food and furnishing. Edmund C. Wendt. 
CACTUS GRANDIFLORUS. This is the well-known 
plant, night-blooming cereus, of the order Cactacese. A 
native of Jamaica and the West Indies. It has been intro- 
duced as a cardiac tonic, and is said to have certain ad- 
vantages over digitalis. A fluid extract and a tincture 
are prepared. The dose of the former is from 1 to 5 
minims. The tincture is made of the strength of one 
part in six of alcohol, and the dose is 5 to 10 minims, 
which may be increased to 30 minims. It has been rec- 
ommended to have the preparations made from the fresh 
plant. An alkaloid, cactina, has been separated which 
possesses all the active properties of the plant. 
The advantage that cactus grandiflorus has over digi- 
talis is its continuous stimulating action on the heart. 
Digitalis, it has been shown, acts first on the pneumogas- 
tric nerve, stimulating the heart and increasing the blood- 
pressure ; this is followed by a relaxing of the vaso-motor 
vessels and depression of the vagus. The new drug, on 
the other hand, is supposed to be free from this sec- 
ondary effect, and may be given for a prolonged period 
without producing exhaustion. It is likely to prove use- 
ful in asthenic rather than sthenic cardiac troubles. 
It is supposed to act on the medullary centre and 
through the pneumogastric and sympathetic on the 
heart. It is a stimulating tonic and invigorates the car- 
diac plexus, and promotes the nutrition of the heart. No 
ill effects have been observed from its use. It has been 
employed as a substitute for digitalis in cardiac dropsy 
and acted most favorably, its use being continued for 
some time, supporting the heart and circulation ; and in 
some cases in which repeated tapping had been required, 
this procedure wTas found to be no longer necessary. 
Its greatest use, however, appears to be in functional 
and neurotic affections of the heart, palpitation, irregu- 
larity, fluttering, slow or rapid action, and other condi- 
tions arising from debility, worry, dyspepsia, the exces- 
sive use of tobacco or tea, and such other conditions, 
where no organic disease exists. It has also been used 
with success in pseudo-angina pectoris and in exophthal- 
mic goitre, relieving the sense of oppression and pain, 
and producing a more regular action of the heart. 
Beaumont Small. 
C/ECUM AND APPENDIX, DISEASES OF. Since the 
first edition of this article our knowledge of diseases of 
the caecum and appendix has been increased greatly by 
observations made during the course of operations under- 
taken for relief of inflammatory conditions. It is recog- 
nized that more than ninety per cent, of all inflammatory 
conditions in the right iliac fossa commence in the appen- 
dix, and in a large number of these the starting-point is 
an aggregation of probably dried faeces within the appen- 
dix ; hence the term appendicitis has replaced the various 
other terms applied to inflammations in that region- 
typhlitis, perityphlitis, paratyphlitis. As our pathologi- 
cal information increases, unquestionably other terms 
will be coined, but, for the present, appendicitis is a good 
working word and suggests the origin of the trouble. 
Inflammation in the right iliac fossa occurs under many 
forms and much the larger proportion do not fall under 
the care of the surgeon, being curable by medical means 
alone. 
On the other hand, a certain number require prompt 
and immediate attention from the surgeon, and the ques- 
tion of diagnosis is one of paramount importance. It is 
not very difficult to lay down rules as to what cases 
should be subjected to such and such treatment, but 
when face to face with the patient it may be safely said 
that with our present knowledge an accurate diagnosis 
is not obtainable. Much better are we now able to recog- 
nize the condition of affairs about the appendix than a 
very few years ago, but much still has to be done, and 
no doubt the observations made during life and the con- 
ditions recognized during operations are the factors upon 
which we shall have to depend for future improvement. 
Increase of knowledge, based on clinical observation 
Salrnade. 
Marie. 
Parts. 
Parts. 
Silica 
.... 0.0041 
0.0530 
Oxide of iron 
.... 0.0059 
0.0024 
Red oxide of manganese 
.... 0.0019 
0.0020 
Alumina 
.... 0.0012 
0.0011 
Calcium 
.... 0.1519 
0.1880 
Magnesium 
.... 0.0500 
0.0540 
Carbonic acid (in combination).... 
.... 0.7390 
0.7277 
Arsenic 
. . .. 0.0005 
0.0004 
Sulphuric acid 
.... 0.0904 
0.0800 
Chlorine 
.. .. 0.0507 
0.0497 
Sodium 
.... 0.3495 
0.2890 
Potassium 
.... 0.0340 
0.0204 
Lithium 
.... 0.0012 
0.0010 
Phosphoric acid 1 
traces 
Boracic acid, fluorine ) 
Total of solids 
.... 1.5414 
1.4759 
Free carbonic acid 
.... 2.8719 
2.4934 
Temperature 
. .. 54° F. 
50° F. 
Indications.-Mr. Wolff is authority for the state- 
ments that, "the treatment at Bussang is not a very seri- 
ous affair. There is no restrictive diet of any sort. You 
go to Bussang mainly to gather strength, and pick up the 
crumbs dropped at more exhausting watering-places. 
Durand-Fardel, the acknowledged authority on French 
waters, recommends Bussang water for dyspepsia, gas- 
tralgia, and chlorosis, and as a capital substitute for 
Vichy in the case of people who cannot stand the 
strongly mineralized spring of that place. Dr. Onimus, 
the doctor of the spa, also speaks of excellent results 
obtained through its contracting action upon the bladder. 
Constantin James places it, for its effects, midway be- 
tween chalybeate and alkaline springs. Its main use is 
as what the French call a reconstituant, and for this ef- 
fect there could not be a happier combination of water 
and high position than is actually found at Bussang." 
Accommodation.-The village hotels are primitive. 
There is a good new Hotel des Sources, in close proximity 
to the bathing establishments. There are no particular 
amusements, and the place is decidedly " quiet." 
Edmund G. Wendt. 
BUXTON. One of the most popular thermal stations 
in England. 
Location.-Buxton is pleasantly situated in a pictu- 
resque part of Derbyshire, about thirty miles northwest 
of Derby. It is nine hundred feet above sea-level, and 
surrounded at some distance by hills of moderate eleva- 
tion. The mineral springs are the most noted in Eng- 
land, and the town resembles in its newer sections the 
fashionable Continental spas. The air is pure and brac- 
ing, but like other English resorts, the place is visited by 
too many damp and rainy days to be always enjoyable. 
The springs were known to the Romans. There are 
many public and private baths, and there is a large pub- 
lic hospital, the Devonshire Hospital, where the waters 
are much used. Season, June to October. 
Access.-Buxton is reached from London (St. Pan- 
eras Station) by the Midland Railroad in four hours. 
Analysis.-The principal ingredients of the Buxton 
waters are, carbonate of lime, carbonate of magnesia, 
chloride of sodium, chloride of calcium, silica, all in rel- 
atively small proportion. Indeed the efficacy of the 
springs is scarcely due to their mineralization, but almost 
wholly to systematic external use and the diluent action 
of pure water. The temperature of the springs varies 
from 60° to 82" F., and the water contains a large amount 
of nitrogen. 
There is also a chalybeate spring at Buxton, known as 
St. Anne's Well, but it is only sparingly used. 
Indications.-The Buxton waters are employed al- 
most exclusively in gouty, rheumatic, or lithaemic condi- 
tions. But dyspeptics, and sufferers from genito-urinary 
troubles are also sent there. Patients with hysterical 
palsies also go to Buxton in large numbers. 
Accommodation. - The Buxton thermal establish- 
ments are good, though less perfect in their appliances 
and comforts than many Continental places. The hotels 
are clean and typically English, which means that they 
147 Caecum. 
Caffeine. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
during the past few years, justifies the opinion that ap- 
pendicitis occurs in females nearly as often as in males, 
and from very early childhood to middle life. 
The starting-point usually is the appendix, in excep- 
tional cases only is it the caecum, and then probably tuber- 
culosis exists. The inflammation appears to begin in the 
lining membrane of the appendix, and may be catarrhal in 
character, without obvious cause; but a concretion is found 
in very many cases, and this is probably the foreign 
body spoken of under the name of "prune-stone, date- 
seed, coffee-berry," etc., which have been occasionally 
referred to in the medical periodicals of the day. It is 
likely that a piece of beces has entered the appendix and, 
remaining for a certain time, has become dried more or 
less by absorption of the watery constituents ; or perhaps 
retained by a fold of mucous membrane it has become em- 
bedded and hardened by the process already mentioned. 
Certain it is that a foreign body has been found again 
and again to be present in cases of appendicitis, more 
often than could possibly happen by accident; hence, a 
place in the causation of the disease is to be given to the 
more or less large mass of hard substance-probably fe- 
cal-so often present. The coats of the intestine may 
give way gradually until the actual rupture takes place, 
or the thinning of the wall of the bowel may occur with 
successive attacks of inflammation. It would be ex- 
pected, as the intestinal wall becomes thinner, that ad- 
hesions between adjacent coils of bowel would take place, 
and that this does happen is testified to by the many 
cases of circumscribed suppuration about the appendix ; 
but occasionally the failure of adhesions to take place 
permits general septic peritonitis to occur. Just why an 
inflammation should take place in the appendix without 
the presence of the foreign body as an exciting cause, we 
are unable to say, but so many cases are met with at 
post-mortem inspection which give evidences of cured 
inflammation about the appendix that the fact has to be 
admitted. As the appendix is probably the relic of a 
large caecum existing formerly, it would be proper to 
consider this part of the intestine as an organ not capable 
of resisting disease to the same extent as do the other 
portions of the bowel; hence it would be the place of 
least resistance. The formation of pus is thus to be 
looked upon as an intra-peritoneal, not an extra-perito- 
neal formation. It has been my fortune, on one occa- 
sion, to be able to lift such an abscess, circumscribed by 
coils of the bowel, out through the abdominal incision 
and open it outside of the body. The point where the 
inflammation begins may be at the apex or at the base of 
the appendix, or between the two. When it is situated 
at the base of the appendix, the caecum is also found to be 
inflamed, but so soon as the pus forms it is not a matter of 
much consequence what is the extent or the exact local- 
ity of the abscess, for everything is tied up together. It 
may of course happen that the peritoneal adhesions are 
very dense, and the pus may make its way into the con- 
nective tissue about the caecum or other organ. 
The onset of an attack may be either sudden or gradual. 
In the latter case there will have been attacks of bowel 
disturbance, constipation and diarrhoea, with abdom- 
inal cramps, for a certain period ; not enough, perhaps, 
to have caused the patient to seek the services of a phy- 
sician, but sufficient to have caused a certain anxiety on 
his, the patient's, part. Perhaps the physician may have 
been consulted, but if so, it has been for indigestion or 
some slight disorder. In a certain number of cases the 
onset of the disease is acute, pulse and temperature both 
rise, acute pain is present and is referred to the right iliac 
fossa, although possibly elsewhere. The patient may be 
cognizant of a certain stoppage in the bowel, as he de- 
scribes it, and he becomes anxious. Pain, while generally 
referred to the locality mentioned, is not always so by 
any means. Sometimes the epigastric region is indicated, 
sometimes the navel, and sometimes a corresponding 
point on the left side of the abdomen. In one or two 
of my cases the pain has been referred to the right loin, 
not far from the spine. On one occasion, where the pain 
was referred to the epigastric region, it could be miti- 
gated or often made to disappear by pressure of the hand 
(SUPPLEMENT.) 
on the right groin. The place of greatest sensitiveness 
has been referred to a point inside the right iliac spine, 
about two inches distant on a line drawn from the ante- 
rior superior spinous process to the navel, which point is 
supposed to be over the base of the appendix. I have 
found this to be the case, and while pressure in that re- 
gion causes pain I have not been able to locate it so accu- 
rately as has been done by others. Rigidity of the ab- 
dominal muscles is very constant, and more often seen 
on the right than the left side, but it sometimes requires 
pressure to induce it. Temperature shown by the ther- 
mometer is generally not high, unless in the late stage of 
the trouble. Purulent septic peritonitis may exist with 
subnormal surface or mouth temperature. Rectal tem- 
perature is higher by several degrees than mouth or sur- 
face temperature. I attach much less weight, in forming 
my opinion of the patient's condition, to the amount of 
fever than 1 do to the condition as shown by the pulse. 
This latter is a vastly better index. Constipation is often 
present, and may be so marked as to be mistaken for ob- 
struction ; indeed a certain number of cases have been 
treated for obstruction. Doubtless the cause is paralysis 
of the intestinal wall in consequence of the presence of 
the inflammation, but a change from constipation to diar- 
rhoea, brought about by medicine, is seen in cases of abscess 
rather than in diffuse peritonitis. When, therefore, fre- 
quent passages are induced by medicines following an 
apparent obstruction, I am inclined to think that my pa- 
tient has escaped a general septic peritonitis. Tympa- 
nites. occurring early during an attack, is not favorable ; 
continuing constantly, it is not a favorable symptom, and 
if associated with constipation it indicates loss of power 
in the intestinal wall. Shock is marked when perfora- 
tion takes place, otherwise it is not a prominent symp- 
tom. Vomiting of the contents of the stomach, and sub- 
sequently of the contents of the upper part of the small 
intestine, suggests peritoneal involvement ; in general 
peritonitis the material vomited is apt to resemble finely 
cut spinach in color. The color changes to brown as the 
scene closes, and is apt to be very profuse in the last 
hours of life. (Edema of the abdominal wall is met with 
where an abscess is immediately adjacent. Tumor in 
the right iliac fossa is not found at the commencement 
of the attack, but may appear shortly. At first it is 
probably due to an adhesion of the intestines around the 
focus of primary inflammation or the swollen appendix. 
Later, as pus forms, the tumor naturally becomes larger 
if walled in by adhesions. Where the inflammation is 
not shut off by adhesion from the rest of the peritoneal 
cavity the tumor is wanting ; such cases are rapidly fatal 
and call for active interference at an early day. The 
rigor and chill may occur with the commencement of the 
inflammation, or later, but they are rarely wanting at one 
time or another. Free extension of the thigh often causes 
pain. Digital examination by the rectum is occasionally 
useful and should not be neglected, but will be of especial 
use when the intra-peritoneal tumor has acquired a cer- 
tain volume or where it extends downward toward the 
rectum. An appendix which hangs over the brim of the 
pelvis, if inflamed, may be recognized early in the disease 
by the rectal touch. In cases where inflammation extends 
into the pelvis, involvement of the peritoneal covering 
of the bladder may occur; hence, frequency in passing 
water is a symptom of value. It is usually accompanied 
by scalding along the urethra, with pain at the meatus, 
and spasm of the bladder, sometimes very severe. Fluc- 
tuation is not to be expected, although occasionally met 
with; its presence indicates a large amount of pus situ- 
ated superficially, and certainly is wanting in the early 
stage of the trouble. Its presence should not be expected, 
either for diagnosis or treatment. Percussion is rarely 
dull, for often, if pus is present, it will either be overlaid 
by intestine or so closely in relation therewith that dul- 
ness is wanting, and pus may be under the abdominal 
wall so that it can be cut into without difficulty, yet a 
tympanitic note will exist. The countenance is apt to 
indicate the gravity of the trouble moderately well ; dark 
circles about the eyes are not a hopeful sign, and appar- 
ent receding of the eyes within the sockets suggests ex- 
148 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Caecum. 
Ca Heine. 
treme illness. The introduction of the needle of a hypo- 
dermic syringe into the affected area, with a view to the 
discovery of pus, is most unwise. I believe incision to 
be safer. There is no knowing just what the needle may 
reveal, and it may conceal much. 
A large number of cases recover from appendicitis, 
usually the catarrhal form, and they do not fall under the 
notice of the surgeon. A few days' rest and gentle pur- 
gation, and the patient recovers. Some cases, on the other 
hand, are not followed by perforation, but they induce 
suppuration within the peritoneal cavity, which becomes 
promptly circumscribed and walled in by adhesions of 
adjacent intestinal loops, thus shutting off the general 
cavity from infection. In another class of cases perfora- 
tion does take place, but this also is walled in as in the 
preceding class. Finally, another class exists in which 
perforation occurs, but without the walling in just de- 
scribed ; whereupon a general infection of the perito- 
neum follows. These latter cases die, with few excep- 
tions. The difficulty which presents itself to the phy- 
sician is the recognition of those cases which will be 
circumscribed and those which will not, and it is to be 
regretted that at present it is impossible to certainly dif- 
ferentiate between them. They are apt to be alike in 
commencement, for a certain number of hours, at all 
events, and yet early operation will prevent the rupture 
and general peritonitis in the one class, while in the 
other surgical interference is not needed. 
The term "early " used here is not intended to apply to 
the length of time that the attack has lasted. It does re- 
fer to the pathological condition, and refers especially to 
perforation, so that an operation undertaken soon after 
the commencement of the pathological condition which 
would eventuate in rupture, may be in the one case a few 
hours and in the other case several days after the com- 
mencement of the illness. The term "early," then, as 
ordinarily used, is a misnomer in my opinion. 
Probably a position of armed neutrality is the proper 
one for the physician to assume, and when I say physi- 
cian, I mean that the attending physician, if not a sur- 
geon, should promptly call in a surgeon, and together the 
two should conduct the case. It is right that the sur- 
geon should see the case from the start, but equally he 
should know how to withhold his hand, and not think, be- 
cause he is called in, that he should at once operate. In 
no class of cases is good judgment of more value to the 
patient, and equally may it be said that in no class of 
cases is a correct judgment more difficult to form. Per- 
foration usually takes place, if it takes place at all, in the 
first three or four days after the onset of the disease ; 
hence the necessity for forestalling a fatal rupture is ap- 
parent. Where the abscess is circumscribed, the opera- 
tor has time to open and drain, and general peritonitis is 
then very rare. Where perforation takes place without 
formation of adhesions, fatal peritonitis results. Such a 
condition should be prevented by prompt operation and 
removal of the appendix, which is the starting-point 
of the trouble. Only careful and continuous observation 
will enable the surgeon to recognize the necessity for in- 
terference. The pulse progressively increasing in fre- 
quency, the temperature rising or remaining high, acute 
pain on pressure in the right fossa, perhaps near the point 
already referred to, constipation present, with or with 
out a swelling in the right fossa, rigid right rectus- 
these are the indications which may be held to call for 
an operation. The pulse not frequent, diminishing pain, 
moderate temperature, absence of tympanites, will jus- 
tify the surgeon in waiting. The incision, when made, 
should be as long as may be necessary to give free access 
to the seat of disease, and the centre of the incision 
should fall on a line drawn from the navel to the an- 
terior superior spinous process, about two inches from 
the bone. The peritoneal cavity should be opened to 
the same extent as the skin incision ; unless the opera- 
tor finds adhesions closing in the seat of inflammation, 
these should not be disturbed. The coils of bowel are 
to be pressed aside, the seat of inflammation found, and 
the pus evacuated. In circumscribed cases the adhe- 
sions should not be ruptured, but the appendix should be 
sought for and explored by touch and sight, if possible ; 
if a concretion be present it should be removed and the ap- 
pendix tied off, but not if by such action the general peri- 
toneal cavity is likely to be opened. On the other hand, 
where no abscess exists and the appendix is the cause of 
the trouble, with or without contained concretions, the 
appendix is to be tied off by a ligature applied close to 
the caecum. It is well to apply pure carbolic acid to the 
stump. This removes the cause of the trouble, and is an 
operation essentially different from the one referred to 
first. The wound is to be lightly filled with gauze which 
will be removed later, and healing by granulation allowed. 
Whether it is necessary or not to flush the general peri- 
toneal cavity, will depend on the condition found. If 
suspicion of septic peritonitis exists it would probably 
be wise to do it. I do not think that it is necessary to re- 
move the appendix in all cases, especially in cases where 
pus is circumscribed. The appendix in these cases is 
generally closed by adhesive inflammation, and I believe 
that much injury is done by indiscriminate search for 
this organ by rupturing adhesions, rather than by leaving 
them alone after the pus is evacuated, and permitting the 
cavity to heal by granulation. A perforated appendix 
heals without difficulty. 
Opium I give rarely ; it produces quiet on the part of 
the patient without arresting-the progress of the inflam- 
mation ; hence it masks symptoms which might necessi- 
tate an operation. On the other hand, saline purgatives 
I use freely, for reasons already stated, hoping to produce 
frequent evacuations from the bowels. Irritants or blis- 
ters to the abdominal wall have yielded, in my hands, no 
good results ; more comfort follows the application of ice 
over the seat of inflammation. 
Recurrent Appendicitis.-Appendicitis is met with 
occasionally as a recurrent trouble, and the question will be 
raised as to treatment. It is impossible to say, first of 
all, whether the attacks are dangerous or not, or whether 
a person having escaped one, the next attack may not be 
fatal. Such a disease generally calls for operation, the 
chosen time being the period between two attacks. The 
operation which should be done will be the uncovering 
and the removal of the appendix, in which the cause of 
the trouble exists. Undoubtedly such an operation car- 
ries with it a certain amount of danger, but probably not 
so much as would be present with an attack of appendi- 
citis. Generally speaking, it may be said that where at- 
tacks of appendicitis recur with sufficient severity to 
cause much inconvenience, or imperil existence, then an 
operation is proper. On the other hand, slight attacks of 
cramp in the right fossa, unless there be some special in- 
dication, may be considered as a trouble which will cease 
without operative interference. 
Louis McLane Tiffany. 
CAFFEINE. This alkaloid and its salts continue to be 
used for their stimulant and diuretic properties, and nu- 
merous communications indicate that it still proves of 
service in headaches, migraine, neuralgia, cardiac debil- 
ity, and dropsy due to heart disease. It has latterly been 
advocated as a cardiac stimulant and restorative in the 
prostration and debility of typhoid fever, pneumonia, 
and post-partum hemorrhage. Two to four grains are 
advised to be given every four hours ; in the latter con- 
dition, where a more prompt action is required, eight or 
ten grains may be administered hypodermically. It also 
has been found that its diuretic properties are increased 
and its general effect improved by combining with par- 
aldehyd. Four or eight grains are to be used with thirty 
or forty-five minims of paraldehyd. Its diuretic action 
has been clearly shown to be due to a direct effect on the 
secreting tissue of the kidney, which, in addition to its 
action on the circulation, makes it a most effective and 
rapid diuretic. It differs from digitalis by this prompt- 
ness of action. The influence of digitalis is not exerted 
until the blood-pressure has been raised and then suc- 
ceeded by a relaxing of the renal vessels, which may not 
be effected for some days. The influence of caffeine is 
much more rapid, and may be noticed in a few hours. 
Notwithstanding the extent to which it has been em- 
149 Caffeine. 
Canada. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
ployed and the success attending its use, our knowledge 
regarding the modus operandiot caffeine is meagre and un- 
satisfactory. To a very great extent it has been of an em- 
pirical character, and not based on any very precise data. 
Researches during the past few years have thrown some 
light on its effects on the circulation and metabolism, and 
on the ultimate effects produced by its administration, 
and as a result our views regarding its action on the 
heart must be greatly changed, and its continued use in 
cardiac debility must be guarded and cautious. In 1890 
Professor Germain See presented to the French Acad- 
emy of Medicine the result of some experiments made by 
himself and M. Lapicque, to verify its reputed restorative 
and stimulating properties. These experiments, which 
extended over a period of twelve months, demonstrated 
very clearly its influence over the muscular system. He 
found that untrained men could perform long journeys 
and enter races without enduring fatigue or exhibiting 
any sign of distress. By the means of registering appa- 
ratus it was found that there was no alteration in the re- 
spiratory or circulatory rhythm, and numerous other 
facts proved that the use of caffeine enabled a trained or 
untrained person to perform muscular efforts that other- 
wise could not be undertaken. He concludes that small 
quantities, amounting to about ten grains in the day, 
may with advantage be given to soldiers on the march, or 
where any muscular effort is required, as it prevents 
shortness of breath and palpitation and supplies vigor 
and endurance. He considers that the caffeine acts on 
the cerebro-spinal centres, stimulating the motor nerves, 
favoring the combustion of nitrogenous elements, and 
promoting the excretion of carbonic acid and other prod- 
ucts of tissue change. By this means strength is fur- 
nished, not by supplying anything new, but at the ex- 
pense of the individual by enabling him to draw upon the 
energy that is latent in the system. In no sense does it 
replace food, and unless this drain upon the system is 
replaced an unfavorable result follows. Professor See 
likens its special stimulating power to that possessed by 
food which will prove a source of stimulation by its 
presence before it is in any way acted upon by the gastric 
juices. As to its action on the heart and blood-vessels, 
he considers that but little is known and cannot be prop- 
erly understood until xanthin and its series of products 
has been studied, caffeine being chemically tri-methyl- 
xanthin. 
The experiments of Dr. Reichert, of the University of 
Pennsylvania, on animals, form a valuble corollary to 
the views of Professor See, and add much to our knowl- 
edge of the action of caffeine on the heart and blood-ves- 
sels. Reichert's experiments were instituted because he 
considered that the drug was but little understood, and 
because the very prevalent idea that it was a beneficial 
cardiac stimulant, was based on experiments that were 
incomplete and open to serious objections. He benefited 
by the experience of others and avoided their sources of 
error, with very satisfactory and important results. In a 
series of experiments on the production of heat during the 
administration of caffeine, he shows conclusively that the 
amount of heat produced and the amount dissipated are 
augmented, and in consequence with the increased energy 
a corresponding drain on the system takes place. Its 
reputed stimulating properties he considers to depend on 
a general excitation of the cerebral centres, the effect of 
which he likens to the energy and force exhibited by 
persons when the subject of a fright, hysteria, or mania, 
during the influence of which unusual deeds of endur- 
ance and strength are performed, but at the expense of 
the system. 
His experiments to determine the condition of the 
blood-pressure and the effect on the heart were very com- 
plete. Solutions of caffeine were introduced into the ex- 
ternal jugular vein and also hypodermically ; the pressure 
was recorded by a manometer in the carotid artery and 
the action of the pulse carefully observed. The effect 
was noted in dogs in their normal state, in others with 
the pneumogastrics severed to cutoff the influence of the 
inhibitory centres, and in a third series in which the up- 
per spinal cord was cut to determine the influence of the 
accelerator centres. The results of his observations are 
given in the following conclusions : 
1. The pulse rate may be diminished during the first 
and last stages of the poisoning, but is generally de- 
cidedly increased. During the first stage the diminution 
is due to a stimulation of the cardio-inhibitory centres in 
the medulla oblongata and heart, and during the last 
stages to a direct depression of the heart. The increase 
in the pulse-rate is due to a depression or paralysis of 
the above cardio-inhibitory centres. 
2. Arterial pressure during the first stages of poison- 
ing is generally unaffected or diminished, but occasion- 
ally a trifling increase is noted. The increase is due to a 
direct stimulant action upon the blood-vessel walls, in- 
creasing vascular tension. The diminution is due chiefly 
to a direct depression of the heart, and to some extent, 
doubtless, to a secondary paralysant action on the vessel- 
walls. 
3. The acceleration of the heart-beats may be accom- 
panied by no appreciable alteration in blood-pressure, 
but generally by a more or less decided diminution, 
which is dependent upon cardiac depression. 
4. Caffeine diminishes the heart's efficiency for work, 
arrests it in diastole, sometimes induces sudden paralysis, 
and is therefore a cardiac depressant. 
5. The asserted stimulant action upon the circulation 
is doubtless subjective and dependent upon an excitation 
of the cerebral centres. Beaumont Small. 
CAMBO. A popular thermal station in the depart- 
ment of Basses Pyrenees, France. 
Location.-Cambo is charmingly situated, not far 
from fashionable Biarritz, to which fact, as well as to its 
mineral springs and a well-managed bathing establish- 
ment, it owes the growing favor with which it is regarded. 
Although it is open all the year round, there are really 
two seasons, one from April to June, and the other from 
September to the latter part of October. The climate is 
soothing. Cambo is 200 feet above sea-level. 
Access.-By railroad to Bordeaux, and via Dax to 
Bayonne. Three hours by stage from Bayonne. 
Analysis.-There is an alkaline sulphur spring, hav- 
ing a temperature of 80° F., with the following chief in- 
gredients : Sulphate of lime, sulphate of magnesia, sul- 
phate of sodium, small quantities of arsenic and lithium. 
It is rich in free carbonic acid. There is also a cold 
chalybeate spring. 
Indications.-Cutaneous affections, lithaemia, chronic 
diseases of the organs of respiration, catarrhal affections 
of the alimentary canal, scrofula, and anaemic states are 
chiefly treated at Cambo. It is a good place also for 
convalescents from acute diseases, there being pleasant 
and sheltered promenades and fine scenery. 
Accommodation.-The Grand Hotel d'Angleterre, 
and the Hotel de Paris are good hotels. The thermal 
establishment has the usual appliances. 
Edmund C. Wendt. 
CAMPHORIC ACID, CtHu (COOII)2, is formed by the 
oxidation of camphor, and may be prepared by heating 
camphor with nitric acid. The acid forms in small color- 
less needles or plates, odor faintly aromatic, taste acid 
and bitter, very sparingly soluble in cold water, more 
soluble in hot, soluble in alcohol and ether. Ten per 
cent, of alcohol added to hot aqueous solution prevents 
it from being deposited on cooling. This acid has long- 
been known, but it is only during the last two years that 
its therapeutic properties have been utilized. Its latest 
use is for the treatment of diseases of the respiratory 
tract and as a preventive of night-sweats. 
For the latter purpose it promises to be one of the 
most valuable additions to our materia medica. Com- 
pared with atropine its effect is more certain and more 
prolonged, while it does not produce the difficulty in 
swallowing, dryness of the pharynx, disturbed sleep, and 
vertigo, which often accompany the use of the latter drug. 
Compared with atropine its mode of action differs, as its 
beneficial effect is thought to be due to its power of de- 
150 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Caffeine. 
Canada. 
stroying the ptomaines in the blood which cause this dis- 
tressing symptom. 
The dose as an anhydriotic is thirty grains at bed- 
time, or fifteen grains during the afternoon and the same 
dose repeated at bedtime. The action is not rapid, and 
in some instances no effect has been noticed until the 
following day. The effect of a single dose often con- 
tinues for several days. The reports of cases treated show 
beneficial results in a great majority of them ; it does not 
in any way interfere with the appetite or digestion, and 
in most instances a quiet sleep followed its use. As the 
taste is somewhat disagreeable, it is best administered in 
wafers or capsules. In diseases of the mucous mem- 
brane of the respiratory tract, camphoric acid is used by 
applying locally and as a spray. In acute coryza, phar- 
yngitis, and laryngitis a half to one per cent, solution 
may be used every three hours, or tampons saturated in 
the solution maybe introduced into the nasal cavities; in 
ulcerated throat, a solution of two to six per cent, may 
be applied. This drug has no corrosive action ; it pos- 
sesses antiseptic properties and produces contraction of 
the blood-vessels of the mucous membrane. Internally, 
it is also used for intestinal diarrhoea of a catarrhal char- 
acter, and where intestinal antisepsis is desired, the dose 
is from five to ten or fifteen grains. It is excreted by 
the kidneys and renders the urine clear and acid in two 
or three hours. 
In cystitis, when the urine is alkaline, it has proved of 
benefit. In this condition it is also used as a wash in a 
half of one per cent, solution. The bladder is to be ir- 
rigated twice a day, about an ounce of the solution being- 
left behind. Beaumont Small. 
CANADA, CLIMATE OF.* The climate of a country 
must ever be considered of the greatest moment to hu- 
man welfare. What is climate ? It is not obliquity of 
the sphere with respect to the horizon, from which re- 
sults the inequality of day and night; it is not the im- 
aginary circles parallel to the equator ; nor is it the 
weather peculiar to a given country; nor its heat, nor 
its cold, nor its dryness, nor its moisture; nor the course 
or character of the winds ; nor the changes of the sea- 
sons ; but all these combined, together with its salubrity 
and insalubrity. It is, in a word, according to Hum- 
boldt, "the changes in the atmosphere which sensibly 
affect our organs, as temperature, humidity, variation in 
the barometrical pressure, the calm state of the air, or the 
action of opposite winds, the amount of elastic tension, 
the purity of the atmosphere, or its mixture with more 
or less noxious gaseous exhalations, the degree of ordi- 
nary transparency and clearness of the sky, the organic 
development of plants, and the ripening of fruits." But 
to these must be added the feelings and mental and social 
condition of man as affecting and modifying the influ- 
ence of climate everywhere. Distance from the equator 
and height above the level of the sea are not therefore 
the only conditions comprised in the function of climate. 
Climate is influenced markedly by the physical geog- 
raphy of a country. The Registrar-General for Scot- 
land, in explanation of certain phenomena, the causes of 
which are not quite obvious to the reader, generally de- 
scribes Scotland to be of extremely irregular figure, and 
attributes the disturbance of the mortality tables to that 
cause. Writers generally admit that there is neither 
conceit nor irrelevancy in the matter. Climate affects 
our stature, our strength, and complexion; causes and 
cures disease ; prolongs or shortens life. Its influence 
may be seen in the great variety of races which inhabit 
the earth, presenting every tinge and hue of complexion, 
from the pale white to the ebony black ; and in the vast 
variety of intermediate races-all descended from one 
common parent,-the theories of the pluralists to the con- 
trary notwithstanding. 
There must be added a third element, which affects 
man in health and disease, and which influences the 
tables of mortality, viz., the ordinary condition of wealth 
and comfort, or the reverse. 
Before entering upon the subject of the paper it may 
be well to state the conviction that the influence of cli- 
mate upon man and upon the brute creation is marked, 
-more marked, indeed, upon the lower animals than 
upon man,-for the latter is not so completely exposed to 
the influence of climate as are the former. A few gen- 
erations will so change many animals as to make them 
scarcely recognizable; while man requires a period so 
great that some are disposed to doubt that any amount 
of intra- or extra-tropical influence can convert a white 
into a black man, or a negro into an Esquimau. 
As has been said, climate generally has an intimate re- 
lationship to the physical geography of a country, and 
the climate of Canada is not an exception. Its vast ex- 
tent of country, from the Atlantic in the east to the 
Pacific in the west, and from the Arctic Ocean, Baf- 
fin's Bay, and Davis's Strait on the north and north- 
east, to the boundary line, forty-fifth degree, and the 
great chain of lakes in the south and southeast, would 
necessarily give it a varied climate. 
Canada occupies a great portion of what has been 
styled the Interior Valley of North America-a valley 
which may be said to occupy six million square miles, 
beginning with the tropics and terminating within the 
Polar Circle, traversing the continent from north to 
south and passing through the entire northern zone. This 
valley rests upon, and is indented by, the Gulf of Mexico 
on the one side, and by Hudson's Bay on the other; a 
valley which is protected from the Pacific Ocean on the 
west by the Rocky Mountains-mountains varying from 
ten to fourteen thousand feet in height, which greatly 
modify the distribution of rain, the direction of winds, 
and in many ways influence the climate. The Appala- 
chian chain of mountains-a chain interrupted only at 
the forty-second degree of latitude by the Great Lakes 
and the St. Lawrence-bounds this valley in the east. 
The distribution of these chains of mountains permits 
a more direct oceanic influence on the Atlantic or eastern 
side than on the western or Pacific side. 
The enormous fresh-water lakes within that valley in- 
fluence most materially the climate of Canada. The ba- 
sin of the St. Lawrence alone has an area of upward of 
half a million square miles, and contains lakes having an 
area of one hundred and thirty thousand square miles. 
The St. Lawrence basin is hemmed in on both sides by 
mountain ranges : the Laurentide on the north, the moun- 
tains of Notre Dame on the south. The latter form the 
Vermont Mountains, mountains which exert so potent an 
influence upon the climate of both the United States and 
Canada. The ranges of these mountains vary in alti- 
tude from a few feet to four thousand feet above the sea. 
At different heights along these mountain ranges numer- 
ous watersheds are met with, in addition to those in the 
basins already alluded to-the Lacustrian chain, which 
begins in a cul-de-sac formed by the Arctic Ocean and 
the Rocky Mountains. So great in number are these 
fresh-water lakes that many of them have not yet re- 
ceived names. Some of these lesser watersheds have not 
been fully explored, yet their genial influence upon the 
climate of the country is admitted. The low altitude of 
Canada is favorable to its climate and to its vegetation. 
Were the plateaus on the north coast much elevated, 
vegetation would be confined to the mosses, and animal 
life to a few hardy, thick-furred animals. But all the 
long gentle slopes descend toward the Atlantic and the 
Frozen Ocean ; while all the short and rapid slopes, or 
counter-slopes, are directed toward the Pacific. The 
land in Canada ascends in a series of plateaus as we ap- 
proach the interior, and we reach the height of table- 
land, as it is termed, on the south side of Hudson's 
Bay. 
Canada consists for the most part of laurentian, devo- 
nian, and silurian rocks. 
The size and shape of this country operate in control- 
ling the distribution of heat. It is admitted that the 
greater the land surface the greater the measure of heat; 
and as the continent of America widens as we ascend in 
* The present article is, in considerable measure, a condensation of my 
work on "The Climate of Canada, in its Relations to Life and Health," 
to which I refer the reader for ampler information.-W. H. H. 
151 Canada. 
Canada. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
latitude we find the centre of the system of atmospheric 
circulation north of the geographic equator. 
The series of vast lakes and rivers exerts unmeasured 
influence on the climate of Canada'. It would be enter- 
ing upon too elementary a question to discuss it at 
length. I may say, however, that the influence which 
large areas of fresh water exert is in a measure propor- 
tioned to their depth rather than to their surface. If the 
collections of water are deep, their surfaces are steadily 
maintained at a higher or lower temperature than the 
surrounding air. In summer the surface waters are 
heated, and when heated become specifically lighter, 
and in consequence continue to float upon the surface ; 
during the night a portion of surface water, cooled by 
the withdrawal of the sun's rays or by the low tempera- 
ture of the air, becomes denser and sinks, while the 
warmer water ascends to take the place of the colder ; but 
at no great depth from the surface of these great bodies 
of water the temperature is uniformly cold, being 
scarcely modified by our summers and winters. 
Canada without its lakes would be like the north of 
Europe in being both continental and oceanic. But its 
oceanic features are limited. The cold air from the 
lakes affects vegetation near their shores, but not at a 
great distance from them. It is to the lakes and rivers, 
on the other hand, that we are indebted for so great a 
range of animal and vegetable life. Thus vegetation in 
longitude 110° and latitude 54°, upward of seven hun- 
dred miles from Toronto, has nearly the same character 
as it has in the capital of Ontario. 
The climate of Canada is more uniform than is that of 
Europe-the meteorological differences being such as 
are produced by position alone. It is regarded as a dry 
climate, yet more rain falls in Canada than in Britain ; 
but it falls in a shorter period, and in larger quantities at 
a time. The average fall in Canada is fifty inches a 
year ; while in Great Britain the rainfall is but thirty 
inches. If we seek comparisons in Europe, we find a 
parallel to the Canadian winter in St. Petersburg, and 
to the Canadian summer in Paris. But the sky of 
Canada rivals those in clearness-a clearness which is 
obscured only for a short period every few days. 
It is customary elsewhere to divide the year into sea- 
sons of three months each ; but this division, arbitrary at 
best, is totally inapplicable to Canada. Spring and au- 
tumn are here of short duration. A line of forty degrees 
mean temperature, according to Blodgett, passes through 
Nova Scotia, near Halifax, Montreal, then parallel with 
the St. Lawrence, north of Kingston, through Toronto, 
south of Penetanguishene to the Red River of the North. 
That is the temperature of April, but advance in tem- 
perature is uniform for the next two months. The ad- 
vance is illustrated by corresponding changes in the ani- 
mal world. The earliest birds, as the song sparrow, be- 
gin to sing in the month of March; the robin, also re- 
turning from the South while snow yet dapples the 
ground, makes short and frequent attempts at song ; the 
moose deer leaves his winter haunts about the same pe- 
riod, and approaches the marshes, ponds, and rivers, in 
search of food; wild-geese move northward about the 
22d of April ; and the frog, with a regularity that is sur- 
prising, begins in the last week of April in Eastern Can- 
ada its harsh guttural croaks. 
The mean summer temperature ranges from 55° F. in 
the northern to 65° F. in the southern parts of the 
country ; but the extremes of heat are very great, the 
thermometer sometimes indicating a temperature more 
exalted than that of the blood. The mean distribution 
of rain for the three months of summer is ten inches. 
The early part of autumn is a season of peculiar 
beauty; the transition from the heat of summer to the 
temperature of autumn is very sudden ; the autumn col- 
oring of the leaf in various tints is but the prelude to the 
rustling of its dry, lifeless form. While the first of these 
autumn months-September-might be claimed by sum- 
mer, the last, November, is in reality a winter month ; 
the mean temperature of the latter may be stated at 
43° F. 
The regularity of the advent of birds from the North, 
in springtime, is equalled by the regularity of their depart- 
ure in autumn. A mysterious influence-which has been 
variously explained by some as the advancing heat, or 
by others as the demand of impending ovulation-seems 
to lead various classes of birds to take their departure 
for the more congenial influences of the South at about 
the same time ; and birds of strongest wing and most 
rapid flight are very often those which leave the north- 
ern portions of Canada with the greatest regularity. 
Thus the wild-goose, which, according to Dr. Rae, visits 
the extreme North on April 23d, comes back again to us 
about the 25th of October. 
A foretaste of wunter is afforded us by sharp frosts, 
piercing winds and snowfall, interrupted for a day or 
two by soft balmy breezes, which we call " Indian Sum- 
mer," but which the French habitant styles : 
" L'ete St. Martin, 
Du Soil- au Matin." 
This is a short period, of uncertain occurrence and of 
uncertain duration. 
In winter the snowfall does not bear a direct ra- 
tio to the cold. The largest amount of snow usually 
falls in the months of December and February, and 
although occasionally the temperature of those two 
months falls below that of January, it is only in the 
aggregate, as considerable allowance must be made for 
what is termed the " January thaw." 
The snow crystals which fall in different months, and 
in various parts of the country, are very different in 
form. The aggregated flakes vary in their combination, 
but in whatever part of the country they are met with, 
they present as distinct a mathematical form of crystal- 
lization as that which characterizes the more lasting crys- 
talline gem from inorganic nature. The snow-crystals 
are well-defined hexagonal or six-sided prisms, very com- 
monly of a stellar or star form ; but the electrical condi- 
tions of the air influence the form. Vitreous or positive 
electricity gives a result different from that given by neg- 
ative or resinous electricity, but chiefly in the matter of 
the grouping. 
As forests or herbage which cover the surface influ- 
ence climate, that of Canada is certainly undergoing im- 
portant modifications. Forest trees cannot be cut down, 
and the earth cannot be upturned or pierced with drain- 
age-tubes without the climate being sensibly affected. 
From the oak and elm and beech and maple on the one 
side, to the pine and cedar and still hardier lichens, the 
mixed forest is met with in Canada in rich luxuriance. 
In some districts the pine and spruce are interspersed 
with beach and maple ; but plants with slender shrunken 
leaves and feeble stems are nowhere to be met with in 
Canada. The wild grape flourishes as far north as fifty- 
two degrees of north latitude, and is abundant in the 
Kaministiquoia. 
As a wheat-growing country Canada equals Russia. 
From the valley of the Saskatchewan, and from far down 
the Mackenzie River in the northwest, along the chain of 
lakes and rivers, wheat of the finest description is grown 
-inferior in gluten only to that cultivated near the 
shores of the Mediterranean. Were it not for untimely 
frosts the wheat-producing power of the northwest of 
Canada would be greatly increased. 
The climate of Canada is highly stimulating. It is a 
matter of observation by residents and travellers that the 
thermometer cannot register this quality, though Euro- 
peans, accustomed during their lifetime to the use of 
stimulants, quickly perceive that if they wish to preserve 
health in Canada the quantity must be diminished: 
temperance is almost a matter of necessity. 
A residence in Canada is attended with certain physio- 
logical changes. The transition from youth to manhood 
is often sudden, the period of childhood being short ; but 
not to climate alone, but to domestic education as well, 
and to social influence, must be attributed this most unat- 
tractive feature. Many of the tissues of the body, as the 
skin, hair, etc., become drier by a residence in Canada, and 
physicians recognize still further changes in some of the 
152 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Canada. 
Canada. 
internal organs ; but these changes are not prejudicial to 
life or to health. On the contrary, the maritime and 
continental features, harmoniously blended in a Canadian 
climate, are favorable to the highest development of a 
hardy, long-lived people. 
It is generally admitted that a change takes place in 
the European's constitution after a longer or shorter res- 
idence in this country. Between the emigrant of to-day 
and the children of emigrants of fifty years ago we 
observe marked differences. The high color which 
flushes the cheeks and reddens the lips of Europeans 
fades somewhat, and the skin becomes less soft and moist; 
the hair becomes drier and straighter ; the fat, which 
cushions the cheeks' muscles and gives roundness to the 
general outline, disappears to some extent; and the teeth, 
thanks to a pernicious mode of living, decay sooner. 
The various seasons influence persons differently ; but 
it is, perhaps, the great heat of summer which influences 
most. The temperature of winter comes next. The 
milder seasons of spring and autumn exert less influence, 
being more like those seasons in Europe. In Canada it is 
not alone the hot weather which acts so severely upon 
the human body, but, apart from the relaxing influence 
of heat per se, it indisposes to take food in large quantity. 
It is during the hot weather that mortality is greatest in 
Canada-very different from what it is in the north and 
west of Europe, where the mortality is higher in cold 
than it is in warm weather. 
The cold of Canada in winter is severe, but it is not 
destructive ; the sharp, clear, bracing temperature is more 
easily and more agreeably borne than is the humid, raw air 
of a higher temperature. It is remarked that the cold dur- 
ing winter seems to be more superficial, as it were, and to 
call into activity the capillaries of the surface of the body. 
A marked difference is noticed between the influence of the 
cold of Canada, with its low altitude, and the same tem- 
perature in high altitudes elsewhere. If, for instance, 
we ascend Mount St. Bernard till we reach a temperature 
equivalent to that of a Canadian winter, the air is found 
to be too vivifying ; respiration becomes too hurried, and 
among those who permanently dwell there great lon- 
gevity is rare. In Canada the cold is indeed exhilarating, 
but not for early destruction. The exhilarating influence 
of a Canadian winter depends much upon its peculiar 
electrical condition. The sensations of cold in winter 
are but relative : when the body is inured to severe cold 
a moderate degree of elevation is easily felt. It is sur- 
prising how easily we adapt ourselves to a climate where 
the changes in temperature pass through a cycloid very 
much greater than exists, perhaps, in any other part of the 
world. Europeans, if sheltered from the piercing winds, 
inure themselves readily to the severest cold in winter. 
The rapidity with which the country has been recently 
opened up, especially the west and northwest, makes 
any attempt at correct vital statistics impossible ; but the 
reports furnished by the surgeons of the American and 
British armies supply that want-to a considerable extent. 
It has been found that stations improve in salubrity in 
direct ratio to their proximity to the frontier and to the 
great chain of Canadian lakes. Canada is the healthiest 
station in the British Army, Malta alone excepted,-much 
more favorable to life and health than Great Britain 
itself ; much more favorable than those favorite stations, 
Gibraltar or the Ionian Islands or the Bermudas ; and 
immensely more favorable than Ceylon or Bengal, or any 
other Indian station. 
There are no diseases known in Canada which are not 
met with elsewhere, though many diseases are greatly 
modified by residence in Canada. 
The selection of climate is oftentimes a matter of some 
difficulty ; thus, portions of Canada are singularly favor- 
able to consumptives ; but this must be taken with some 
qualification. The climate is favorable to persons in 
whom tubercles are being deposited, or are already de- 
posited, or to those who have a condition of lung which 
seems prepared for the reception of tubercle. But for 
those in whom tubercular softening exists, or in whom 
large or even small cavities are found, Canada is not a 
favorable climate, except, perhaps, that of its western 
(SUPPLEMENT.) 
extremity at the Pacific Ocean. The air in tjie north, 
otherwise so healthy, is too stimulating under these cir- 
cumstances ; while that of the east is too humid. Writers 
on the diseases of hot climates were formerly in the habit 
of recommending consumptive patients to visit warm 
regions-to pass a winter in the South of Europe, or in 
Africa, or in the warmer portions of the American con- 
tinent ; but there has for many years past been a change 
in the opinion of physicians on this question, and pa- 
tients are sent to cold rather than to hot regions. Some- 
times patients are sent on whaling expeditions off the 
coast of Greenland. But whaling expeditions are not 
easily arranged for, and are attended with risks and dis- 
comforts of a nature to counterbalance, in great measure, 
the advantages of change of air. 
The varieties of climate in Canada differ widely, em- 
bracing almost every moderate degree of heat and every 
still more moderate degree of moisture, and affording 
greater differences than are to be found perhaps in any 
other country. Its vast extent of territory would account 
for so great a range ; but, as I have said, north and south 
are not the only questions where climate is concerned ; 
and even the poles and the equator are but elements in its 
formation. 
As in Canada we have almost every variety of climate, 
and as we are not restricted in selection, places must 
needs be chosen where comfort, which is so essential to 
enjoyment, may be most easily obtained. Since there 
has been direct railway communication between the At- 
lantic and the Pacific coasts through Canadian territory, 
where the mosses at one end, the umbrageous foliage at 
the other, and the variegated forests along the route give 
evidence of the great variety of climate traversed in the 
eight days' rapid journey, a choice of locality is not diffi- 
cult. With a country joining two oceans; with every 
variety of physical configuration ; with every degree of 
temperature, and with a moderately varying dew-point, a 
choice may easily be made by those conversant with the 
subject, for it must be borne in mind that not temperature 
alone, nor dryness, nor equability is exclusively to be con- 
sidered, nor yet the all-important question of comfort, 
but all these taken in connection one with another. It 
is pleasing to add that the condition which the medical 
authorities of the United States Army wisely object to- 
high temperature and with it a high dew-point-is not 
met with in Canada. One must be prepared, however, 
to lay down general rules for the guidance of patients in 
special cases. The many hundreds of miles of the Atlan- 
tic coast afford a selection for one class ; the more shel- 
tered parts of the St. Lawrence valley will suit another 
class ; the hilly districts in Eastern Canada would benefit 
a third ; the western lakes would suit others ; the large 
basins of water, the Saguenay or Gaspe, or Baie de 
Chaleur, a fifth ; the shores of those inland seas of 
purest water, another class; the western regions from 
Winnipeg to the base of the Rocky Mountains, espe- 
cially the neighborhood of Banff, another class ; spots 
here and there on the Rocky Mountains themselves, an- 
other class ; the western slopes of the Rockies, another 
class ; and the varied shores of the Pacific coast, still 
another class ; and when chronic bronchitis or pleurisy 
is under consideration, the more genial influence of the 
Pacific will be found more beneficial. In the months of 
December, January, and February, and the first two 
weeks of March, in almost any of these districts, but 
especially in Eastern Canada, generally as far as the 
Rockies, the advance of phthisis is checked in persons 
who have strength enough to live much in the open air. 
The healthiness of the climate has been a matter of ob- 
servation by every writer from Charlevoix to the present 
day. The early French writers in sending accounts to 
their " Mere Patrie" were enthusiastic over the purity of 
the atmosphere, the magnificence of the forests, the trans- 
parency of the waters, and the health-giving qualities of 
the air. 
Old age, in Canada, is a green, an active, a vigorous 
old age. The census shows a large number of persons 
living from eighty to one hundred years of age. Life 
assurance companies have found it to their advantage to 
153 Canada. 
Cannabis Indica. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
change the scale so that Canadian lives may be accepted 
at a lower rate than British lives. This continues till the 
age of thirty-six, when the rate is the same ; after which 
it gradually increases, as insurance companies have to 
take cognizance of a life of greater wear and tear in Can- 
ada, which tells, in the course of time, even upon the stur- 
diest. 
The healthiness of the climate is, moreover, manifest 
in the natural increase of the inhabitants. A section of 
the population-the French Canadian-has increased at 
a ratio infinitely greater than that of any other country, 
not even excepting that of Russia. Canada, in this re- 
spect, presents a marked contrast to many other coun- 
tries, where the birth-rate is sometimes alarmingly small. 
The increase in Canada is, no doubt, due to a consider- 
able extent to early marriages, which are in every way 
encouraged, and also to an absence, among the married, 
of that nameless, shameless, crime of marital limitation, 
which unhappily obtains in many places elsewhere. 
A circumstance not generally known may here be men- 
tioned, viz., that the weight of children born in Canada 
is nearly a pound more than that of the children born 
in the maternity hospitals in London. If, then, Canadian 
children are so favorably handicapped at the start, may 
it not be presumed that they will continue it to the finish ? 
Certainly, up to a certain period in youth they grow more 
rapidly, and attain greater height at an earlier age than 
they do in Great Britain ; but this may be due, to some 
extent, to that forcing process which certainly develops 
but may not solidify. This question, however, is of too 
extensive a nature to be dealt with here, but this may be 
stated, that the colonist is superior in strength and height 
and weight to his progenitor, and the French Canadian 
markedly so. The Teuton, the Irish, and the Scotch are 
not yet long enough in possession of the soil to enable 
one to make trustworthy comparisons between them 
and their ancestors ; but, following the figures furnished 
by Professor Forbes, of Edinburgh, some years ago, I, 
on two occasions, established the height, weight, ami 
strength of the students attending the medical schools of 
Montreal, and I found that the British Canadian, though 
he could count but one or two generations born in Canada, 
had gained over his ancestors in height, weight, and 
strength. The French Canadian could count seven, 
eight, and sometimes ten generations born in Canada, 
and the advance in height, weight, and lumbar strength 
was greater. It is undeniable that the French, in 
France, have diminished in stature; that wars have 
carried off the taller; and that revolutionsand wars have 
cut off many of the generators of tall men, till the stand- 
ard is much less than formerly. In France dynasty has 
followed dynasty, sometimes with feverishness and un- 
rest ; sometimes with violence ; sometimes with blood- 
shed ; but always with disturbance of the quiet of the 
people. And that disturbance of the people's quiet is as 
prejudicial to development as it is to gestation. In Can- 
ada, on the other hand, it has been one almost unbroken 
chain of undisturbed quiet. 
There remains the question of acclimatization, and 
with this must be considered the habits of the people. 
In Canada acclimatization has gone on without affecting 
prejudicially those who are subjected to its operation. 
There is no sign of decay in those who are in the pro- 
gressive state. Those coming from Europe to Canada 
have, it is true, to clothe themselves differently, to take 
food of somewhat different character, and, very often, 
to diminish the quantity of stimulants to which they 
may have been accustomed. It has been pointed out by 
those who are not favorable to the country that there are 
local exhibitions of that more general decay which Dr. 
Knox of evil omen prophesied is the lot of the denizen 
of the North American Continent, when he says : " Were 
the supplies from Europe not incessant, a European could 
not stand his ground in those new countries. A real ■ 
native, permanent, American or Australian race, of pure 
Saxon blood, is a dream which can never be realized. 
Man cannot ever exist permanently in any country to 
which he is not indigenous ; cannot ever become native 
true-born American ; cannot hold permanency in any 
portion of any continent but the one on which he first 
originated." The prophet has passed away, and in the 
country, too, to which he was indigenous, and, notwith- 
standing his prophecy, the descendants of the Saxon and 
the Celt present, seemingly, all the characteristics to fit 
them for the permanent occupation of the soil. 
It has been claimed, on the other hand, by writers, that 
had the aborigines of the country been left to themselves 
they would eventually have disappeared without hostile 
action on the part of the white man, on the hypothesis 
that new-comers are victors in every great struggle for 
existence. It is claimed to be with men as it is with 
European plants transferred to Canada. They take 
vigorous hold of the soil and attain a vigor unknown in 
Great Britain ; and when taken back to the soil whence 
they came, they there again comport themselves with 
modesty. The aborigines are rapidly disappearing, but 
has not the white man changed for them their surround- 
ings ? Or had they their own period of active infancy 
and vigorous age, as they now have that of decay ? For 
are they not representatives of a race much older than 
the races which have supplanted them ; and have they 
not been associated with the flora that is passing away ? 
The low birth-rate among the aborigines is pointed out 
as an evidence of the baneful influence of this climate 
upon natural increase. But it must be borne in mind 
that climate is not the only factor in determining pro- 
lificness, and that the procreative power in a country has 
a certain degree of relationship to the ability of the soil to 
support its inhabitants and to the precarious living of these 
scattered tribes, some trusting entirely to hunting, some 
to fishing. Fishing necessarily implies temporary abode, 
in moderate numbers, at the borders of lakes and rivers ; 
while hunting necessarily implies still more moderate 
numbers, and a still greater extent of country to roam 
over. As food is limited in quantity, and cannot be 
brought along with the natives, and as the necessities of 
the wild animals impel them to move hastily from one 
part to another, it follows that food is often insufficient. 
Scarcity and insufficiency are not less hindrances to 
population than are the enforced scattering of the tribes, 
and the enforced neglect of the women by the men of the 
tribes. Where food is scarce, the men are obliged to keep 
greatly in advance of the women, and the latter are little 
valued. There is another cause of limitation among the 
aborigines : The deformed, among the children, are in- 
variably sacrificed, except where Christianity has stepped 
in to save. The healthy, strong, vigorous, and well- 
formed are alone permitted to live. The mother suckles 
the child, five, six, and seven years, sometimes for a 
longer time ; and during the whole period of lactation the 
husband does not disturb her. Ante-natal life has its 
dangers also: the severe toil of the mother ; exposure 
to the inclemency of the seasons ; forced marches, etc., 
are so many risks to the unborn. Among the young 
children the absence of ventilation, the habits of gor- 
mandizing after enforced fasting, and all those hin- 
drances to increasing population inseparable from a no- 
madic existence, are met with. Add to these, polygamy. 
Abbe Lacombe states that wherever it exists among tbe 
aborigines, the number of births is smaller than among 
the monogamous. This is quite in accordance with what 
is met with in Eastern Europe, where Christian families, 
where monogamy exists, consist of a greater number of 
children than do Mahommedan families in which polyg- 
amy is met with. 
It is true that tbe teeth, among the whites, decay at a 
much earlier period in Canada and in the northern 
United States, and that has been seized upon as a partial 
fulfilment of Knox's prophecy. I have fully admitted, 
in my work on the climate of Canada, the general prev- 
alence of an earlier decay of the teeth ; but I have also 
asserted that the climate has nothing whatever to do with 
that decay. The aborigines, throughout Canada, have re- 
markably good teeth. In the extreme north, toothache is 
unknown. The teeth of the Esquimau, by constant trit- 
uration, are sometimes worn away ; or a disease in some 
measure equivalent to rheumatism may cause an occa- 
sional crumbling ; but toothache is unknown. The Iro- 
154 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Canada. 
Cannabis Indira. 
quois and the Huron Indians have teeth beautifully 
regular and equally strong. Teeth decay early with 
us because there is an impairment of the function of 
digestion. Functional disturbance is the common cause 
of decay. The Canadian child subjects his digestive ap- 
paratus to an ordeal to which it is not equal, and for 
which it is not prepared. I have elsewhere reduced the 
causes of this decay of the teeth to several: Taking too 
much food-therefore decomposition of a large portion 
of it ; taking too hot articles of food into the mouth- 
therefore cracking the teeth ; taking too cold articles- 
therefore a like result; taking acids and a variety of con- 
diments, vinegar especially-therefore dissolving them ; 
chewing insufficiently-therefore allowing them to rust ; 
drinking while eating, therefore washing food out of the 
mouth by fluids of various kinds before the first and 
most important stage of digestion is accomplished ; spit- 
ting, therefore robbing the food of its first and chief 
chemical solvent and leaving it unfitted to be acted upon 
by the gastric juice later on ;-in a word, forgetting that 
the purposes of food are to nourish the body, and to 
sustain its heat, and not, by the tricks and refinements of 
the gastronomic art, to spur the appetite beyond its own 
better sense. William H. Hingston. 
CANARY ISLANDS. The "Canaries" (Insula For- 
tunata) are situated in the North Atlantic Ocean, about 
sixty miles from the west coast of Africa. They lie 
between lat. 27° 4' and 29° 25' north, and long. 13° 25' 
and 18° 16' west. There are seven principal islands in 
the group, which are named as follows : Teneriffe, 
Grand Canary, Palma, Lanzarote, Fuerteventura, Go- 
mera, and Hierro. The islands cover an area of 4,000 
square miles. They are supposed to be, like Madeira 
and the Azores, of volcanic origin, but their climate is 
warmer and drier than that of the islands named. " Their 
coasts are bold, abrupt, and rocky, and their surface is 
broken up by mountains, of which the loftiest, Pico de 
Teyde, in Teneriffe, is 12,182 feet high. There are no 
rivers in the islands, but after heavy rains torrents pour 
down the mountain slopes and ravines " (Scoresby-Jack- 
son, "Medical Climatology"). 
Teneriffe is the largest of the Canary Islands, and 
its capital, Santa Cruz, is annually visited by many 
invalids. It is, however, less attractive and offers fewer 
comforts to those in search of health than Orotava, on 
the northwestern side of the same island. The climate 
of Orotava is " softer " than that of Santa Cruz. Laguna, 
on a lofty plain in the northern part of Teneriffe has a 
much lower range of temperature than Orotava and 
Santa Cruz. Scoresby-Jackson gives the following 
table of temperature in degrees of Fahrenheit: 
the different islands of the archipelago, thus affording 
good opportunities for pleasant excursions. Although 
the Canaries belong to Spain, there are plenty of English 
residents, and in the chief resorts the English language 
is sufficient for all practical purposes. Finally, it may 
be worth mentioning that the more hardy and adventur- 
ous can find a variety of " local climates," owing to the 
difference in altitude of many of the smaller settlements. 
Invalids should not arrive before November, unless they 
intend to visit the higher altitudes. 
. Edmund C. Wendt. 
CANNABIS INDICA. This drug owed its introduction 
as a therapeutic agent to its reputation in the East as an 
exhilarating and intoxicating drug. It was shown to 
possess active medicinal properties as an hypnotic and 
anodyne, and retains its position in the Pharmacopoeia, 
but has never been received with much confidence. The 
objection to its use has been the great variation in the 
quality of the drug and the uncertainty of the effect to 
be produced. This arises from several causes, among 
which may be mentioned the different seasons in which 
it is collected, the want of care displayed in the cultiva- 
tion of the plant, and the age and preservation of the 
drug, and its preparations. Of late the attention of the 
profession has been directed to its value, and it has been 
utilized to a much greater extent than formerly. Greater 
care has been given to the drug itself and more precision 
in its preparation ; in consequence the old objection to its 
use is to a great extent removed, as a reliable and trust- 
worthy preparation may now1 be obtained. 
It was formerly thought to be a very powerful toxic 
agent, but recent investigations have shown that although 
it may very readily give rise to mild toxic symptoms, it 
is only where excessive doses have been given that fatal 
consequences may occur. It has even been said that no 
well-authenticated instance of a fatal case has been re- 
corded. In experimenting on animals, Dr. Hare found 
that ten minims of a fluid extract produced the well- 
marked physiological action in a man, but three to five 
drachms were given to a dog without a fatal effect, and 
death was only produced when about one ounce was ad- 
ministered. 
Among the many communications that have recently 
appeared, two particularly deserve attention, as record- 
ing the views of careful clinical observers : one by Dr. 
Russell Reynolds, in The Lancet of March, 1890, and the 
other a report by Professor Germain See to the French 
Academy of Medicine, in the same year. Dr. Reynolds 
gives the result of some thirty years' study of the drug in 
mental and nervous diseases. He found it of particular 
value in the aged when the mental faculties are weakened 
generally and much restlessness and sleeplessness is an 
accompaniment. In doses of one-third to one-fourth 
grain at bedtime a calm and quiet sleep is secured, and 
the same action may be secured for weeks without in- 
creasing the dose. In melancholia and chronic alcoholic 
delirium of the aged, accompanied by depression, it has 
acted as an exhilarant, has produced the desired sense of 
strength, and has secured quiet and rest. In the restless- 
ness of general paralysis and " temper diseases," in both 
adults and children, it has also been of the greatest ser- 
vice. 
In painful maladies it has acted best in those of a func- 
tional character, such as neuralgia and migraine, either 
alone or when combined with constitutional remedies, as 
iron, quinine, and zinc, when such are indicated. In 
neuritis it only proves of service when given in addition 
to mercury, iodine, and other such remedies. It has also 
proved very serviceable in the formication, tingling, 
numbness, and other sensory disturbances of the elderly 
and gouty. 
In clonic muscular spasms it has been very successful, 
such as the convulsions of children and adults due to 
reflex causes, in epileptiform convulsions due to organic 
disease of the central nervous system, and in cases of 
brain tumor accompanied by convulsions and other indi- 
cations of central irritation. In true epilepsy it has 
proved useless. In numerous cases it has been given for 
Santa Cruz. 
Laguna. 
Annual 
71.15 
62.63 
Winter 
64.85 
56.42 
Spring 
68.87 
59.75 
Summer 
76.68 
68.29 
Autumn 
74.17 
66.06 
While the Canaries are popular as health-resorts, they 
are, nevertheless, exposed to east and southeast winds, 
which are hurtful to certain invalids. The climate of 
the islands is, on the whole, less relaxing than that of 
Madeira, but it is not by any means bracing. 
The class of cases likely to do well at Teneriffe are the 
early stages of phthisis, asthma, winter bronchitis, gout, 
rheumatism, and neurasthenia. Apart from Teneriffe 
and Grand Canary the accommodations for invalids are 
inadequate. It is the clear skies and dry atmosphere of 
the Canaries, together with the (in general) mildness and 
equability of the climate which have given these islands 
their title to rank as climatic stations of some importance. 
In the Grand Canary, Las Palmas has recently been 
made much more attractive than formerly. There is 
now a good steamboat-landing at this resort, a fine sandy 
beach, comfortable quarters, and almost daily communi- 
cation with England. The Canaries may be reached from 
England by the steamers of the Cape and New Zealand 
lines. There is also a line of steamers plying between 
155 Canuabis Indira. 
Cataract. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
a prolonged period until its full physiological action was 
produced, and yet has failed to influence the disease in the 
slightest degree. It relieves the distress of spasmodic 
asthma and has proved very serviceable in spasmodic 
dysmenorrhoea devoid of metritis or inflammatory causes. 
In the hands of Dr. Reynolds it failed entirely in 
chronic and acute mania, sciatica, lumbago, pleuro- 
dynia, and in all forms of hysterical pain. It also proved 
useless in torticollis, writer's cramp, paralysis agitans, and 
tetanus. 
Professor See directed his investigations to its use in 
painful gastric disorders that were not accompanied by 
any apparent organic change. He considers Indian hemp 
a true sedative to the stomach without any of the dis- 
turbing effects of opiates, chloral, bromides, and similar 
drugs. Its effect he thinks is due to the sedative action 
on the pneumogastric nerve. He has used it in all pain- 
ful dyspepsias and neuroses of the stomach and always 
found it of value. Its beneficial effect is increased by 
attention to the state of the secretions and the use of al- 
kalies, purgatives, salines, and antiseptics when such rem- 
edies are indicated. 
In using this remedy it is advised that the article 
should always be obtained from the same source. Dr. 
Reynolds, throughout his many years of practice, ob- 
tained the drug from the same establishment and found 
that although its strength would vary with the seasons, 
the desired effect could always be obtained. He recom- 
mends that the dose, to commence with, should be one- 
fifth of a grain every four or six hours for adults, and 
one-tenth of a grain for children, gradually increasing 
until its effect is produced. 
One grain of the extract he has found will produce 
toxic symptoms in the majority of individuals, if given 
as an initial dose, but when gradually administered it 
may be increased to four or five grains with immunity. 
In some instances a dose of one-fourth or one-third grain 
has caused mild intoxication. The preparation that he 
prefers to use is the tincture. The Pharmacopceial 
strength is one part in twenty and forms a ready means 
of giving the required dose, especially to children. Dr. 
Reynolds has also prepared a tincture of double the of- 
ficial strength as more convenient for the fuller doses. 
This is ordered to be taken on sugar, which is an easy 
method of administration, and renders unnecessary the 
disagreeable and uncertain emulsion which otherwise 
would have to be formed. The pills and solid extract 
produce an uncertain and delayed action ; they are apt 
to become dry, and are often insoluble. The preparation 
advocated by Professor See is a fatty extract made by 
dissolving the alcoholic extract in butter by the aid of 
heat and washing with water. It is given in doses of 
one-fourth grain three times a day. Other observers 
are now advocating its use in greatly increased doses, 
pushing it rapidly to two or three grains -if its sedative 
and anodyne effects are desired. When its action is re- 
quired in dysmenorrhoea and in pelvic disorders, its use 
as a suppository produces the desired effects more rapidly. 
Analysis of this drug has not produced any preparation 
that has proved superior to the crude drug. It yields 
numerous principles, but none of any practical value as a 
substitute for the drug itself. The poisonous constituent, 
teta no-cannabine, is not utilized and whatever advantage 
the alkaloid and resin may have is due to the absence of 
this powerful toxic principle. Gannabinon is a resinous, 
balsamic substance, dark brown in color, of the consis- 
tency of treacle ; it is insoluble in water, soluble in alco- 
hol and oils. Its taste is disagreeable. It is used as a 
sedative in mania, hysteria, and sleeplessness, but its un- 
certainty of action and the production, in many in- 
stances, of severe toxic symptoms have led to its disuse. 
The dose is one-fourth to one or two grains. The alka- 
loid cannabine is a translucent, brown, sirupy liquid with 
the odor of Indian hemp. Its dose is from one to five 
grains daily in divided doses, but its use is replaced 
by what is termed tannate of cannabine, which has been 
recently introduced, and is probably the most useful of 
all the principles of hemp. In its preparation the poison- 
ous volatile principle is removed and a tannate of the 
remaining constituents formed. It is a yellow, or brown- 
ish yellow, amorphous powder, with a very bitter and as- 
tringent taste and a faint odor of Indian hemp. It is 
slightly soluble in cold water, more so in hot, and freely 
soluble in hot water that is acidulated with hydrochloric 
acid ; it is also soluble in alkaline solution, and very sol- 
uble in acidulated alcohol. The dose is from two to ten 
grains-which may be increased to twenty grains,-taken 
an hour before bedtime. It does not produce intoxica- 
tion and is recommended as an hypnotic of particular 
service in acute mania and nervous sleeplessness. 
Beaumont Small. 
CANNSTATT. A watering-place in Wurtemberg, 
Germany. 
Location.-Cannstatt is prettily situated in a valley 
near Stuttgart, from which place it is easily reached by 
horse-car or carriage. It is less than 700 feet above the 
level of the sea, has an agreeable, rather warm, and equa- 
ble climate. It is well sheltered by hills, except tow- 
ard the south. There are over thirty springs belonging 
to the saline and chalybeate group. The temperature of 
the water varies from 50° F. to 70° F. The principal 
springs are the Wilhelmsbrunnen and Mannlein and 
Weiblein. 
Access.-By rail to Stuttgart, and thence by carriage. 
Cannstatt is also a railroad station, and all the local trains 
stop there. 
Analysis.-In 1,000 parts of the Weiblein water there 
are contained : 
Parts. 
Chloride of sodium 2.454 
Chloride of potassium 0.(131 
Chloride of magnesium 0.019 
Carbonate of lime 0.S93 
Carbonate of iron 0.031 
Sulphate of sodium 0.581 
Sulphate of lime 0.931 
A number of springs have been united to feed a large 
reservoir used for bathing. The prickling sensation of 
gaseous bubbles on the skin is not unpleasant. 
Indications. -The thermal establishments of Cannstatt 
are modern, complete, and well managed. The waters 
are employed for every conceivable variety of bath and 
external application. The resort is chiefly frequented by 
those suffering from nervous affections, chronic catarrhal 
troubles, diseases of women, and anaemia. But a great 
number of other diseases are likewise treated in several 
special establishments. Thus, skin diseases, scrofula, 
gout, rheumatism, neuralgias, and paralytic states are said 
to be treated with satisfactory results. The writer of 
this article has visited Cannstatt on several occasions and 
always received a favorable impression of the thorough- 
ness of the methods employed there. The resort is not 
an international one, however, being little known, and 
not yet " in vogue " outside of Germany. 
Accommodation.-The principal hotel of Stuttgart is 
the Marquardt, but there are also several moderately 
comfortable hotels in Cannstatt proper. 
Edmund C. Wendt. 
CANTHARIDINATE OF POTASSIUM. The appli- 
cation of the cantharidinates to the treatment of tubercu- 
losis was introduced at a meeting of the Berlin Medical 
Society on February 25, 1891, by Dr. Oscar Lieb- 
reich. The value of this drug as a remedy rested on 
its well-known property of promoting exudation of 
serum from the capillaries ; an effect not only directed 
to the vessels of the surface of the body, but also pro- 
duced in various organs, as the kidneys, sexual organs, 
and lungs, particularly when the drug is administered in- 
ternally. This is the special action of the drug on the 
healthy tissues, and he assumed that an irritated condi- 
tion of any set of capillaries would favor this process of 
exudation, at which time a dose too small to produce any 
effect on healthy capillaries would cause an exudation 
from those inflamed. This would relieve the congested 
cells and restore the tissues to a more healthy state ; and, 
further, he claimed, as it had been shown that serum 
possessed decided germicidal properties, it should prove 
156 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Cannabis Indlca. 
Cataract. 
antagonistic to the growth of tubercle and assist in the 
effort at repair. 
A number of cases treated by his method were shown 
by himself and some of his colleagues ; cases of laryngeal 
phthisis, lupus, and pulmonary phthisis were all said to 
be benefited. When the diseased parts could be ob- 
served, the action of the drug was such as had been de- 
scribed by Dr. Liebreich, the ulcerated surface being 
more healthy and showing signs of repair. When the 
lungs were affected the expectoration became free and 
profuse, the oedema decreased, and the local condition 
improved ; the fever also diminished, and other constitu- 
tional disturbances lessened. Liebreich stated that no 
reaction followed its use, but other observers reported a 
slight rise of temperature, headache, disturbed digestion, 
diarrhoea, etc. If the dose be too great it produces the 
characteristic symptoms of cantharides-poisoning-pains 
in the loins, albuminuria, strangury, and haematuria. 
The cantharidinate of potassium and the cantharidinate 
of sodium in solution were selected as the salts most suit- 
able for using the drug hypodermically. As the amount 
of cantharidin in these salts varies greatly, Liebreich ad- 
vised the use of a certain solution which he had found 
by experiment to be most suitable. It is prepared as 
follows: Cantharidinin, 0.2 gramme; potassic hydrate, 
0.4 gramme, most carefully weighed and heated over a 
water-bath in a 1,000 c.c. flask, with about 20 c.c. of 
water, until a clear solution results ; then add water 
gradually, while still heating, to the full quantity. 
Of this solution 8 to 16 minims are administered hypo- 
dermically. Its use should not be continued for any 
length of time ; at least every third day should be allowed 
to intervene without the drug being administered. 
The effect on the kidneys must be carefully watched, 
and the dose lessened, or its administration stopped, 
should any symptoms of strangury occur. In kidney 
disease its use is, of course, contraindicated. To over- 
come the painful local irritation that frequently follows 
at the site of injection, it has been recommended to pre- 
pare a solution containing cocaine, which prevents the 
pain. Two parts of the hydrochlorate of cocaine are 
added to one of cantharidin and two of caustic soda; 
this is formed into a solution, and to T|o grain is 
used as a dose. The addition of cocaine is also thought 
to lessen its tendency to irritate the bladder or kidneys. 
This treatment has been extensively applied to all 
forms of tubercular disease, but it has not proved of suf- 
ficient value to warrant its continued use, and it is now 
rarely resorted to. It undoubtedly produces the action 
described by Liebreich, causing a freer exudation of 
serum, etc., but this does not lead to any improvement 
in the symptoms or tend to any permanent benefit. Post- 
mortem examinations of patients who have been subjected 
to this treatment fail to furnish any evidence of repair 
or beneficial effect on the disease. Beaumont Small. 
CATARACT. Antiseptic Measures.-The differ- 
ence of opinion as to the value of antiseptic precautions 
in cataract operations having disappeared, and their em- 
ployment having become practically universal, the fa- 
vorite methods will now be detailed. The precautions to 
be taken are in regard to the instruments, the operator, 
and the patient. 
It is in regard to the sterilization of the instruments and 
the manner of bringing this about that the greatest diver- 
sity of practice has perhaps obtained and the most differ- 
ent methods have been adopted. The delicate instruments 
used in ophthalmic surgery must naturally be handled 
with greater care than many of those employed on other 
parts of the body. Immersion in solutions of corrosive 
sublimate corrodes metal and ruins the edge of the knife. 
A four per cent, solution of carbolic acid has been proved 
insufficient to destroy the suppurative germs. To bring 
about this result with certainty, probably no agent is more 
efficacious than heat, either in the dry or the moist form. 
Yet each of these has its disadvantages. Steaming or boil- 
ing, the latter in simple water or in alkaline solution, is 
apt to be followed by rusting. Baking at a temperature 
of 150° Centigrade, continued for an hour or more, is 
(SUPPLEMENT.) 
absolutely certain. But all instruments subjected to this 
must be made with metal handles in place of ivory or 
bone, and it is doubtful whether the tine knives used for 
the corneal section would, after such baking, retain a per- 
fect edge. Many operators, influenced by the above con- 
siderations, content themselves with immersing their in- 
struments, previously thoroughly cleansed, in a bath of 
absolute alcohol before the operation, and withdrawing 
them one by one as they are wanted for use. 
The surgeon and his assistant should wear special outer 
garments. Those made of linen, freshly washed and 
ironed, answer a useful purpose. The hands should 
be thoroughly washed in warm water and with soap, 
scrubbed with a nail-brush, afterwards dipped in alcohol, 
and, just before proceeding to operate, in a solution of cor- 
rosive sublimate, one to three thousand. That the hands 
are thus made absolutely aseptic is not claimed, the ut- 
most that can be said is that certain sources of danger 
are averted. 
It is well to give the patient a warm bath the night be- 
fore the operation. The next day the vicinity of the eye 
is to be carefully cleansed with soap and water, and a 
compress soaked in a sublimate solution, one to five thou- 
sand, should be kept on the eye for at least an hour pre- 
vious to the operation. Just before commencing, the con- 
junctival sac may be washed out with the same solution, 
applied by means of a sterilized glass tube with rubber 
bulb. Particular attention is to be paid to the state of 
the lachrymal sac, and its freedom from infectious secre- 
tion is to be positively ascertained. 
Anaesthesia.-General anaesthesia, brought about by 
ether or chloroform, has now, in the vast majority of cases, 
given place to the local anaesthesia induced by cocaine. 
This agent was introduced and its properties explained 
by Koller in 1884. Its use has become general. Em- 
ployed ordinarily in the form of the hydrochlorate, and 
in a solution varying from twro to five per cent, in 
strength, its contact with the eye brings about anaesthesia 
of the conjunctiva and cornea, coming on in from one to 
two minutes and lasting some ten minutes. In an opera- 
tion for the extraction of cataract it should be applied 
two or three times. It is well to remember that the sen- 
sitiveness of the iris is not materially affected by the co- 
caine, and to prepare the patient for a certain amount of 
pain in case an iridectomy forms part of the operation. 
Besides producing anaesthesia of the surface of the eye- 
ball, cocaine brings about other changes. It contracts 
the blood-vessels of the iris, and thus gives rise to a tem- 
porary mydriasis; it empties also the conjunctival blood- 
vessels. On account of this double effect the annoying 
hemorrhage that sometimes so much embarrasses the 
performance of an extraction is much less likely to occur. 
There is also noticed a wider opening of the lids and a 
lessened tendency to wink. Finally, the intraocular 
pressure becomes slightly reduced. 
If the surgeon finds it impracticable to prepare a ster- 
ilized solution of cocaine on the spot, he may use a one 
to five thousand solution of sublimate as a menstruum. 
It is best to prepare the patient for a slight smarting sen- 
sation when the first application is made to the eye. This 
very rapidly disappears. 
Extraction of Senile Cataract without Iridec- 
tomy.-Toward the close of the article of which this is a 
continuation, written some half dozen years ago, the hope 
was expressed that experience would before the present 
time have demonstrated the true value of iridectomy in 
connection with extraction, and have either established 
the grounds of its necessity or indicated the propriety of 
its omission. That hope has proved fallacious. Opinion 
on the subject is still divided, although it is but just to^ 
admit that the advocates of simple extraction constantly 
appear in larger numbers, and assume a bolder front. 
Unanimity, however, has not been attained. Operators 
of skill and of established reputation are to be found 
ranged on either side. At the Heidelberg Congress in 
1888 Critchett brought the matter home to all present by 
propounding a simple question. "If one of you," he 
said, "were the victim of a cataract, which operation 
would you wish to have performed, that with iridectomy, 
157 Cataract. 
Cliatel-Guyon. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT ) 
or the simple extraction ? " Unquestionably the majority 
of the members would have then pronounced in favor of 
the former, although the minority was large and influen- 
tial. It is difficult to say which party would, at the pres- 
ent day, be the more numerous. 
The advantages of the non-performance of an iridec- 
tomy are simply and concisely stated by Professor Pflii- 
ger (KI. Monatsblatter fur Augenheilkunde, May, 1892, 
p. 161). He considers the return to simple extraction to 
be the greatest improvement in the cataract operation 
that has occurred for twenty-five years, and for the fol- 
lowing reasons: 
The conservation of the normal pupil combines optical 
with antiseptic advantages, in regard to the first part it 
having been proved that the corneal refractive power is 
at its best in the centre of that membrane ; moreover, 
(1) There is no wound of the iris, and hence far less 
likelihood of a depot for the collection of offensive, that 
is, infectious material ; 
(2) There is no bleeding into the anterior chamber, to 
obscure the subsequent steps of the operation ; 
(3) The wound is protected by the intact iris from con- 
tact with fragments of capsule, the presence of which so 
often causes slow healing and secondary infection, lead- 
ing it may be to chronic irido cyclitis and even to sym- 
pathetic affection of the other eye ; 
(4) There is a certain amount of protection against 
loss of vitreous ; 
(5) Pfltiger's experience leads him to think, strange as 
the fact may appear, that there is less danger of second- 
ary glaucoma in the case of a simple extraction. 
It is not asserted bv either side that the percentage of 
corneal suppuration is affected by the performance or 
non-performance of an iridectomy. Stress is laid on the 
claim that, after successful simple extraction, the excen- 
tric vision is better and light better borne. On the other 
hand, it may be replied that the iridectomy need not be a 
large one, and that being made directly upward it is 
largely covered by the upper lid, thus ensuring a consid- 
erable use of the centre of the cornea. 
Furthermore: 1. Considering the extent of the cor- 
neal wound, as well as the frequently large solution of 
continuity of the conjunctiva itself, the additional ter- 
rain afforded by the iridectomy for the collection of in- 
fectious material would be a matter of small account. 
2. Bleeding is reduced to a minimum by the action of 
the cocaine, and frequently is entirely absent. 
3. If prolapse of the iris, or even dislocation of the 
pupil occurs, the capsular fragments may yet come in 
contact with the wound, and these capsular fragments, 
as well as cortical remains, can be both more perfectly 
detected and thoroughly removed where the area is laid 
bare by an iridectomy. 
4. That the statistics of simple extraction show a les- 
sened percentage of vitreous prolapse, as compared with 
the Graefe operation, is not as yet universally admitted. 
5. The same may be said in regard to the occurrence 
of glaucoma. The experience of individual operators is 
here at variance. Dr. Knapp, in 1890, reported three 
cases of glaucoma as occurring among one hundred sim- 
ple extractions (Archives of Ophthalmology, vol. xix., p. 
299). 
There are two serious drawbacks to simple extrac- 
tion :- 
The first is the difficulty in clearing the pupil of cortical 
and capsular remains, after the lens has been delivered. 
It is obvious that, with an iridectomy, there is a larger 
pupillary area in view and a wider aperture for the ex- 
trusion of whatever may occupy it. Moreover, the ma- 
noeuvres we generally employ for the clearing of the 
pupil, the tilting and rubbing, tend to maintain, if not to 
produce, the presence of the iris between the lips of the 
wound, and to render its ultimate reposition more diffi- 
cult. 
This leads directly up to the main objection to simple 
extraction, the liability to iris prolapse. This accident 
is met with in from seven to ten per cent, of all cases of 
this operation. Its disadvantages are the change there- 
by wrought in the corneal curve, the dislocation of the 
pupil, the lengthened convalescence entailed, and the 
tendency to cystoid cicatrization of the wound. It is 
most likely to occur in consequence of a sudden motion 
or injudicious effort on the part of the patient within the 
first few days after the operation, and may be brought 
about by the forcible contact of the hand with the eye 
during sleep. The wound being ruptured, the aqueous 
humor escapes, and carries with it the iris, which re- 
mains incarcerated between the lips of the wound. A 
sudden sharp pain is sometimes felt and arouses suspic- 
ion as to what may have occurred. But there are cases 
where no imprudent motion is known to have taken 
place, and no warning has been sounded, and yet where 
the first inspection of the eye, several days after the 
operation, reveals an extensive iris displacement. 
The tendency of the eye to undergo this accident is 
well illustrated by the statistics of a third series of one 
hundred cataract extractions without iridectomy, pub- 
lished by Dr. Knapp (Archives of Ophthalmology, vol. 
xix., p. 280). 
In seven of these cases iridectomy had to be performed 
during the operation. 
In two cases the iris folded itself over the knife and 
was excised. 
In eight cases prolapse and incarceration of the iris 
occurred during the healing process. 
Eighty-three of these patients therefore recovered with 
fair, round pupils, fifteen either had iridectomy per- 
formed or would have been better off had this been done. 
Performance of Simple Extraction.-There is 
but little to add to the account of this operation given in 
the article which the present one is intended to supple- 
ment. The long, narrow knife of Graefe may be used 
for the corneal incision, the puncture and counter-punc- 
ture being made just above the horizontal meridian of 
the cornea, in the transparent periphery of this mem- 
brane, the apex of the cut alone encroaching on the lim- 
bus. This is the course taken by experienced operators 
like Knapp, who aim at the avoidance of the peripheric 
section of former years. The capsule opening is made 
by some at the same time, and with the same knife used 
in the incision ; by others with a special cystitome, and 
may be central or peripheric, either method having its 
advocates. Sometimes a piece of the anterior capsule is 
removed with forceps specially constructed for this pur- 
pose. After the delivery of the lens, the pupil, if still 
occupied by fragments of cortical or remains of capsule, 
may be freed by judicious manipulation, or irrigated 
witii a sterilized solution of boric acid or common salt, 
either one-half or one per cent, in strength. These solu- 
tions should be slightly warmed and but little force used 
in their introduction. For this reason the syringe orig- 
inally employed by McKeown will be found less manage- 
able, as well as more difficult to sterilize, than the appar- 
atus of Lippincott (" Transactions American Ophthalmo- 
logical Society, Twenty-seventh Meeting," p. 115), or the 
" undine " of Wicherkiewicz. The writer has modified 
the latter instrument by attaching to its large aperture a 
short rubber tube, ending in a glass mouthpiece. Both 
hands of the operator are thus left free ; he holds the 
mouthpiece between his teeth, and is enabled at will to 
modify the pressure to any extent, or even to reverse it 
and withdraw masses of cortical by suction into the 
apparatus itself. Solutions of corrosive sublimate are no 
longer used for irrigation, on account of the corneal opac- 
ities they were found to occasionally induqe. Care must 
be taken to keep the opening of the irrigator as far from 
the pupillary edge as possible, prolapse of the iris being 
readily encouraged by its too immediate contact with 
this region. 
After the clearing of the pupil and anterior chamber 
have been completed the iris must be carefully replaced, 
there being no better instrument for this purpose than a 
flat, narrow rubber spatula. If reduction be found im- 
possible, or the iris shows a tendency to fall back into 
the wound, a small iridectomy must be made on the spot. 
In any case a solution of eserine (one per cent.) or pilo- 
carpine (two per cent.) should be dropped into the eye 
before closing it. 
158 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Cataract. 
Cli&tel-Guyon. 
Every operator has his favorite method of dressing the 
eye after extraction. A circular piece of linen, dipped in 
a solution of corrosive sublimate, one to five hundred, 
may be applied directly over the closed lids, the orbital 
cavity then packed with corrosive cotton, and the whole 
retained in place by a few turns of a light roller. These 
dressings may be withdrawn from the steam sterilizer, if 
one be provided, at the instant they are needed. 
It has of late been seriously proposed by certain sur- 
geons that the nou-operated eye be left unguarded, that 
only a light dressing be applied to the other, and that the 
patient be kept in an undarkened room and allowed much 
freedom of motion. Good results are claimed from such 
an absence of treatment. This, if true, would reverse 
our traditions and revolutionize our practice. But as 
yet the only evidence in its favor is that of vague asser- 
tion, unsupported by definite statistics. Its advocates are 
at present few. 
Iris prolapse being, as has been stated, often due to the 
sudden escape of the aqueous humor, consequent on a 
rupture of the corneal wound, an ingenious means of 
obviating this has been devised by Dr. H. B. Chandler, 
of Boston, and proposed by him as a modification of the 
operation. He makes a small opening in the iris in order 
to allow the free escape of the aqueous, which collects 
behind this membrane, and claims that this prevents 
prolapse. 
His description of the operation is as follows : " After 
making a corneal cut, exactly at the cornea-scleral junc- 
tion, a very small piece of iris, about one or two millime- 
tres from the periphery, is caught up, either by means of 
a fine iris forceps, with teeth situated on the lower por- 
tion of the blade, as near the point as possible, or by 
means of a sharp hook, the bent portion being at right 
angles and about one millimetre long, and gently drawn 
out, is cut horizontally as close to the gripping instru- 
ment as possible ; this leaves a small round opening, not 
more than one to two millimetres in diameter " (Boston 
Medical and Surgical Journal, October 16, 1890, p. 366). 
For two or three days after a simple extraction greater 
quiet is necessary than is the case when iridectomy has 
been performed, the patient being cautioned to avoid 
straining and all sudden exertion. The occurrence of 
severe pain in the eye, or even a feeling of irritation, such 
as might proceed from the presence of a foreign body, 
should arouse suspicion of prolapse. If this comes on 
within two days after the operation the eye must be 
opened and the protruding iris reduced or excised. Other- 
wise it is better to leave it alone until the wound is 
thoroughly consolidated. After a lapse of several weeks 
the prolapse, if it shows no signs of flattening, may be 
excised or cauterized. 
The exclusive employment of one method of extract- 
ing cataract would seem unwise. Each case must be 
taken on its own merits ; its history, the condition of the 
eye, and the disposition of the patient carefully con- 
sidered, and the operation selected that seems likely to 
be followed by the best results. Doubtless a successful 
simple extraction leaves the eye in a more normal con- 
dition, and thus affords a more perfect result. To gain 
this result the operator requires a maximum of experience 
and skill, while the patient must be prepared for a some- 
what more burdensome convalescence, and must also be 
willing to incur a slightly increased risk of accident. 
Hasket Derby. 
CHANNEL ISLANDS. This group of islands, belong- 
ing to England, although geographically French, has 
long been "favorably regarded as possessing certain cli- 
matic advantages. 
Location.-The Channel Islands are small, their total 
area being only seventy-five square miles. The best 
known of the group are Jersey, Guernsey, Alderney, and 
Sark. The first-named is perhaps the most popular as a 
health-resort. These islands are situated in the great 
Bay of St. Michael, in the English Channel, and at a 
short distance from the western coast of Normandy. 
Access.-The islands are easily accessible from France. 
From England a steamer, leaving Southampton daily, 
(SUPPLEMENT.) 
reaches Jersey in eight hours. The actual distance from 
Jersey to Carteret, in the Department of Manche, is only 
thirteen miles. St. Helier's, the chief town and port of 
Jersey, lies at the eastern extremity of St. Aubin's Bay. 
Indications.-The Channel Islands are resorted" to 
principally by invalids with " weak chests " and neuras- 
thenia. According to Dr. Hooper, the monthly and sea- 
sonal variations in temperature are as follows : 
Degrees Fahr. 
Annual mean 53.06 
Winter " 43.82 
Spring " 50.97 
Summer " 62.84 
Autumn " 54.63 
January 41.58 
February 44.62 
March 45.75 
April 50.09 
Degrees Fahr. 
May 57.08 
June 61.31 
July 63.5" 
August 63.72 
September. 59.8 i 
October 55.65 
November 48.42 
December 45.27 
The number of rainy days is less than in England, al- 
though the actual precipitation of moisture is greater. 
It is important to remember that the climate, although 
mild and equable, is very humid. Dr. Scholefield speaks 
as follows on this point (Scoresby-Jackson, "Medical 
Climatology ") : 
" Besides its insular position, the island (Jersey) is 
everywhere thick set with wood, every little section of 
ground being hedged in with four rows of trees. The 
island, moreover, is continually intersected at intervals 
of a few hundred yards by pathways, beset with their 
double tile of trees, planted on high embankments. Here 
neither the sun's rays can penetrate, nor can currents of 
air freely ventilate the earth. 
" Of course, in the absence of high mountains, the 
islands are exposed to every variety of wind, and fre- 
quent gales are observed. Westerly winds predominate. 
The cold northwest winds of spring are apt to annoy in- 
valids. Apart from this the islands enjoy an equable, 
soft, humid atmosphere, with astonishingly mild days, 
and very little frost or snow. The day and night varia- 
tions of temperature are slight. The climate is thus 
rather relaxing, and patients requiring a vigorous, 
bracing air and exhilarating conditions should not be 
sent there." Edmund C. Wendt. 
CHARLOTTENBRUNN. A watering-place in Silesia, 
Germany. 
Location.-Charlottenbrunn is prettily situated in a 
valley, at an elevation of 1,300 feet above the sea. The 
hills afford it ample protection against the cold north and 
northwest winds, and leave it exposed only to the warmer 
southern breezes. Pine-woods surround it. The springs 
are cold, alkaline chalybeate ones. But the place owes 
its reputation quite as much to its climatic advantages as 
to the mineral waters. It is a quiet spot, and only semi- 
fashionable. Season, May to October. 
Access.-Bad Charlottenbrunn is a railroad station on 
the Dittersbach-Glatz Railroad. 
Analysis.-The Charlottenquelle and There sienquelle 
are both moderately powerful alkaline iron springs, hav- 
ing the usual composition of chalybeate waters. 
Indications.-Neurasthenia, heart disease, chlorosis, 
and all diseases with a tendency to anaemia, derive benefit 
from a course of these waters. 
Accommodations.-Attractive hotels and boarding- 
houses, modern thermal establishments, with all comforts, 
are found here. Milk, whey, kefir, and " herb-juice " 
cures are special features. Edmund C. Wendt. 
CHATEL-GUYON. A watering-place in the Depart- 
ment of Puy-de-D6me, France. 
Location.-ChAtel-Guyon is charmingly situated in a 
beautiful region of Auvergne, and at an elevation of 
1,300 feet above sea-level. The climate is pleasant and 
equable. There are over twenty saline chalybeate, mag- 
nesia springs, their temperature varying from 50c F. to 
110° F. The French lay great stress on the purgative 
quality of these waters. But they cannot in any way 
compare with those of Carlsbad. The water contains 
free carbonic-acid gas, and the baths are said to be both 
159 Chatel-Guyon. 
Chloroform. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
tonic and soothing. On account of the bubbles collect- 
ing on the skin, they are called " Champagne-baths." 
Access.-By the Paris, Lyons & Mediterranean Rail- 
road to Riom, vid Nevers. Thence by carriage in fifteen 
minutes to Chatel-Guyon. 
Analysis.-According to Lefort, the Deval spring 
contains in 10,000 parts of water : 
Grammes. 
Hydrochloric acid (in combination) 21.33 
Sulphuric acid (in combination) 2.93 
Silicic acid 1.26 
Carbonic acid (in combination) 10.92 
Carbonic acid free 13.50 
Potash 1.12 
Soda 12.87 
Magnesia 6.70 
Lime 9.90 
Oxide of iron 0.21 
Alumina 0.08 
Indications.-These springs are chiefly employed in 
gastric and hepatic derangements, associated with con- 
stipation, as well as in female diseases with a tendency 
to anaemia. But French physicians also recommend 
them in gout, diabetes, Bright's disease, and many other 
chronic ailments. Taken at the rate of about four to six 
glasses a day, they are purgative, but smaller quantities 
fail to act on the bowels. The season lasts from the 
middle of May to the middle of October. 
Accommodations.-There are several bathing estab- 
lishments, with the necessary appliances, but the Etab- 
liasement Brosson, being the most modern, is to be 
preferred. Hotels fairly good. The place is not a fash- 
ionable one. Edmund C. Wendt. 
CHLORALAMID. Introduced in 1889, by Professor 
von Mering, of Strasbourg, for its hypnotic properties, it 
is now looked upon as one of the most useful drugs we 
possess for this purpose. It results from the chemical 
combination of two parts of chloral anhydride, CC13 
CHO, and one of formamide, CHO NH2; its formula is 
CCls CH. OH, CONH2. It is not a mechanical mixture, 
and would be more correctly named chloral formamide, 
or formiate of chloral. It occurs in white crystals, 
which have a faint bitter taste, no odor, and are neutral 
in reaction. It is soluble in cold water, one part in ten, 
and in one and a half part of alcohol. The salt should 
never be dissolved in hot water, or heated above 120° F., 
as at that temperature it decomposes. It is also decom- 
posed by alkalies and alkaline carbonates. It is compat- 
ible with weak acids which increase its solubility and 
render the solution more stable. 
Chloralamid is supposed to be decomposed in the 
circulation by the free alkalies in the blood, and its 
hypnotic action1-produced by the chloral set free. The 
depressing effect on the respiration and heart does not 
follow, as this is counteracted by the stimulating action 
of the formamide. 
In addition to this absence of depressing action, it has 
numerous advantages. It is free from any disagreeable 
taste, and its solubility renders it easy of administration. 
It does not derange the digestive organs, and no danger- 
ous or alarming symptoms follow its use. It is not fol- 
lowed by headache, giddiness, or any disturbance of the 
nervous system. The sleep induced is tranquil and easy, 
and the awakening gradual and pleasant. It follows in 
from half an hour to one and a half or two hours after 
taking the dose, and lasts for five or eight hours. Occa- 
sionally a drowsiness continues, or the sleep is much pro- 
longed, but it has never been found to be of serious im- 
port. The drug does not possess any cumulative action, 
nor does it give rise to a craving. It may be administered 
for a prolonged period without it being necessary to in- 
crease the dose. 
Since its introduction, chloralamid has been used with 
safety in all forms of insomnia. It has proved of great- 
est service in the sleeplessness of a purely nervous ori- 
gin, especially when unaccompanied by pain, or with pain 
very slight in character ; in nervousness, in hysteria, in 
neurasthenia, in old age, in spinal diseases, and in chronic 
alcoholism, its effect will be very decided. When pain is 
(SUPPLEMENT.) 
very marked its action is not to be depended upon, but 
reports of its use in such cases show that it may be of 
much benefit in locomotor ataxia, and in the pains arising 
from aneurism and neuralgia. In chronic mental dis- 
eases, as melancholia, and mania unaccompanied with 
much excitement, it has proved of marked benefit. In 
cardiac disease where chloral hydrate cannot be used, it 
may be given with perfect safety, and in such cases as car- 
diac asthma, dyspnoea, its happiest results are obtained. 
In febrile states, as in phthisis and typhoid fever, it acts 
favorably ; in the former it lessens the cough and night- 
sweats, and lessens the depression that accompanies these 
symptoms. The effect is thought to be due to its stimu- 
lating action on the respiration which promotes the re- 
spiratory changes, and lessens the carbonic acid in the 
blood. In whooping-cough, laryngismus stridulus, as 
well as in pulmonary asthma, the drug not only pro- 
duces sleep, but also allays the disease, the paroxysms 
becoming less severe, and the intervals more prolonged. 
The dose advised when the drug was first used was from 
twenty to forty-five grains, and this has been very gener- 
ally adhered to. The average dose employed is about 
thirty grains. As a rule, it is advisable to begin with a 
smaller dose of fifteen to twenty grains, when the insom- 
nia is not accompanied by pain or excitement. On ac- 
count of its solubility in alcohol, it is easily given in solu- 
tion diluted with some aromatic elixir. Brandy- or 
whiskey is a favorite means and adds to its beneficial 
action. If alcoholic solution is not desired, dilute hydro- 
chloric acid will be found to serve the purpose. It may 
also be given in cachets. For whooping-cough and other 
spasmodic affections, it is given in doses of two grains 
every two hours. Enemata may also be employed when 
such a means of administering the drug is desired. The 
following formula is recommended : Chloralamid, 14 
grains ; dilute hydrochloric acid, 3 drops; alcohol, 20 
drops ; water, 3 ounces. Beaumont Small. 
CHLORALIMID (Trichlorethylidenimide), CCh CH 
NH. This substance is obtained by the action of acetate 
of ammonia on chloral hydrate ; it may also be formed by 
heating chloral-ammonia. It is a crystalline acidular 
powder without taste, smell, or color, insoluble in water, 
soluble in alcohol, ether, and oils. It is not affected by 
heat or moisture. It possesses similar properties to chlor- 
alamid, but is more active. As an hypnotic, it is given in 
doses of from five to thirty grains. It is introduced as a 
substitute for chloral hydrate and chloralamid. It has 
not the acrid taste of the former nor the bitter taste of the 
latter. In smaller doses it is said to have an antipyretic 
and analgesic action. This drug has not been used to 
any extent, and its superiority to chloralamid has yet to 
be determined. Beaumont Small. 
CHLOROBROM is the registered trade name of a 
combination of chloralamid and bromide of potassium. 
This combination, which possesses the active properties 
of both its constituents, has recently been advised by 
Professor Charteris, of Glasgow, as a remedy for sea- 
sickness. He had used it in many cases with very grati- 
fying results. A dose is given after the stomach has been 
emptied of its contents, the sense of depression is relieved 
and nausea checked, a quiet sleep follows, from which 
the patient awakes relieved of all the distressing symp- 
toms. The remedy may be prepared as follows : Chloral- 
amid, bromide of potassium, of each one and a half 
drachms ; water, 2 ounces ; syrup, 1 ounce. One to 
one and a half tablespoonful for a dose. 
Beaumont Small. 
CHLOROFORM ; HYDERABAD COMMISSION. 
Chloroform during the past few years has received its 
share of attention (see article on Anaesthetics) and a large 
amount of experimental research has been devoted to 
anaesthetics. Perhaps the most important work done on 
this subject since the use of anaesthetics was introduced, 
has been the investigations and report of what is known 
as the Hyderabad Chloroform Commission. In 1888 
the Nizam of Hyderabad appointed the first commis- 
160 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Chatel-G u you. 
Chloroform. 
sion, composed of Surgeon P. Hehir, M.D., I. A. Kelly, 
L.R.C.P.S. Ed., and A. Chamarette, I.M.S., to perform a 
series of experiments upon dogs with chloroform, express- 
ing a wish that they should have a practical bearing on 
the way in which the administration of the anaesthetic 
ought to be conducted in the human subject. This com- 
mission was formed at the suggestion of Surgeon-Major 
Lawrie, President of the Hyderabad Medical School. 
Mr. Lawrie had been a pupil of Syme, of Edinburgh, and 
retained the views of that eminent surgeon regarding the 
action of chloroform. Professor Syme had always main- 
tained that chloroform was a safe anaesthetic if properly 
administered ; that its toxic action always showed itself 
on the respiration before the heart was affected, and that 
no accident would occur if the respiration was carefully 
watched. 
Opposed to this was the very generally accepted view 
of what is known as the London school, which considers 
that the heart is the source of danger, and that death dur- 
ing chloroform anaesthesia was due to its failure. 
The purpose of the commission was to inquire into the 
effect of the anaesthetic on the respiration and heart, and 
the value of artificial respiration to resuscitate when a 
fatal termination was threatened. A great number of 
experiments were made upon dogs, to which chloroform 
was given in various quantities and under varying condi- 
tions, to produce a fatal result. The conclusions reached 
were in accord with the views of Mr. Lawrie ; in every 
instance the respiration ceased before the heart, and 
where artificial respiration was commenced when danger 
was indicated by the breathing, recovery followed, but if 
precautions were neglected until the pulse gave warning, 
it was too late to resuscitate. The report concludes with 
the opinion " that death from chloroform narcosis in 
dogs is absolutely avoidable, and ought never to occur 
from surcharging of the blood with chloroform. Once 
anaesthesia is induced, so long as the respiration is kept 
up there is no fear of a cumulative action-the drug is 
rapidly eliminated. Interference with this elimination 
brings about changes in the respiratory mechanism which 
ought to arouse suspicion and prepare us for artificial 
respiration." 
When the editors of the London Lancet became aware 
of these experiments and the conclusions so much at vari- 
ance with their own, they criticised the latter rather severe- 
ly. It was thought that such important conclusions were 
arrived at rather hastily, and the experiments were not 
considered sufficiently precise to justify their acceptance. 
In consequence, the Nizam, with great liberality, de- 
cided to have another commission appointed to repeat 
the experiments of the former commission in a more 
scientific and exact manner. A check for one thousand 
pounds was forwarded to the editors of The Lancet, that 
they might select any one they wished to conduct the 
experiments in such a manner as they might think neces- 
sary. Dr. Lauder Brunton was chosen and sent to India 
as their representative. His qualifications were all that 
could be desired : he was an authority in therapeutics 
and was known to hold views not in accord with the 
conclusions of the former commission. 
The second Hyderabad Commission was composed 
of Surgeon-Major E. Lawrie, M.B. Ed., Dr. Lauder 
Brunton, F.R.8., Surgeon-Major G. Bomford, M.D. 
Lond., Dr. Rustomji of the Nizam's Medical Service, 
and associated with them were the members of the former 
commission. The experiments were begun in October, 
1889, and continued for some two months. They were car- 
ried on in the hospital in connection with the Hyderabad 
Medical School, and the native government afforded 
every facility for making the work as thorough and per- 
fect as possible. The most approved apparatus and ap- 
pliances were provided for observing the action of the 
pulse, the respiration, and the blood pressure. 
The objects kept in view by the commission were the 
suitability of chloroform as an anaesthetic, the effect of 
pushing it until dangerous symptoms or death took place, 
and the modifications of the anaesthesia that were effected 
by various degrees of asphyxia, by shock, and by the ad- 
ministration of various drugs. 
(SUPPLEMENT.) 
The experiments numbered over four hundred and 
thirty. The majority were upon dogs and.monkeys, but 
some were made upon horses, goats, cats, and rabbits. 
Two methods of administering the chloroform were 
chiefly employed. In the first a known quantity was 
allowed to evaporate in a certain amount of air, and the 
animal made to breathe the mixture, in the other method 
a certain amount of chloroform was administered without 
attention being given to the amount of air inhaled. 
To keep a record of the blood pressure two tracings 
were taken on different drums. One recorded the press- 
ure throughout the whole experiment, but was too slow 
to indicate any variation in the pressure during the 
diastole and, systole of the heart, the other was taken on 
a rapidly revolving drum and would indicate the slight- 
est variation. The tracing of the latter would have been 
too lengthy to preserve, but it was so arranged that the 
pressure could be taken at any moment and for any 
length of time during an experiment. In certain in- 
stances the motion of the heart was registered by a needle 
inserted through the chest-wall and into the heart, and 
the movements conveyed by means of a thread extending 
from the free end of the needle to a lever writing on the 
moving surface of the drum. 
The records of the respiratory movements were ob- 
tained by inserting a needle through the chest • wall 
into the diaphragm, the movements of the free end be- 
ing recorded. All these records were photographed and 
reproduced for publication, and, together with the de- 
tailed account of the experiments, provide an amount of 
evidence which any one may inquire into, and by its means 
corroborate or disprove the conclusions arrived at by t^e 
commission. The work of the commission, including the 
account of the experiments, the tracings, and a large num- 
ber of letters and papers, has been published in the 
lengthy report issued. For the report itself, the pages of 
the London Lancet for 1890 may be consulted. 
The result of their work was to corroborate the conclu- 
sions of the first committee, and these conclusions were 
fully concurred in by Dr. Brunton, who became con- 
vinced that the respiration was the part first affected and 
should be watched for signs of danger. 
The commission agrees, up to a certain point, with 
many of the views of their opponents. It is admitted 
by all that there is a gradual fall in the blood pressure 
throughout the administration of chloroform, and that 
this may terminate in death. The commission, however, 
hold that this is due to impoverished blood acting on 
the medulla and producing vaso motor paralysis; the 
others consider it due to a direct depressing action on the 
heart itself. Both sides also agree that early in the ad- 
ministration of the anaesthetic a rapid fall in the blood 
pressure frequently occurs. Upon this fall the greatest 
interest centres, as it is at this period that so many fatal 
results occur. The commission say this fall is due to 
accidental causes, producing asphyxia, and that it might 
always be avoided by care in administration. The as- 
phyxia by acting on the vagus reduces the action of the 
heart and lessens the supply of poisoned blood. They 
consider the slowing of the circulation as nature's method 
of protecting itself. The opponents to this view hold 
that it is due to a direct paralyzing action on the heart. 
A series of very valuable experiments have since been 
made by Professor McWilliam, of Aberdeen, who demon- 
strated that with this early fall in blood pressure, a dila- 
tation of the heart takes place, in some instances, even 
before the reflexes are lost. When this becomes extreme 
the heart fails to contract, although it may continue to 
beat in a feeble and uncertain manner. These observa- 
tions have since been confirmed by many others, among 
them, Dr. Hare, of Philadelphia. 
In consequence of such a diversity of opinion in such 
an important subject we are left in a very unsettled and 
unsatisfactory state of mind. Fortunately at this junc- 
ture His Highness the Nizam again comes to the rescue, 
and in a very creditable and liberal manner determines 
upon another commission, with the hope of reconciling 
the opposing views. The appointment of Dr. H. A. 
Hare to conduct the investigation will give general satis- 
161 Chloroform. 
Chloroform. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
faction, and is all the more gratifying as his views are 
known to be in opposition to those of the last commis- 
sion, thus indicating an earnest desire, on the part of the 
Nizam, to have all sides generously treated. 
The following conclusions of the second Hyderabad 
Commission are reproduced in full, as they are of historic 
importance and will be of interest in connection with the 
work of the forthcoming commission : 
1. Chloroform, when given continuously by any 
means which insures its free dilution with air, causes a 
gradual fall in the mean blood pressure, provided the 
animal's respiration is not impeded in any way, and it 
continues to breathe quietly without struggling or in- 
voluntary holding of the breath, as almost always happens 
when the chloroform is sufficiently diluted. As this fall 
continues, the animal first becomes insensible, then the 
respiration gradually ceases, and lastly, the heart stops 
beating. If the chloroform is less diluted the fall is 
more rapid, but is always gradual, so long as the other 
conditions are maintained ; and however concentrated 
the chloroform may be, it never causes sudden death 
from stoppage of the heart. The greater degree of dilu- 
tion the less rapid is the fall, until a degree of dilution is 
reached which no longer appreciably lowers the blood 
pressure or produces anaesthesia. 
2. If the inhalation is interrupted at any stage, the fall 
of pressure still continues at a rate which depends alto- 
gether on the rapidity of the fall while the chloroform 
was being inhaled. This after-fall is probably due to 
absorption of a portion of the residue of chloroform in 
the air-passages after the stoppage of the inhalation. In 
this way it often happens, if chloroform is given rather 
freely, that, though the respiration may be going on 
when the chloroform is discontinued, it afterward stops. 
3, If the administration of the chloroform is stopped 
at an early stage, the pressure very soon begins to rise 
again, and gradually becomes normal ; but if the chloro- 
form is pushed further, there comes a time, not easy to 
define, when the blood pressure and respiration will no 
longer be restored spontaneously, although the heart con- 
tinues to beat after the inhalation is stopped. 
4. If the fall has been very gradual it may occasionally 
happen that the respiration stops completely, and still 
the blood pressure rises again, the respiration recom- 
mencing spontaneously in the course of the rise. In the 
same way, when the inhalation has been discontinued, 
the respiration may stop during the after-fall of the 
blood pressure and begin again spontaneously. As a 
rule, if the respiration has stopped, or even becomes slow 
and feeble at the time when the inhalation is discontinued, 
and artificial respiration is not resorted to, the fall in 
blood pressure will continue until death ensues. 
5. There are two conditions which frequently disturb 
the gradual fall of the blood pressure, viz., struggling 
and holding the breath-and it is only by great care that 
they can be avoided in animals. 
6. Struggling, independently of any change in the 
respiratory rhythm, appears generally to raise the blood 
pressure. In one case of a dog much weakened from 
phosphorus, the pressure fell every time he struggled. 
7. When struggling is accompanied, as it often is, by 
acceleration of the respiration and pulse, especially if the 
respiration is deep and gasping, it leads to a more rapid 
inhalation of chloroform, and consequently to a more 
rapid fall of blood pressure and a greater after-fall. In 
order to keep the chloroform cap or inhaler in its place 
during the animal's struggles, the administrator is obliged 
to hold it down more tightly over the nose and mouth, 
and this materially assists in hastening the rapidity of the 
inhalation, and consequently of the fall in blood pressure. 
8. The effect of involuntarily holding the breath- 
which, as anybody can prove by experiment upon 
himself, must happen when an inhaler saturated with 
chloroform is first applied to the face-is much more 
remarkable, the pressure often falling with great sudden- 
ness, while the heart's action is markedly slower. As 
soon as the animal draws breath again, the pressure rises 
as suddenly as it fell, but the gasping respirations which 
succeed then cause very rapid inhalation of the chloro- 
form, with immediate insensibility and a rapid fall of 
blood pressure, which quickly becomes dangerous. 
9. The combination of struggling with alternate hold- 
ing the breath and gasping, which results if chloroform 
is applied closely to the face without sufficient dilution 
with air, causes the violent fluctuations, and then a 
speedy fall of the blood pressure, which very soon leads 
to a dangerous depression with deep insensibility and 
early stoppage of the respiration. The after-fall under 
these circumstances is rapid and prolonged. It is this 
combination of events which causes struggling animals 
to go under chloroform so quickly. 
10. The effect of holding the breath may occasionally 
cause a temporary fall of blood pressure after the chloro- 
form inhalation has been stopped, or even when the 
animal is quite out of chloroform. This fall is recovered 
from directly the animal breathes again. 
11. Slight continuous asphyxia, such as is produced by 
pressure on the neck by straps, a badly fitting muzzle, 
or hindrance of the chest movements by the legs being 
too lightly bound down, give rise to exaggerated and 
irregular oscillations of the blood pressure, and slowing 
and irregularity of the heart's action. If it leads to, or 
is accompanied by, deep gasping inspiration, it is apt, 
like anything else which causes this, to increase the 
intake of chloroform, and bring about a rapid decline of 
blood pressure. 
12. Complete or almost complete asphyxia, as by 
forcibly closing the nose and mouth or closing the 
tracheal tube after tracheotomy, has an effect similar to, 
but more marked than, that produced by holding the 
breath, and the' character of the trace corresponds pre- 
cisely to that produced by irritation of the peripheral end 
of the cut vagus. The pressure falls extremely rapidly, 
sometimes almost to zero, and the heart's action becomes 
excessively slow, or even stops for a few seconds. If the 
Fick trace of Experiment 148 be compared with the 
photographic reproduction of Trace A, of the Glasgow 
Committee, it will be seen that they are identical, and 
that the slow action of the heart with great fall of press- 
ure, which the Glasgow Committee attributed to some 
capricious action of chloroform upon the heart, was un- 
doubtedly due to asphyxia. 
13. This effect of asphyxia is the result of stimulation 
of the vagi. The proof of this is (a), that the trace corre- 
sponds exactly, as stated above, to that produced by 
direct irritation of the vagus ; (b), division of both vagi 
entirely abolishes it, and (c), the administration of atro- 
pine, which paralyzes the vagus, also abolishes it. 
14. In Trace 158 (Fick 4), which was taken during 
asphyxia after a full dose of atropine, it will be seen that 
there is an alternately slow and rapid pulse according to 
the phase of the respiratory movement, but no continued 
slowing of the heart, as in vagus irritation. But there 
was still a distinct fall of pressure after the atropine 
when the breath was held, and it was thought that the 
slowing of the pulse above noted in this condition might be 
due to the disturbance of the heart from tension in the pul- 
monary vessels in the absence of respiratory movement, 
rather than to irritation of the vagi. To test this point 
Experiment 184 was instituted. In this experiment the 
dog's chest was forcibly inflated with bellows connected 
by a tube with the trachea, and the effect of this proceed- 
ing was to cause a fall of pressure and slowing of the 
heart exactly the same as involuntary holding of the 
breath. The dog was then poisoned with atropine, after 
which inflation of the chest still caused a fall of pressure, 
but without slowing of the heart. The fall of pressure 
must be in some degree independent of vagus irritation, 
which, however, usually accompanies it. 
15. It only remains to be considered whether the slow 
action or temporary stoppage of the heart with great fall 
of pressure produced by vagus irritation is, in itself, ap 
element of danger in chloroform administration, and if 
it is not, wherein the danger actually lies. 
16. The experiments in which deliberate irritation of 
the vagi was carried on during anaesthesia, show unmis- 
takably that irritation of these nerves diminishes rather 
than enhances the danger of anaesthetics. The effect 
162 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Chloroform. 
Chloroform. 
upon the heart is never continuous, and as the vagus 
becomes exhausted, or when the irritation is taken off, 
the blood pressure rises again, as it does when the same 
result is produced by asphyxia. The slowing of the 
heart and circulation which is produced by irritation of 
the vagus by any cause, such as holding the breath in 
chloroform administration, retards the absorption and 
conveyance of chloroform to the nerve-centres, just as 
holding the breath, whether voluntary or involuntary, 
prevents chloroform from entering the lungs ; and of 
itself, slowing, or temporary stoppage of the heart in 
chloroform administration', is not dangerous. 
17. To answer the second part of the last question in 
paragraph 15 is easy enough, if it is kept in mind that 
the effect of vagus irritation upon the heart is never con- 
tinuous ; and in chloroform administration, as the press- 
ure rises again after the slowing of the heart and tem- 
porary fall of pressure produced by any form of as- 
phyxia, violent respiratory efforts with bounding heart's 
action lead, as in the case of struggling, to a rapid and 
dangerous inhalation of chloroform, and consequent 
rapid and dangerous decline in blood pressure. It is, in 
fact, the temporary exhaustion of the vagi after stimula- 
tion that is to be feared, and not the actual stimulation, 
as long as it is continued. 
18. In accordance with this fact it will be found that 
in chloroform administration neither holding the breath, 
even if involuntary, nor vagus inhibition can be kept up 
beyond a certain time ; and if the chloroform is not re- 
moved from the face, one or both of two things may 
happen : (a), When the animal breathes again, it takes 
deep and gasping inspirations, the lungs become filled 
with chloroform, and an overdose is taken in with ex- 
treme rapidity ; (5), when the restraining influence of 
the vagus is taken off the heart, through the irritation 
ceasing or the nerve becoming exhausted, the heart 
bounds on again, and the circulation is accelerated in 
proportion. The blood then becomes quickly saturated 
with chloroform, and an overdose is at once conveyed to 
the nerve-centres. The theory which has hitherto been 
accepted is, that the danger in chloroform administra- 
tion consists in the slowing or stoppage of the heart by 
vagus inhibition. This is now shown to be absolutely 
incorrect. There is no doubt whatever that the control- 
ling influence of the vagus on the heart is a safeguard, 
and that it is the exhaustion of the nerve which is dan- 
gerous. 
19. It can be readily understood how a condition in 
which the pulse is rapid and bounding, with high blood 
pressure, leads to more rapid absorption of chloroform 
into the lungs, and a more rapid propulsion of the chloro- 
formed blood to the medulla oblongata, and consequently 
to a more rapid paralysis of the respiratory and vaso- 
motor centres, and precipitous fall in the blood pressure. 
Such a condition is produced in some cases by ether, or 
by division of both vagi, or by a full dose of atropine. 
Not only is the poisoned blood carried more swiftly to 
the vital centres in these cases, but added to this there is 
the fact that, as the heart is already doing its utmost be- 
fore the chloroform is given, it is unable to stave off by 
increased work the fall in pressure that occurs when the 
vaso-motor centre is paralyzed. On the other hand, it 
seems clear from Experiment 92 that the direct action of 
chloroform upon the heart's substance is not the cause 
of the fall of pressure that occurs when it is inhaled. 
20. In Experiment 92, repeated injections of 20 minims 
of chloroform were made into the jugular vein, and its 
effect was not to paralyze the heart, but to produce 
anaesthesia and a gradual fall of blood pressure, exactly as 
if the chloroform had been inhaled. In Experiment 72, 
after a considerable amount of ether had been injected 
into the jugular vein, and a bounding condition of pulse 
had been produced, the effect of injecting chloroform 
into the jugular was much greater, and the fall of blood 
pressure much more rapid and dangerous than in the 
case where chloroform alone was injected. Granting, 
then, the truth of Minger's conclusions from experiments 
on the frog's heart (which have not been repeated and 
confirmed by the commission) that chloroform has a grad- 
ual paralyzing effect upon the heart's tissue, we must 
conclude that such an effect, in the degree in which 
alone it could occur in the practical inhalation of chloro- 
form, would rather be a source of safety than of dan- 
ger. 
21. The committee discussed the advisability of cutting 
the vagi some time previously to experimenting on the 
blood-pressure with chloroform. The effect of this pro- 
cedure is to cause continuous rapid action and tendency 
to exhaustion of the heart, as well as to degeneration of 
the terminal branches of the nerves in the heart if the 
animal live sufficiently long. 
Such experiments might be of some interest theoreti- 
cally, and also have had a practical bearing upon the con- 
dition of the heart in certain cases of chronic alcoholism ; 
but the committee decided not to perform them, as it 
considered the end to be gained did not justify the pain 
they would have inflicted. 
22. In Experiment 178, the case of a dog that had had 
morphine, remarkable slowing, and even temporary ces- 
sation, of the heart's action occurred again and again at 
the same moment as the respiration stopped; but the 
heart invariably recovered itself, and began again to beat 
regularly, before any steps were taken to restore the ani- 
mal, and without any respiration occurring. We find in 
this case that it was possible to restore the animal even 
after unusually long intervals had been allowed to elapse 
between the cessation of the natural and the commence- 
ment of the artificial respiration. The failure of the 
heart, if such it can be called, instead of being a danger 
to the animal, proved to be a positive Safeguard, by pre- 
venting the absorption of the residual chloroform and its 
distribution through the system. 
23. The effect of artificial respiration after the natural 
respiration has ceased, is to cause an alternate rise and fall 
of small amount in the blood-pressure, the trace thus 
formed upon the drum being a coarse imitation, altered 
somewhat by the shaking of the table, of the natural re- 
spiratory curve. The difference consists chiefly in the 
fact that the artificial rise always coincides with expira- 
tion or compression of the chest. After artificial respira- 
tion has been continued for a certain time, the blood press- 
ure begins to rise again, and a little later natural respi- 
ration returns. 
24. The effect of artificial respiration in restoring an 
animal after the respiration had stopped was always 
marked. In a few exceptional cases, such as Experiment 
159-a phosphorus dog-and Experiment 142-a horse 
which had an enormous overdose, although the artificial 
respiration was commenced as soon as possible after the 
breathing was noticed to have stopped, it was not suc- 
cessful. 
25. Complete stoppage of the respiration always means 
that an overdose has been administered, and the overdose 
may have been so great as to produce a very prolonged 
after-fall of blood pressure, and may thus render restora- 
tion impossible. As it is impossible to say whether, after 
chloroform has been pushed and then discontinued, the 
respiration will be restored spontaneously or not, so it is 
never in any case certain that artificial respiration will 
restore the natural respiration and blood pressure, no 
matter how soon it is commenced after the respiration 
stops. A great deal depends upon the amount of the af- 
ter-fall ; in some cases, even after the respiration has 
been restored, the pressure continues to fall and respira- 
tion again ceases, and artificial respiration then fails. 
We thus find respiration restored by artificial respiration 
while chloroform is still being absorbed, and this tends 
to show that artificial respiration does not merely pump 
the chloroform out of the blood, but exerts considerable 
influence in exciting the natural respiration. 
26. The time which elapses before artificial respiration 
succeeds in restoring natural respiration varies very 
greatly. In one case, Experiment 116, it was continued 
for eleven minutes before the first natural gasps com- 
menced. This period is undoubtedly prolonged in some 
cases by a condition of physiological apnoea, which ren- 
ders it unnecessary for the animal to breathe. Conse- 
quently, whenever the pressure rose considerably during 
163 Chloroform. 
Chloroform. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
artificial respiration it was stopped, and the animal then 
generally breathed after a few seconds. 
27. The time which may be allowed to pass with im- 
punity before commencing artificial respiration also 
seems to vary considerably. This point was not particu- 
larly attended to in the manometer experiments, except 
in Experiments 162 and 178, which were instituted to 
test the truth of the opinion formed by the sub-commit- 
tee, that morphine had some slight action in impairing 
the efficiency of artificial respiration. In these cases the 
commencement of artificial respiration was postponed for 
more than two minutes after respiration ceased, and was 
successful; but this is certainly far above the average in- 
terval that can be allowed with safety. The success of 
artificial respiration in restoring the blood pressure is in 
some cases very remarkable ; wide especially Experiment 
40, in which the heart had apparently ceased beating, 
and the dog was believed by everyone present to be dead, 
and yet recovered with artificial respiration. The suc- 
cess in this instance is due to the fact that chloroform 
had only been administered for a few seconds, and that 
the depression was the result, not of continuous chloro- 
form administration until respiration ceased, but of a 
long and severe after-fall. 
28. It corresponds to those cases which are so often 
reported, in which dangerous failure of the heart is said 
to have occurred some minutes after the administration 
of chloroform had been discontinued, and which are some- 
times restored, and sometimes not, by artificial respiration. 
There is nothing at all sudden about the failure of the 
heart in these cases, but the attention of the chloroform- 
ist, which has been wandering, is suddenly called to 
the fact that the patient is apparently dead. When the 
animal was really dead, it was found in some cases that 
artificial respiration still maintained a small amount of 
mean pressure in the manometer. In others the pressure 
seemed to fall to the zero line between each compression 
of the chest. 
29. The dangers of too vigorous artificial respiration 
were illustrated in some of the accidental deaths. In one 
case the liver was badly ruptured, and in another the 
pleural cavity was full of blood. In these cases-Experi- 
ments 80, 92, and 103-rhythmical movements of the 
diaphragm were noticed after the heart had ceased beat- 
ing and after the chest had been opened. It is remarka- 
ble that in two of these cases the splanchnic nerve had 
been divided. The third was a case in which chloroform 
had been injected into the jugular vein, and in this case 
there was a synchronous movement of the jaw as well. 
In all, death and stoppage of the heart had occurred grad- 
ually, and in Experiment 103 the heart was still irrita- 
ble. These movements cannot be called respiration, 
though the last gasp of a crying animal, that ineffective 
jerk of the diaphragm which is such a fatal symptom, 
is very likely in many cases a movement of the same 
character. Similar movements, which were continued 
much longer, occurred in Experiment 104, after the 
thorax was opened, while the heart was still beating. 
Still more remarkable convulsions of the muscles of the 
jaws, ears, and forefeet occurred in Experiment 167, in 
the case of a dog that had been poisoned with nicotine. 
These movements continued at regular intervals for 
more than ten minutes after death, and were sufficiently 
forcible to jerk the handles Of a pressure-forceps, fixed on 
the end of the tongue, off the table at each spasm. In a 
rabbit, in Experiment 153, the auricles of the heart con- 
tinued to beat rhythmically for three hours after it was 
supposed to be dead from chloroform and its thorax had 
been laid open. Irritability of the heart after death was 
noticed in many cases, but seemed to be most marked in 
cases where ether had been used. 
30. Chloroform injected into the heart through the 
jugular vein did not cause clotting of the blood, as was 
the case when ether was injected. 
31. In the course of the experiments of the committee 
various drugs were administered in order to ascertain if 
they had any effect in modifying the action of chloroform. 
The result showed that none of them had any effect in pre- 
venting the typical descent of the blood pressure that oc- 
(SUPPLEMENT.) 
curs when chloroform is inhaled. Atropine, when given 
in a dose sufficient to paralyze the vagi, of course prevents 
the action of those nerves in asphyxia, and by increasing 
the action of the heart it appears to cause a more rapid 
descent in the blood pressure when chloroform is inhaled, 
as has been already explained. Morphine appeared, in 
Experiment 162, to render the rise in blood pressure, that 
occurred when the chloroform was discontinued, slower 
and less complete, and to bring about a more or less per- 
manent condition of anaesthesia. It may be noted that 
the animal used in this was a monkey; and in other ex- 
periments with monkeys, when no morphine had been 
given, it was remarked that the animal, after a few inhala- 
tions of chloroform, would often lie quite quiet, in a state 
of semi-insensibility, for a longtime without further inha- 
lations ; still this condition was much more marked in 
Experiment 162 than in any of the others. No action of 
this kind was noticed in the dog in Experiment 178, but 
other experiments (90 and 94) showed that pariah dogs 
are very indifferent to the action of morphine, and it is 
probable that the dose of morphine in this case was in- 
sufficient to bring about the condition noted in the mon- 
key. The peculiar behavior of the heart in Experi- 
ment 178 was not the result of the previous administration 
of morphine, for a similar phenomenon had occurred in 
other cases (49 and 60) in which no morphine had been 
given. Experiments 162 and 178 prove conclusively that 
morphine had no effect in shortening the period that may 
be allowed to elapse between the cessation of natural res- 
piration and the commencement of artificial respiration. 
32. The other drugs used had no effect on the action 
of chloroform, except when their own special action be- 
came the leading feature in the case-as, for instance, 
during the vomiting from apomorphine (Experiment 104, 
Fick 9), or the convulsions produced by nicotine (Experi- 
ment 167). 
33. In order to test the alleged danger from shock dur- 
ing chloroform administration, the committee performed 
a very large number of those operations which are reputed 
to be particularly dangerous in this connection-such as 
extractions of teeth, evulsions of nails, section of the 
muscles of the eye, snipping of the skin of the anus, etc. 
In many cases the operation was performed when the 
animal was merely stupefied by the chloroform, and not 
fully insensible. In such cases a slight variation in the 
blood pressure would sometimes occur, such as one would 
expect from the irritation of a sensory nerve or from the 
struggling that ensued; but in no case, in any stage of an- 
aesthesia, was there anything even suggestive of syncope 
or failure of the heart's action. In thrusting a needle 
into the heart there was often a momentary but well- 
marked fall of the blood pressure; but even this -was 
absent in all other injuries. If chloroform really had any 
power to increase the tendency to shock in operations, 
it is impossible to believe that it would not have been 
manifested, to some degree at least, in one or other of 
these numerous experiments. The commission was, how- 
ever, not content with this negative result, and deter- 
mined to ascertain the effect of direct irritation of the 
vagi during continued chloroform administration. The 
result of such experiments (65 and others) proved that 
inhibition of the heart's action prevented, rather than 
assisted, the fatal effects of prolonged chloroform inhala- 
tions. An animal that was put into a condition' of extreme 
danger (from which it could only be restored by means 
of artificial respiration) by inhalation of chloroform for 
one minute, recovered spontaneously and readily after 
five minutes of chloroform inhalation, together with in- 
hibition of the heart by electrical irritation of the vagus 
carried on simultaneously. In one of these experiments 
(117) chloroform was pushed for seven minutes ; and 
during continued irritation of the vagus the animal re- 
peatedly came round without artificial respiration. The 
danger really begins w'hen the irritation is discontinued 
or fails to inhibit the heart, and thus enables the chloro- 
form in the lungs to be rapidly absorbed and thrown into 
the system. The danger is certainly increased by delib- 
erately pumping the chloroform into the lungs by means 
of artificial respiration, for animals in which this was 
164 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Chloroform. 
Chloroform. 
done, although they showed a tendency to recover when 
the chloroform and irritation of the vagus were discon- 
tinued, afterward died rapidly. 
34. On another occasion, during Experiment 117, the 
animal was very nearly killed by a comparatively short 
inhalation of chloroform, owing to the electrodes becom- 
ing accidentally short-circuited and failing to keep up the 
irritation of the vagus. Something similar occurred in 
Experiment 177, the effect of the irritation of the vagus 
passing off while the chloroform was still being pushed, 
and thus putting the animal into a condition of extreme 
and unexpected jeopardy. Nothing could be more strik- 
ing than these near approaches to accidental death from 
failure to irritate the vagus efficiently. 
35. Other experiments were made to test the truth of 
the statement that chloroform increases the action of 
electrical stimuli applied to the vagus, and showed con- 
clusively that it has no such effect. In one instance only 
the inhibition seemed to be intensified as the chloroform 
was commenced, and diminished when it was discontin- 
ued : but, apart from the fact that the supposed effect 
ceased much too suddenly, a repetition of the experiment, 
on the same and other animals, showed that there was in 
reality no such effect. The increased inhibition in this 
instance was due to the chloroformist compelling the 
attendant who was holding the electrodes to change his 
position, and thus making him unconsciously apply them 
more efficiently. When the chloroformist withdrew they 
were restored to their former position. This affords an 
instance of the care that has to be taken in making ex- 
periments, if one is not to be deceived. 
36. To test the effect of shock due to vaso-motor change 
rather than to affection of the heart, Goltz's experiment 
on the frog was repeated on three dogs. In one there 
was slight lowering of pressure, which was not extensive, 
and in the others no effect was produced at all. Other 
operations which seemed likely to produce shock, such 
as violent blows upon the testicle, were singularly devoid 
of effect. Failing to lower the blood pressure by any of 
these methods, recourse was had to section of the splanch- 
nics ; but the low condition of blood pressure which this 
produced, appeared, like stoppage of the heart from vagus 
irritation, to be a source of safety rather than of danger 
during chloroform administration. In this .connection 
Experiment 111 may be studied. There was not much 
external hemorrhage, but the splanchnics were divided- 
a proceeding which, as is often said, bleeds the animal 
into his own vessels. The pressure was after this ex- 
tremely low, but chloroform was repeatedly given and 
various other actions taken, and then chloroform had to 
be pushed on a saturated sponge enclosed in a cap for 
eleven minutes before respiration ceased. 
37. The conclusion, then, is this: Chloroform has no 
power of increasing the tendency to either shock or syn- 
cope during operations. If shock or syncope from any 
cause does occur, it prevents, rather than aggravates, the 
dangers of chloroform inhalation. 
38. The experiments on dogs that had been dosed with 
phosphorus for a few days previously, show that the 
fatty, and consequently feeble, condition of the heart 
and other organs so produced has no effect in modifying 
the action of chloroform. The ease with which vagus 
irritation and the Glasgow trace could be produced in 
these animals, by even slight degrees of asphyxia, was 
very remarkable ; but this was equally the case in dogs 
that had been given phosphorus only a few hours before 
the experiment, and whose organs were not yet fatty. 
Many of these cases were in the last stage of phosphorus 
poisoning, and several of their companions died, without 
any experiment having been performed upon them, 
before or on the same day as they died (ride the low state 
of blood pressure in Experiment 163). Numerous at- 
tempts were made in these animals to produce shock by 
operations in the recumbent and vertical positions, but 
without any more result than in those that were healthy. 
39. The truth about the fatty heart appears to be that 
chloroform per se in no way endangers such a heart, but, 
on the contrary, by lowering the blood pressure, lessens 
the work that the heart has to perform, which is a posi- 
tive advantage. But the mere inhalation of chloroform 
is only a part of the process of the administration in 
practice. A patient with an extremely fatty heart may 
die from the mere exertion of getting upon the operation- 
table, just as he may die in mounting the steps in front 
of his own hall-door, or from the fright at the mere idea 
of having chloroform, or of undergoing an operation, or 
during his involuntary struggles. Such patients must in- 
evitably die occasionally during chloroform administra- 
tion, and would do so even were attar of roses or any 
other harmless vapor substituted for chloroform. 
40. The effect of hemorrhage was tested by opening 
the femoral artery and allowing a considerable quantity 
of blood (eight to twelve ounces) to escape. An imme- 
diate lowering of the blood pressure results, and this is 
very slowly recovered from. Such an accident, however 
dangerous it may be in itself, in no way affects the action 
of chloroform, except in so far that a patient who has 
been nearly bled to death would require less chloroform in 
his system to put him into a state of anaesthesia. The 
low condition of his blood pressure produced by the hem- 
orrhage would tend to prevent the too rapid intake of 
chloroform, exactly as in the case of cutting the splanch- 
nics (ride supra, subparagraph 36). 
41. When the hind feet are lowered on to the floor so 
as to place the animal in the vertical position, a consider- 
able fall of blood-pressure in the carotid artery occurs ; 
but when the animal is replaced on the table in the 
recumbent position the pressure is fully restored. Vari- 
ous operations were performed on animals in the vertical 
position, but in no case was anything resembling danger- 
ous shock produced. Inversion of the body, so that the 
animal stands on its head, has exactly the opposite effect, 
the pressure rising in the carotid artery, and again falling 
to its former state when the animal is replaced in the 
horizontal position. Inversion of the body failed to 
restore an animal that was in the last stage of chloroform 
poisoning, though it raised the pressure in the usual way 
as long as it was continued. The change in the pressure 
of the blood of the carotid, which occurs when the posi- 
tion of the body is changed, appears therefore to be due 
simply to the effect of gravity. 
42. As regards the effect of chloroform upon different 
animals, it may be said to be the same as far as its anaes- 
thetic action is concerned. There are certain peculiarities 
in its effect on respiration and circulation, connected with 
its local irritant action on the nostrils and fauces, which 
are interesting to notice. Thus, when concentrated 
chloroform vapor is applied to the nostrils of rabbits, 
they hold their breath, and the heart's action is slowed at 
once. This is always said to be due to reflex inhibition 
of the heart from irritation of the nasal branches of the 
trigeminus reflected through the vagus, and is by no 
means peculiar to chloroform, but is produced equally by 
any irritant vapor, such as ammonia or acetic acid. 
43. In some dogs, and especially in those to which 
phosphorus had been given, stoppage of the respiration 
and slowing of the heart occurred immediately after the 
application of the chloroform to the face, or on forcibly 
pulling out the tongue, and this suggests that the mech- 
anism of the cardiac arrest in them is precisely the same 
as it is in the rabbit. On the other hand, in rabbits, 
as in all other animals, it is possible to give chloroform so 
gently that no spasm of the chest occurs, no reflex effect 
is produced; and then the pressure falls in the same reg- 
ular curve, and with the same succession of phenomena 
(anaesthesia, cessation of the respiration, and lastly cessa- 
tion of the heart-beat) that was above described as typical 
of chloroform inhalation. 
44. Goats have a great tendency to hold their breath 
while inhaling chloroform, and monkeys resemble dogs 
rather than rabbits, as when ammonia was held before a 
monkey's nose (Experiment 98) it did not cause immediate 
stoppage of the respiration and heart as it does in rabbits. 
45. The experiments with ether show that it is impos- 
sible to produce efficient anaesthesia with this agent un- 
less some form of inhaler is used which thoroughly ex- 
cludes the air. If an ordinary cap containing a sponge 
saturated with ether is applied very closely to the face, 
165 Chloroform. 
Chorditis Tuberowa. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
the animal generally holds its breath and struggles, and 
we at once get the fall of blood pressure and slowing of 
the heart that invariably occur under these circumstances. 
If the ether is continued in this way after the animal has 
recommenced breathing, a condition of semi-anaesthesia 
results in which the cornea is sometimes sensitive and 
sometimes insensitive, and the pressure rises and falls 
alternately to a slight amount and forms a wavy trace, 
which may be continued right around the drum without 
any particular change. As soon as the air is rigidly ex- 
cluded, the pressure commences to fall gradually, exactly 
in the same way as with chloroform, and with the same 
succession of phenomena, viz., first anaesthesia, then ces- 
sation of the respiration, then of the heart movements, 
and finally death. How far this is due to ether and how 
far to the results of asphyxia, it is impossible to say, but 
an exactly similar succession of events can be brought 
about by making the animal inhale carbonic acid gas 
alone. 
46. If surgeons continue to be content with a condi- 
tion of semi-anaesthesia, it can no doubt be produced with 
perfect safety, though with discomfort, to the patient, by 
ether held rather closely to the mouth. Such a condition 
of imperfect anaesthesia would never be accepted by any 
surgeon accustomed to operate under chloroform. If 
more perfect anaesthesia is required, it can be procured 
by excluding the air more rigidly, but then there is ex- 
actly the same danger as in giving chloroform. How very 
suddenly and rapidly the pressure may fall and death en- 
sue, is well shown by Experiment 33. Ether injected into 
the jugular vein produces a fall of blood pressure and 
anaesthesia in the same way as chloroform does, but in 
all cases in which it was so injected large clots were 
found in the heart immediately after death. It is inter- 
esting to note that Claude Bernard seems to have formed 
a very similar opinion with regard to ether, as the fol- 
lowing quotations from his work, entitled " Lemonssur 
les Anesthesiques et sur l'Asphyxie," published in 1875, 
show. The first quotation (p. 50) is as follows : " Aussi, 
un certain nombre de chirurgiens proposerent-ils d'aban- 
donner le chloroforme pour revenir & I'ether, dont 
1'usage paraissait moins a craindre. Aujourd'hui en- 
core, les chirurgiens de Lyon emploient preferablement 
I'ether. On croyait le chloroforme plus dangereux que 
I'ether parce qu'il etait plus actif ; mais, en realite, la 
frequence relative des accidents par le chloroforme tenait 
peut-etre tout simplement & ce que c'etait cet agent anes- 
thesique qu'on employait dans 1'immense majorite des 
cas. Plusieurs discussions out ete provoquees par les 
partisans de I'ether, surtout par les representants de 
1'ecole de Lyon, et il a ete constate que I'ether, lui aussi, 
avail produit un certain nombre d'accidents mortels. Les 
deux agents anesthesiques usites peuvent done, 1'un 
comme l'autre, entrainer quelques risques de mort, et la 
chirurgie humaine a conserve presque partout le chloro- 
forme, dont Faction est plus rapide et plus complete." 
The second quotation, to be found on p. 101 of the same 
work, runs.: "Quant a I'ether et au chloroforme, leur 
action est & peu pres la meme au point de vue physiolo- 
gicpie, sauf une difference d'intensiteen faveur du chloro- 
forme, ce qui nous fera generalement employer ce der- 
nier corps de preference a I'ether." Beaumont Small. 
CHORDITIS TUBEROSA (Trachoma of the Vocal 
Bands). This peculiar laryngeal disorder, which is 
always associated with catarrhal inflammation of the 
entire larynx, is characterized by the formation of a 
small whitish nodule upon one or both of the vocal 
bands. 
It is of special interest to the laryngologist because it 
occurs almost entirely in public speakers, singers, and 
actors. It always produces some degree of impairment 
of the voice, and, as it is a lesion which it is difficult to 
eradicate, it is well to appreciate its existence and treat 
it intelligently. Not much has been written about it. 
Most authors have been satisfied with brief mention of 
this, condition as one of the manifestations of chronic 
catarrhal laryngitis. 
Pathology.-Titrck's 1 description of this lesion, to 
(SUPPLEMENT.) 
winch lie first gave the name "chorditis tuberosa," is 
the most comprehensive. Almost every author of recent 
years refers to Tiirck's article when writing of the 
pathology and etiology of this disease. Turek had 
noticed four cases of this peculiar inflammation of the 
vocal bands in singers, and he gives this description of 
the appearance of the larynx : " Midway in the upper 
plane of the bands there is a peculiar uneven surface, 
and, in addition to redness and swelling, some white 
opaque spots as large as poppy-seeds." These white 
spots, he says, become more noticeable as the general 
congestion subsides. He believes this peculiar lesion to 
be due to inflammation of the mucous glands. 
Von Ziemssen,2 speaking of the pathological changes of 
the vocal bands occurring in very protracted cases of 
chronic catarrhal laryngitis, says : " There is sometimes a 
roughness of the surface, which seems to be due to a 
partial dermoid metamorphosis of the mucous membrane 
- a condition called chorditis tuberosa by Thick." 
Wedl,3 who examined specimens from a number of 
trachomatous vocal bands, found only connective-tissue 
hypertrophy with heaps of nuclei. Bosworth4 says : 
''The pathological lesion is probably somewhat analo- 
gous to pachydermia, with the addition of a certain 
amount of connective - tissue hypertrophy ; " and Sir 
Morell Mackenzie,5 in a very brief description, says: 
''The lesion appears to consist in a hypertrophy of the 
connective tissue and a proliferation of its nuclei." 
It is somewhat- difficult to determine whether Vir- 
chow 6 is not describing the same pathological condition 
in his article on "Pachydermia of the Larynx." Cer- 
tainly the appearances of the vocal bands in the earliest 
stages of pachydermia, as Virchow describes them, are 
quite similar to the nodules of chorditis tuberosa. Later, 
the infiltration and swelling are much greater in what he 
designates pachydermia than we see in chorditis tube- 
rosa. He says the swelling is at first localized in the 
middle of the vocal bands. There are raised points with 
tissue-thickening about them, the raised points being the 
swelling of the squamous epithelium and the papillae. 
This condition he believes to be due to long-continued 
congestion-a hyperplastic process, not an irritative one. 
He thinks it cannot consistently be called a chronic 
catarrh of the larynx, as there are neither mucus nor 
pus-corpuscles. 
INe believe that the essential pathological change in 
pachydermia laryngis is in kind like that found in tra- 
choma of the vocal bands, 
but carried much farther 
from the normal condi- 
tion ; - pachydermia, as 
Virchow says, " occur- 
ring in aged drinkers, 
and caused by shouting." 
In an illustration of an ex- 
treme case furnished by 
Ingals,7 in his article on 
" Trachoma of the Vocal 
Chords" (Fig. 68), we 
see a condition very sim- 
ilar to Virchow's pachy- 
dermia laryngis, and a 
much more advanced stage of disease than we have ever 
witnessed in chorditis tuberosa. We think mild cases of 
pachydermia may closely simulate extreme cases of tra- 
choma, but the thickening extending both above and 
below the vocal bands, and forming polypoid enlarge- 
ments, as Virchow pictures the later lesions of pachy- 
dermia, are not seen in chordhis tuberosa. The writer 
has had sections from two nodules which were removed 
from the vocal bands of different patients examined, and 
the result was the same in both instances: both specimens 
showed the result of simple inflammatory changes in 
the hypertrophy and increased number of the small 
round cells and connective-tissue corpuscles. It is es- 
sentially a hyperplastic process due to long-continued 
irritation and congestion of a moderate grade. 
Etiology.-While it is undoubtedly true that a chronic 
catarrhal laryngitis is a predisposing factor in the causa- 
Fig. 68. 
166 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Chloroform. 
Chorditis Tuberosa. 
tion of these peculiar nodular formations of the vocal 
bands, yet the exciting causes to be mentioned have a 
much more important bearing. The description of chor- 
ditis tuberosa should not be buried in a general article on 
catarrhal laryngitis, as it deserves separate treatment, by 
reason of its special etiology. The amount of the gene- 
ral catarrhal inflammation in these cases is not excessive, 
while the pathological changes of the vocal bands are out 
of proportion to the general catarrh. 
The essential exciting cause of chorditis tuberosa is 
excessive use of the voice, and the lesion usually appears 
in singers. During the last two years I have seen eight 
cases of chorditis tuberosa. Six of these cases were in 
singers; the remaining two cases were in people who 
used their voices more than in ordinary conversation, 
one a Hebrew, who read aloud some religious ceremony 
every week, and the other a foreman of a large number 
of laborers, who was in the habit of shouting to his men. 
The six singers were all women and sopranos. It would 
be interesting to know if any cases of chorditis tuberosa 
have been seen in people who do not use the voice except 
in ordinary conversation. I have never seen such a case. 
This may be explained by the fact that probably none but 
singers, actors, public speakers, etc., go to a physician 
on account of the moderate hoarseness which the nodule 
on the vocal band produces. It is my belief, however, 
that this nodule is produced by excessive use of the 
voice in singing and public speaking, and that it is also 
largely attributable to a faulty method of singing or an 
improper manner of using the voice. It is a significant 
fact that six of the eight cases observed were singers 
and sopranos, conditions, as we know, requiring the 
highest tension and the most rapid vibration of the vocal 
bands. In writing the histories of these six cases, some 
attention was paid to the manner in which the voice had 
been trained, and it seemed to me significant that two of 
the patients were in the same class at a grand conser- 
vatory of music where only the "true Italian method 
was taught." During vocalization in both of these cases, 
as the scale was ascended the epiglottis w'as carried far- 
ther downward and backward with each note and the 
larynx was compressed more and more. One of these 
women could sing only a short time without becoming 
quite hoarse. After changing her teacher and using her 
voice in a different manner, she was able to sing at a 
theatre every night, although there is still some nodular 
enlargement on one of the bands. 
One of the patients-an operatic singer of great repu- 
tation-stated the pathology of the condition known as 
"chorditis tuberosa" quite accurately when she said, 
after the laryngoscopic appearances had been described 
to her, " Why, I should say I had corns on my vocal 
bands "-the " dermoid metamorphosis" of Von Ziems- 
sen. 
These nodular enlargements are produced by the rapid 
vibrations of the vocal bands, weakened by catarrhal in- 
flammation and over-use. After the chords become con- 
gested and thickened the friction of one band against the 
other is probably a contributing factor, just as the outer 
layers of the skin of the foot become hypertrophied by 
the friction of an ill-fitting shoe. This is especially true 
when the tension of the chords is unevenly controlled. 
While some congestion of the vocal bands, incident to 
the general catarrh, precedes the nodular swellings, the 
larger portion and the general thickening of the bands 
follow the formation of the nodules on the chords and 
are caused by the nodular enlargement. The nodular 
swellings are therefore in a sense primary, and the other 
changes in the bands secondary. 
The irritation caused by the constant friction of the 
nodular enlargement with the opposite band, and the ex- 
tra exertion necessary to produce a true tone in singing 
or a clear voice in speaking-these cause congestion with 
hyperplastic changes, and eventually an exhaustion of 
the adductors and tensors of the bands. 
Symptomatology.-The nodular enlargements may 
be situated upon one or both bands. In five of the eight 
cases I have seen, the nodule was on the left band. It is 
usually located a trifle more anteriorly than midway be- 
tween the vocal processes and the anterior insertions of 
the vocal bands, and it may be on the upper surface of 
the chord or upon its free margin. 
Fig. 69. 
A nodular enlargement of one band, if the voice is 
persistently used in singing or public speaking, will in 
time produce some alteration in the tissue of the other 
band at the point of contact. Sometimes there is an ap- 
pearance of depression in the second vocal band just op- 
posite the nodule. 
Fig. 70. 
If this depression is examined carefully, the mucous 
covering will present a roughened appearance, a callous 
spot which has been produced by the protruding point 
on the opposite band. This callous depression is really 
raised above the normal surface of the vocal band ; but a 
concavity exists because the edges about the depression 
are elevated to a still greater degree. After the nodule 
has existed for some time the depression on the second 
band is sometimes filled, and later gives place to a second 
nodule. Two nodules are now seen striking against each 
other, and the bands are just so much more prevented 
from approximating during phonation. If these nodules 
are not removed, and if the person is allowed to continue 
singing, the irritative friction and the increased effort of 
the intrinsic laryngeal muscles necessary to bring the 
bands together cause congestion and thickening of the 
entire substance of the bands. If a very careful examina- 
tion of one of the nodules is made in its earliest stages, 
the mucous membrane covering it will seem to be un- 
altered, and the millet-like nodule seem to be wholly 
situated in the substance of the band. It requires strong 
illumination to correctly appreciate the exact amount of 
congestion and swelling of the vocal bands. The nod- 
ules in this disease are, when first formed, pearly white, 
but later become a dirty gray. The color of the nodule, 
however, depends much upon the color of the adjacent 
vocal bands. When the entire band is congested and 
thickened, the nodule can be seen with difficulty ; when 
the congestion of the band disappears, the nodule stands 
167 Chorditis Tuberosa, 
Club-Foot. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
out prominently. With poor illumination the vocal 
bands will seem to be nearly normal; a better light will 
reveal enlarged capillaries, running over the surface, and 
in the substance of the vocal bands, which in color vary 
from a gray to a pale red. The location of the nodule 
may always be easily discovered, because the secretions 
stick to this part of the chord, and when the chords sepa- 
rate during inspiration, a thread of mucus may be seen, 
stretching across from the nodule on one chord to the 
point of contact on the opposite chord. The degree of 
approximation of the bands depends upon the size of the 
nodule and upon the strength of the adductors of the 
vocal chords. The size of the interval between the 
chords varies from day to day, because the nodule changes 
in size rapidly without apparent cause (Fig. 71). 1 have 
seen a nodule develop 
in forty-eight hours, on 
.4.. a vocal band long af- 
- fected, because of over- 
(SUPPLEMENT.) 
pharyngitis sicca bears a specially close and injurious re- 
lation to a trachomatous vocal band, and every effort 
should be made to keep the pharynx moist while treating 
the larynx. 
The local remedies are not many which are of use in 
the judicious treatment of chorditis tuberosa. The nodule 
must be eradicated first of all. Time can be saved, in 
rare instances where the nodule is large enough, by snip- 
ping it off to the plane of the free edge of the band. I 
have twice used successfully a small, circular, snap, guil- 
lotine-knife, the circle about a quarter of an inch in di- 
ameter. 
With the aid of cocaine this circle can be placed around 
the nodule and the band pressed toward the lateral wall 
of the larynx before the knife is sprung. This instrument 
can be used more delicately than a laryngeal forceps, and 
with less damage to the bands. After the nodule has 
been cut off, a solution of zinc chloride or of silver ni- 
trate, from thirty to sixty grains to the ounce, may be 
Fig. 72. 
applied to its base. The forceps may be used to eradicate 
the nodule, but there is danger of injuring the bands, and 
the nodule is usually too small. Labus,8 of Milan, 
recommends flaying the vocal bands with forceps or 
curette; not a useful expedient, we should think. The 
operator must rely upon strong astringent or caustic 
solutions. The solutions of silver and zinc, of the strength 
mentioned above, are the most reliable. A four percent, 
solution of cocaine, sprayed into the larynx, will enable 
the operator to apply the solution to the nodule alone, 
without touching the remainder of the band. Slight in- 
flammatory action follows this application, which disap- 
pears in forty-eight hours. This should be remembered 
when treating a patient who is obliged to sing at the 
earliest possible moment. Mackenzie recommends ap- 
plications of ferri perchlor., 3 ij. ad 5 j- Chromic acid 
crystals may be applied to the nodule by means of some 
form of the guarded or concealed laryngeal applicator. 
This application should not, of course, be made until the 
movements of the larynx are controlled by cocaine. A 
week or ten days must elapse before the larynx recovers 
from this application. 
A fine-pointed galvano-cautery electrode, exposed not 
more than one-eighth of an inch, could, in skilful hands, 
be applied to the nodule as easily as the acids. After the 
nodule has been nearly eradicated, its return may be pre- 
vented by weak astringent solutions sprayed into the 
larynx, such as solut. argent, nit,, gr. v. ad | j. ; zinc 
chlorid., gr. x. ad 3 j. A very weak solution of cocaine 
(one per cent.) may be with benefit sprayed into the throat 
just before the astringent sprays are used. When the 
entire substance of the band is congested and thickened, 
absorption can sometimes be effected with a solution of 
iodol or iodoform in ether ( 3 j. to § j.). I have found 
that oily sprays are of little value and apt to be drying. 
It has been mentioned that the adductors and tensors of 
the vocal bands become fatigued by persistent singing 
in patients who have trachomatous bands, as much more 
than the usual muscular strength is required to bring the 
bands together, on account of the interposing nodule ; 
hence, after the nodule has been removed, the galvanic 
or faradic current should be employed. I prefer the 
faradic ; the two electrodes may be placed one on each 
side of the thyroid cartilage, or one pole may be applied 
to the arytenoid cartilages. The benefit seems to be 
about as great when the poles are applied externally. 
Dr. Gautier's method of applying the galvanic current, 
called "interstitial electrolysis," might be useful in re- 
moving the nodules. He applies a copper electrode posi- 
tive pole, insulated up to near its tip, to the growth, the 
negative sponge electrode to the back or chest ; a weak 
current is used-from five milliamperes up. The action 
of absorption is based upon the fact that oxychloride of 
Fig. 71. 
singing during a single evening. The chords approach 
each other more closely in front of the nodule than be- 
hind it. The failure of the bands to meet each other 
throughout their entire length occasions " phonatory 
leakage," and impairment of voice, w'hich is about the 
only symptom of this affection. 
The degree of hoarseness will depend, not only upon 
the size of the interposing nodule and the amount of 
secondary inflammatory changes in the vocal bands, but 
also upon the skill with which the vocal apparatus is em- 
ployed. We all know how well some singers vocalize 
with greatly altered vocal bands. 
Diagnosis.-The single pearly nodule, as large as a 
pin's head, will be, in the early stages, easily diagnosed 
from other lesions of the vocal bands. When the bands 
become congested and thickened, a little more care will 
be required, but the diagnosis is never difficult. 
" Chorditis tuberosa " should not be confounded with 
the uneven surface of the vocal bands seen in long- 
standing cases of simple chronic chorditis, where the 
vocal apparatus has been abused for many years, and 
strong astringents or caustics have been so frequently 
applied to the larynx that little normal mucous membrane 
remains. Chorditis tuberosa should be differentiated 
from the cicatrices following tubercular and syphilitic 
ulcerations, or from granulation tissue springing from 
the base of ulcers, and also from benignant growths at- 
tached to the vocal bands. 
Treatment.-In no laryngeal disorder must the 
treatment be more painstaking. Skilful manipulation 
will be required to eradicate it. These cases should be 
treated as early as possible before the second band has 
been injured by the protruding nodule on its fellow, and 
before the bands have become congested, thickened, and 
stiffened, and the vocal tensors exhausted beyond recov- 
ery. They should not be allowed to sing or to use their 
voices except in quiet conversation. The voice should 
be rested, not only until the nodular enlargement has dis- 
appeared, but until congestion has abated and the muscu- 
lar tone of the larynx has been restored. 
It is hardly necessary to say that the nose and pharynx 
should be put in good condition. Colds in the head and 
inflammation about the pharynx always aggravate this 
condition of the vocal bands. The condition known as 
168 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, 
(SUPPLEMENT.) 
Cliorditls Tuberosa 
Club-Foot. 
copper is formed at the positive pole, which permeates and 
causes absorption of the growth. The author says the ac- 
tion produces no burning or destruction of tissue, since the 
energy of the current is expended in forming the copper 
salt. 
Finally, after the bands have been made as nearly nor- 
mal as possible, we should insist that our patient, if he 
is a singer, put himself under the instruction of a proper 
teacher. This advice is imperative if we would cure this 
class of patients. A faulty method of using the voice 
will bring back in a short time the catarrhal conditions 
and the nodular enlargement. 
The points I would place emphasis upon are these: 
1. That while chorditis tuberosa is in a sense one of 
the manifestations of a chronic catarrhal laryngitis, yet 
its real cause is excessive use of the voice. 
2. That the nodule on the band is largely the primary 
lesion, while the other changes in the bands are sec- 
ondary. 
3. That this condition is almost always found in sing- 
ers or public speakers, and is occasioned to a great degree 
by a faulty method of using the voice. 
4. That chorditis tuberosa occurs more frequently in 
women than in men, and is seen most often in sopranos. 
5. That a nodular enlargement will in time produce 
change in the second band at the point of contact; and, 
6. That these nodules should -be removed as early as 
possible. Singing should not be allowed until the fiands 
are normal, and faulty methods of using the voice should 
be corrected by proper teaching. Clarence C. Rice. 
1 Tiirck : Klinik der Krankhciten des Kehlkopfes, Wien, 18(i6, pp. 164 
and 204. 
2 Von Ziemssen, vol. iv.. p. 217. 
2 W*dl: Idem. 
4 Bosworth: Diseases of the Nose and Throat, vol. ii., p. 534. 
5 Mackenzie : Diseases of the Throat and Nose, vol. i., p. 294. 
9 Virchow : Verhandlung der Berlin. Med. Gesellschaft, reported in 
Berliner klin. Wochensehrift, 1883, No. 21, 
7 Ingals : Diseases of Chest and Throat, etc., p. 402. 
8 Labus, Archives of Laryngology, 1880. 
CHROMIC ACID. A new use of this escharotic was 
brought to the notice of the profession by Dr. Edward 
Woakes, in The Lancet, June 21, 1890. He there advo- 
cates its use in the treatment of cystic goitre, ranula, 
and other cysts. The cyst or sinus is to be opened and 
thoroughly evacuated and washed, and all haemorrhage 
checked ; a saturated solution of the acid is then applied 
to the secreting surface with a chromic-acid carrier, and 
the patient kept at rest for a few days. No severe re- 
action occurs and the cavity is rapidly obliterated. Re- 
peated applications may in some instances be required, 
four or five days elapsing between each. It is recom- 
mended to apply this method of treatment to all sinuses 
and cavities with a secreting wall. There does not seem 
to be any danger of absorption of the drug, as it coagu- 
lates the albumin of the tissues and forms a thick, dense 
membrane. Dr. Woakes says "repeated observation 
points to a complete and rapid amalgamation between the 
tissues and acid to such an extent that thereafter neither 
the one nor the other retains its former character." 
All haemorrhage should be carefully checked, as it neu- 
tralizes the acid and prevents its action on the cyst-walls. 
This acid has also been selected to destroy the false 
membrane in diphtheria. A forty per cent, solution is 
used and the membrane touched two or three times a 
day by means of a pencil. The applications are to be 
made with the greatest care, to avoid injuring the mucous 
membrane. It does not produce any inflammatory action 
and is painless. The false membrane alone is destroyed 
and the production of the toxic ptomaines arrested. In 
addition antiseptic spraying and constitutional treatment 
tire also adopted. Beaumont Small. 
CINNAMIC ACID. This acid is one of the numerous 
drugs introduced on account of its reputed value in the 
treatment of tuberculosis. It is produced by the oxida- 
tion 6f oil of cinnamon in air or oxygen ; it also exists 
ready-formed in balsams of tolu and Peru, and in storax. 
It may be obtained by the following process : Old, hard 
balsam of tolu is reduced to powder and mixed with an 
equal weight of slacked lime ; this mixture is boiled for 
some time in a large quantity of water, and filtered while 
hot. On cooling calcium cinnamate crystallizes. This is 
redissolved in hot water, digested with charcoal, and fil- 
tered and allowed to cool. The crystals are again dis- 
solved in hot water, and an excess of hydrochloric acid 
being added, it is again allowed to cool, when cinnamic 
acid separates in a pure state. 
It resembles benzoic acid and possesses many of its 
properties. It forms small white plates or needle-shaped 
crystals of perfect whiteness, without odor. It is insoluble 
in cold water ; soluble in hot water, alcohol, and ether. 
Cinnamic acid has antiseptic properties similar to 
salicylic and benzoic acids, and has been used to make 
antiseptic dressings of gauze, jute, etc. 
Its use in tuberculosis has been recommended by Dr. 
A. Landerer, of Leipsic. 
For pulmonary phthisis it is employed only by intra- 
venous injections, the object being to bring the acid in 
direct contact with the diseased pulmonary tissue. A 
five per cent, emulsion of the acid is prepared, and from 
one and one-half to fifteen minims injected twice a 
week. The veins of the arm are selected. The part is 
rendered aseptic and the vessels distended by means of 
gentle pressure. After the injection the part is dressed 
with sublimate gauze and the pressure removed. No 
bleeding or inflammation follows the puncture. No im- 
mediate effects are produced by this medication, but in 
the course of a few weeks the sputum changes its color 
and loses its purulent character, the cough lessens, night- 
sweats cease, all disagreeable symptoms lessen, and the 
general health improves. It is advised to continue the 
treatment for at least three months. 
In surgical tuberculosis the acid is injected into the 
diseased tissue. The injections are made deeply into the 
part, seven and one-half minims being used twice a week. 
In fistulous disease, injections of a five per cent, alcoholic 
solution were used. In lupus vulgaris each tubercle is 
to be injected with one or two drops of the solution. 
After the injections there appears redness and tume- 
faction, which subside in two or three days ; the nodules 
gradually disappear and approach the normal skin in 
composition. The pain of the injection may be overcome 
by combining five per cent, of cocaine with the alcoholic 
solution. Dr. Landerer reports very favorable results 
from this treatment, but others have not as yet adopted 
its use. Beaumont Small. 
CLUB-FOOT. From time to time cases have been re- 
ported to both prove and disprove each of the theories 
previously advanced as to the etiology of congenital club- 
foot, but no new facts have been added to our stock of 
knowledge. 
Treatment.-The treatment consists in correcting the 
deformity, and maintaining the corrected position until 
there is no longer a tendency to relapse. 
The treatment is commenced at the earliest possible 
moment, and the retentive treatment may have to be 
continued for years. Simpler means are always to be 
tried before the more radical operations are attempted, 
but the tendency of the profession is very decidedly in 
favor of rapidly correcting the deformity in place of 
gradual and prolonged stretching by complicated me- 
chanical devices. 
Of the braces used for gradually correcting the de- 
formity by a leverage, or stretching process, none are 
more simple, and yet effective, than those for many years 
employed by Dr. Charles Fayette Taylor (Figs. 73 to 76). 
The sole-piece is of sheet steel, the upright a steel bar 
joined to the sole-piece by a strong rivet, allowing antero- 
posterior motion ; the extent to which the toe is allowed 
to drop is regulated by a set screw. Sufficient straps are 
attached to retain the foot, and these are usually at the 
places shown in the illustrations. The cuts illustrate the 
manner of applying the adhesive plaster and adjusting 
the brace. It will be noted that the upright piece can 
be bent to exert any desired degree of leverage. This 
splint will be found of great service as a retention walk- 
169 Club-Foot. 
Club-Foot. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
ing apparatus after forcible correction or operative pro- 
cedures. 
Forcible correction is accomplished by the hand in 
moderately severe cases in young infants, and by wrench- 
ing and crushing with various machines. The simplest 
(SUPPLEMENT.) 
other hand, subcutaneous incisions to which no thought 
of asepsis has been paid beyond ordinary cleanliness rarely 
become infected ; it is the universal rule that they heal 
without suppuration, while open in- 
cisions rarely escape infection unless 
treated with the most careful aseptic 
precautions at the time of the oper- 
ation and at subsequent dressings, 
should such be necessary. Strict asep- 
sis demands no little personal care as 
to the preparation of dressings in 
private practice, and, in the dressing 
of these wounds of the feet, demands 
at least one trusty assistant. Strict 
asepsis, it must be admitted, 
is not possible for verv manv 
Fig. 73. 
Fig. 74. 
Fig. 78.-The Thomas Wrench applied to a Case of Talipes Equino-varus. 
* 
men who are called upon to treat deformed feet. I would 
not be understood as saying that in the hands of such 
the subcutaneous operation is the safer, for it is not, but 
it is reasonably safe, and if suc- 
cessfully performed will result 
in healing within three or four 
days as against as many weeks 
if the wound must heal by gran- 
ulation. 
Thomas'* Method. - This 
method of stretching the foot 
into a corrected position dif- 
fers from all other stretch- 
ing methods for the cure 
of congenital varus. It 
takes a middle place be- 
tween stretching by 
braces, which on the one 
hand exert "continuous 
Fig. 75. 
Fig. 76. 
Figs. 73 to 76.-The Taylor Club-foot Brace. 
effective machine is the Thomas wrench, Fig. 77. It 
may be used as the primary procedure, or as secondary 
to operation. When used as supplementary to a cutting 
operation the patient is anaesthetized, and the attempt is 
made to fully correct the deformity at a single sitting. 
One of the most powerful devices for forcible correction 
is Dr. Phelps's machine, Figs. 84 and 85. This machine 
Dr. Phelps uses only when the patient is anaesthetized, 
and generally, if not always, as a supplementary proced- 
ure to a cutting operation. 
Forcible correction by machine should not be attempted 
in cases where correction can be accomplished by the 
hand. It may be employed with equal advantage after 
Fig. 79. - The Deformity Partially 
Corrected by the Wrench. 
Fig. 77.-The Thomas Wrench. 
leverage," or " elastic traction," 
or " the weight of the body as a 
corrective force," and the ma- 
chines which forcibly correct the 
deformity under an anaesthetic at 
a single sitting, on the other hand. 
By the wrench shown in Fig. 77, 
and applied in Figs. 78, 79, and 
80, the foot is stretched, or 
"wrenched," or sprained to a 
degree just sufficient to abolish 
the resiliency of the shortened 
tissues. The foot is then retained 
in a simple metal brace (Figs. 81 
and 82) until at the end of from 
two to six days the resiliency be- 
subcutaneous and open incisions of the soft parts, and I 
after the cutting operations upon the bones. 
The choice between subcutaneous and open incisions 
for the division of the soft parts depends upon the skill | 
of the operator, the severity of the deformity, and the I 
care with which strict asepsis can be carried out. It 
surely requires more manipulative skill to thoroughly 
divide all of the shortened parts subcutaneously than 1 
openly, and in some cases a satisfactory subcutaneous 
division cannot be accomplished. In old and severe de- [ 
formities much time is often wasted in futile subcutane- 
ous operations. An open wound is certainly a safer 
wound than a subcutaneous one when infected. On the i 
Fig. 80.-The Deformity 
Fully Corrected by the 
Wrench. 
170 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Club-Foot. 
Club-Foot. 
gins to return and the foot tends once more to assume its 
old position ; then the wrenching is repeated. These 
wrenchings are repeated every few days, the intervals 
becoming longer as the foot comes into a better position, 
until the deformity has been 
fully corrected, and shows no 
tendency to relapse. 
Tenotomy.-In doing subcuta- 
neous division of the shortened 
soft parts, surgeons for the most 
part proceed as follows : 
For the ordinary form of con- 
genital talipes equino-varus the 
tendo Achillis is first divided 
about an inch and a half above 
the point of its insertion. The 
patient lies on his face, the as- 
sistant puts the tendon on the 
stretch by flexing the foot, the 
skin is drawn somewhat to one 
side, and with a pointed teno- 
tome a puncture is made at the 
side of the tendon, nassins- be- 
neath it. With 
this same knife, 
or with a blunt 
pointed one in 
its place, the 
tendon is then 
divided by 
turning the 
edge of the 
knife toward 
the tendon, and 
moving it with 
a gently sawing motion. As soon as the assistant feels the 
snap of the divided tendon, he should instantly relax the 
flexion. When the cavity left by the incision has filled 
with blood, the operator attempts full flexion of the foot. 
In a certain number of cases this will not be found pos- 
sible, and the choice then is between a section or a forc- 
ible rupture of the posterior ligament of the ankle-joint. 
Section of this ligament is accomplished by a spear- 
shaped tenotome passed through the middle of the tendo 
Achillis, then turned half around and swept from 
side to side. Most surgeons, however, prefer to 
rupture the ligament by the hand, the wrench, or 
some other mechanical device. 
Unless full flexion at the ankle 
joint be made possible before the 
anterior portion of the foot is 
subjected-to operation, it will be 
found very difficult of accom- 
plishment. The next step is a 
division of as much of the deltoid 
ligament as may be neces- 
sary, and such other short- 
ened tendons as may be 
reached by the knife through 
the same incision. The foot being 
put on the stretch in the direction 
of outward rotation, a sharp, point- 
ed tenotome is entered flat close to 
the anterior border of the inner 
malleolus with its back next the 
bone, and carried around under the 
tip of the malleolus. It is then 
removed and replaced with a blunt 
knife, preferably convex on the 
edge; the edge is turned toward 
the ligament, and as much of it 
divided as may be necessary. 
Through the same opening the tendon of the posterior 
tibial, and the anterior tibial, and astragalo-scaphoid 
capsule may be divided. By passing the tenotome some 
what deeper and close to the bone, the tendon of the 
long flexor of the toes may be divided. The tendon of 
the extensor of the great toe stands out prominently over 
the metatarso-phalangeal articulation, and here it is 
(SUPPLEMENT.) 
divided from within, outward, when required. The ab- 
ductor of the great toe and the plantar fascia are divided 
just in front of the inner tuberosity of the os calcis. 
When all resisting bands that can be made out to the 
touch have been divided the foot should be forcibly 
overcorrected by the hand, or the wrench, or some other 
mechanical device, and should be retained permanently 
in that position. Strict asepsis should be practiced in 
these tenotomies, and the wounds 
sealed with collodion and a small bit 
of gauze. No permanent pressure 
should be made to check bleeding. 
If the bleeding is sufficient to demand 
pressure, a free incision should be 
made and the bleeding vessel liga- 
tured. Pressure diminishes the quan- 
tity of plastic effusion, and may be 
the cause of a weak union between the 
divided ends of the tendons. Dressed 
without pressure, perfect union 
may always be confidently ex- 
pected, no matter how far the 
cut ends may be separated. 
The method, formerly in gen- 
eral use, of leaving the foot in 
its deformed position for a few 
days until soft union between 
the divided ends of the tendons 
had taken place, and then grad- 
ually stretching this new mate- 
rial, may be held responsible 
for many cases of weak union, and even of non-union. 
Phelps's Operation.-This consists in making an open 
incision commencing in front of the inner malleolus, and 
extending one-third the distance across the sole of the 
foot, and carried down to the neck of the astragalus, on 
its inner side. (Fig. 83.) Through this wound, the ad- 
ductor pollicis, tibialis posticus, the plantar fascia, the 
flexor brevis, the long flexor tendons of the toe, and the 
deltoid ligament, all its branches, if necessary, can be 
cut. This is done after subcutaneous tenotomy of the 
tendo Achillis has been performed. Great force is then 
used by the machine shown in Figs. 84 and 85, to rupt- 
ure the deep ligaments and super-correct the foot. 
Fig. 81.-The Thomas 
Retention Club-foot 
Brace. A. the foot- 
plate. curled up at 
the inner side ; B, 
the leg-plate; C, D, E, the main stem ; F, hori- 
zontal section of leg-plate and main stem, show- 
ing the plate extending farther to the inner 
side of the stem than to the outer. 
Fig. 83.-The solid line indi- 
cates the incision in Phelps's 
operation. 
Any case that can be 
corrected by the hand, or 
by subcutaneous ten- 
otomy, should not be sub- 
jected to Phelps's opera- 
tion ; and when the oper- 
ation as described fails to 
easily supercorreci me root, a linear osteotomy should 
be made through the neck of the astragalus. If this 
fails, a V-shaped piece should be removed from the 
os calsis, the point of the V meeting the linear osteotomy 
of the astragalus. This failing, the removal of the 
cuboid and scaphoid is indicated. And, as a last resort, 
Pirogoff's amputation should be resorted to. 
Fig. 82.-The Thomas 
Club-foot Brace applied. 
Fig. 84.-Phelps's Machine adjusted. 
171 Club-Foot, 
Club-Foot. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
The wounds of Phelps's operation are sutured or not, 
as may be possible, and dressed without drainage, with 
the aim to obtain blood-clot organization. The feet are 
dressed in the super-corrected position, in plaster -of- 
Paris. 
Phelps first operated in 1879, and to him more than to 
any other is due the credit of leading the way to perfect 
results in inveterate cases of club-foot. 
Ridlon's Operation.-This is a modification of Phelps's 
operation, designed to avoid a tender scar on the sole of 
the foot. In Phelps's earlier operations, the incision was 
(SUPPLEMENT.) 
underneath the bones, closely hugging them. As these in- 
cisions are made, an assistant constantly keeps the parts 
on the stretch in the direction of correction of the de- 
formity, and each part as it appears to resist the correct- 
ing influence is divided. When any considerable degree 
of equinus is present, the first incision passes beneath the 
Fig. 85.-Phelps's Machine in Use. 
carried two-thirds across the sole of the foot; at present 
it is carried but one-third that distance, and the objection 
to a tender scar holds less well than before the modified 
operation was devised. 
The operation which bears the writer's name consists 
of an incision commencing on the dorsum of the foot just 
in front of the inner malleolus, at the point where the ten- 
don of the extensor longus digitorum muscle crosses to 
the inner side of the foot; from here it is carried directly 
anterior half of the inner malleolus, and in some cases be- 
neath the whole of it. The deltoid ligament, and the 
tendons of the tibialis anticus, extensor proprius hallucis, 
extensor longus digitorum, extensor brevis digitorum, 
tibialis posticus, flexor longus digitorum, and flexor 
longus hallucis, are readily reached. From the second 
Fig. 86-Ridlon's Operation ; Lines of Incisions. 
Fig. 87.-A. Plaster of-Paris imprint from a boy of eleven, after excision 
of the astragalus for resistant club-foot. B. Drawn from a photograph 
of a boy of eleven, after osteotomy of the neck of the astragalus for 
club-foot. (Bradford.) 
toward the sole, to meet near its middle a second incis- 
ion made parallel with the sole from near the inner tub- 
erosity of the os calcis to the middle of the first metatar- 
sal bone, or beyond (Fig. 86). The plane of the first 
incision leads directly downwards to the bones ; the plane 
of the second incision slopes upwards and outwards to 
reach the bones at their nearest border; thence it is carried 
incision the abductor hallucis, the plantar fascia, and any 
other resisting structure maybe divided. By carrying 
the second incision in the plane directed, it will almost 
always be possible to avoid dividing the internal plantar 
artery and the nerve. The division of all tight bands 
having been made, the foot is overcorrected by the hand 
172 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Club-Foot. 
Club-Foot. 
or by the wrench. As in Phelps's method, we believe it 
better to divide the tendo Achillis and correct the 
equinus, rupturing, if necessary, the posterior ligament 
of the ankle-joint, before commencing the operation for 
correcting the deformity of the anterior portion of the 
foot. The dressings are the same as in the Phelps's 
operation, namely, suturing, in so far as possible without 
(SUPPLEMENT.) 
the deformity ; fourth, when this cannot be readily done, 
do a linear osteotomy of the neck of the astragalus, fol- 
lowed if necessary by cuneiform osteotomy of the os 
calcis ; if this is not sufficient, enucleate the astragalus, 
or remove any bone or portion of bone which blocks the 
way ; and if this is not sufficient, amputate. 
Dr. Bradford has recently pointed out that in some 
Fig. 88.-Sole imprint of a case of club-foot 
corrected by tenotomy with inversion of 
the foot without contraction. (Bradford.) 
Fig. 89.-Imprint of a normal foot. (Brad- 
ford.) 
Fig. 90.-Imprint of a foot of a child six 
years old, treated when one year old, for 
congenital club-foot. (Bradford.) 
putting the parts at too great tension, and covering the 
wound with Lister protective and aseptic dressings, with 
the expectation that healing by blood-clot organization 
will take place. Over all is applied a plaster-of-Paris 
dressing with the foot in the supercorrected position. 
In inveterate cases where the foot cannot be easily held 
in the supercorrected position, operations on the bones 
are indicated as pointed out under Phelps's operation. 
The principles, first clearly laid down, we believe by 
Phelps, must never be lost sight of : First, correct all 
cases possible by hand ; second, correct all possible by 
subcutaneous incision ; third, of the remaining cases, 
divide by an open incision all resisting soft parts, and 
with the hand or some mechanical device supercorrect 
cases there is elongation of the outer border of the os 
calcis and a consequent obliquity of the anterior (cuboid) 
articulating surface which can only be remedied by re- 
moving the wedge-shaped piece from its outer side just 
posterior to the cartilage. In the normal foot a line 
drawn antero-posteriorly through the centre of the heel 
and the centre of the front part of the foot meet to form 
a straight line (Fig. 87, B), while in the foot with a dis- 
torted os calcis, the lines meet to form an angle (Fig. 
87, A). An imprint of a normal foot is seen in Fig. 89, 
and of a corrected club-foot in Fig. 90, while Fig. 88 
shows a foot with a deformed os calcis which, after 
tenotomy, could readily be fully corrected, but which at 
once drops back into inversion because of the obliquity 
91.-Imprint of a right foot before opera- 
tion. (Bradford.) 
Fig. 92.-Imprint of the same foot after opera- 
tion. Osteotomy of the neck of the astralugus 
and os calcis. (Bradford.) 
Fig. 93.-Judson's brace. 
173 Club-Foot. 
Cocaine. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
of the calcaneo-cuboid articulation. In these cases where 
distortion of the os calcis is present, correction by force, 
by tenotomy, by open incision on the inner side of the 
foot, and even by enucleation of the astragalus, fails to 
permanently remove the inward twist of the anterior por- 
tion of the foot. Figs. 89 and 90 show the improvement 
which may be gained in inveterate cases. 
An imprint of the foot as shown in these illustrations 
will be found a most convenient guide and a valuable 
record. A sheet of paper is smoked over a piece of burn- 
ing camphor, and after an imprint has been made by the 
patient stepping upon it, it is rendered permanent by 
pouring over it a little photographer's varnish. The 
composition of the varnish is: Gum sandarach, oz. li ; 
alcohol, oz. 8 ; castor-oil, dr. 2. Mix. 
Whatever method be employed to correct or super- 
correct the deformity, it is but the first step in the treat- 
ment of the case. Suitable dressings must be employed 
to retain the foot in the corrected position until the slack 
has been taken up in the elongated tissues of the convex 
side, and until use has rendered supple the articular sur- 
faces in their new relations. After operative procedures, 
plaster-of-Paris forms the most convenient dressing until 
the wounds have healed ; after that the Taylor shoe is a 
simple, inexpensive, and satisfactory dressing. 
Valgus.-Pure valgus is an exceedingly rare deformity. 
In congenital cases the outward deformity is almost in- 
2. The long weak foot seen in adolescence, which, 
though of little importance at the time, often becomes 
most confirmed and painful in later life. 
3. Weak feet in older subjects, particularly women 
who have grown stout and are obliged to stand much of 
the time. 
4. The most important cases, usually seen in young 
adults, where we find marked deformity and muscular 
Fig. 95.-A. The flat-foot. B. The overcorrected foot. 
spasm, so that the foot is quite rigid, and cannot be re- 
placed in normal position. 
5. True flat-foot, or pes planus, which may be actually 
inherited or be the result of rachitis in infancy. 
The first and second class find relief in well-fitting 
shoes, the inner border of the soles of which have been 
built up from one-fourth to one-half inch, from the ball 
Fig. 94.-Judsons's brace applied. 
variably associated with a dropping of the heel-calcaneo- 
valgus ; in the non-congenital deformity the same condi- 
tion may be present, or there may be drawing up of the 
heel-equino-valgus. In the congenital deformity the 
foot can, as a ride, be readily replaced by hand, ami only 
requires a simple apparatus to retain it in that position. 
Occasionally, section of one or more tendons anteriorly 
is required. In equino-valgus, tenotomy of the tendo ' 
Achillis is indicated. Judson's brace, shown in Figs. 
93 and 94, serves the best to retain the corrected foot in 
these outward deformities, as it also does in pure calcan- 
eus. The brace consists of a sheet-steel foot-piece with a 
flange running its full length, turned up on the side to 
which the deformity looks, and on the opposite side a 
flange from one-half to one inch in width, turned up 
opposite the heel, to form the heel-cup. To the first 
flange is riveted an upright piece of soft bar-steel which 
runs along the side of the leg to the garter-line, where a 
band encircles the leg. The brace is held in position by 
straps so placed as to retain the foot in its new position. 
Flat-Fool. The treatment of flat-foot, or acquired val- 
gus, has been greatly advanced by the work of Dr. Royal 
Whitman, of New York. He divides the cases clinically 
into five groups : 
1. Cases known as weak ankles in weak or rachitic 
children, or accompanying slight knock-knee. 
Fig. 97. 
FlGS. 96 and 97.-Whitman's flat-foot brace. A, the part applied to 
the inner side of the foot; B, that applied to the outer side. 
of the foot to the tip of the heel, so that the weight is 
thrown to the outer side, and may be permanently cured 
by learning to walk properly, i.e., with their toes in 
front so that the inner borders of the feet are parallel, and 
not with toes turned out. 
To this treatment the third class should add hot foot- 
174 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Club-Foot. 
Cocaine. 
baths, manipulations and rubbing, and in some cases Whit- 
man's brace may advantageously replace the tilted shoe. 
The fifth class requires no treatment unless pain is 
present. 
It is to the fourth class that Whitman's principles of 
treatment are especially applicable, and the class in 
which his brace finds its greatest usefulness. 
The procedure with it is as follows : 
The deformity is forcibly reduced and overcorrected. 
This is quite a different thing from remoulding the arch 
(Fig. 95). Under ether, the foot is grasped by the hands, 
or the hands and knees, or by the 
Thomas wrench, and bent and 
twisted inward until all restriction 
to normal motion is completely over- 
come. The foot is then placed in 
extreme adduction or equino-varus, 
and retained by a well-padded plas- 
ter bandage. In a week, or less if 
there be no pain in the foot, the band- 
ages are removed and a plaster cast 
taken for the support which is to be 
used. The plaster cast of the foot 
goes to the iron founder, who re- 
produces it in iron. Upon the iron 
cast is moulded, from thin sheet-steel 
while hot, the brace, in the form 
shown in the illustrations (Figs. 96, 
97, 98) and afterwards it is tempered, 
nickeled, or tinned, and coated with 
Japan varnish. The brace is not a 
spring ; it is inelastic. It is worn 
inside, but not attached to the shoe. 
The shoe recommended is one of 
the Waukenphast pattern, with a 
sole, broad enough to support the 
foot, having an inward twist to al- 
low room for the great toe. In advanced cases the inner 
side is built up after the method of Thomas. 
Meantime the foot is manipulated daily to stretch the 
contracted and shortened tissues, until every part is free 
and supple. Voluntary exercises are also made use of to 
strengthen the weakened muscles. And lastly the patient 
is re-educated in the proper manner of walking and sup- 
porting weights (Fig. 99). The feet should be parallel as 
COCAINE. Since the appearance of this Handbook 
cocaine has maintained its place as a local anaesthetic, 
and has gained for itself quite an extensive field of use- 
fulness. It has been incorporated into the Pharmacopoeia 
of all countries. Since attention has been directed 
toward the anaesthetic properties of cocaine quite a num- 
ber of other bodies have become known that have lo- 
cal anaesthetizing effects, as for instance, erythrophleine, 
menthol, and other compounds, part of which belong 
to the groups of glycocides or resins. All these bodies 
have that in common, that they act as intense irritants 
upon the terminations of the sensitive nerves, and that 
after a longer or shorter period of irritation a period of 
paralysis (anaesthesia) follows, which is the case also with 
cocaine. In most of these drugs the primary irritation is 
very much stronger than in cocaine, a circumstance 
which did not permit their substitution for it. Some of 
the alleged rivals of cocaine have been disclosed as 
downright deceptions, as for instance stenocarpine (mixt- 
ure of cocaine and atropine). With the increased 
knowledge regarding the chemical constitution of cocaine 
(see under that heading), the time does not seem dis- 
tant when cocaine, or some body of similar constitution 
and physiological action, will be synthetically manufac- 
tured for practical use, as in fact has been done already 
in the laboratory. 
Mode of Manufacture and Statistics.-Great 
progress has been made in the manufacture of cocaine, 
which has led to a remarkable reduction of its cost, the 
market price at present (end of 1892) being $6 the 
ounce. The table below (for which the writer is in- 
debted to the courtesy of Messrs. McKesson & Robbins) 
shows the following decrease in price : 
Autumn of 1884 (abnormally high price).. .$3.00 per grain. 
End of 1884 50 " 
1885 30 " 
End of 1885 05 " 
1886 05 " 
1887 7.50 per ounce. 
1888 7.00 " 
1889 6.00 " 
1890 5.50 " 
1891 8.00 " 
1892,... 8.00 " 
End of 1892 6.00 " 
The former process was essentially the one used by 
Niemann, only somewhat modified. The alkaloid was 
extracted from the leaves by means of acidulated alcohol, 
much ether being used in the further steps of the pro- 
cess, as described in Vol. II., p. 217, of this Handbook. 
The main improvement consists in dispensing entirely 
with the alcohol and using ether in very moderate quan- 
tity only. Cocaine, like other alkaloids, is soluble in 
kerosene oil, while its salts are not soluble in it. If 
ground leaves are moistened with a five per cent, solution 
of sulphuric acid, percolated, and the percolate is agi- 
tated with kerosene and an excess of carbonate of sodium, 
the alkaloid is held in solution by the kerosene, compar- 
atively free from other matter. It can be washed out of 
the kerosene by means of acidulated water. For pur- 
poses of purifying it is precipitated again by carbonate, 
of sodium, then dissolved in ether, from which it is 
washed out by dilute hydrochloric acid as the hydro- 
chlorate salt. This process has also been improved upon 
by doing away with the extraction from the leaves by 
means of acidulated water. The ground coca leaves 
are moistened with a solution of carbonate of sodium, 
and the alkaloid directly extracted from them by perco- 
lating with kerosene. From this kerosene solution the 
alkaloid is washed out by means of weak sulphuric acid, 
and for purposes of purifying precipitated again by car- 
bonate of sodium in the presence of a small portion of 
kerosene to dissolve it again. This process of precipitat- 
ing and redissolving is repeated several times. At last 
the crystals of the crude alkaloid are dissolved in dilute 
acid and freed from kerosene by means of ether; then 
the alkaloid is precipitated again in the presence of ether, 
the clear ethereal solution (of the alkaloid hydrate) shaken 
out with hydrochloric acid, and the solution of the hy- 
Fig. 98. - Whitman's 
brace, as seen from 
below, when applied 
to the foot. 
Fig. 99.-A. Improper position of the feet in walking. B. Proper posi- 
tion of the feet in walking. Each step is a gymnastic exercise. 
to their inner borders, so that the weight will not be un- 
duly thrown to the inner side of the foot, as is the case 
when the toes are far apart; and by walking over the toes 
instead of over the inner side of the foot, each step be- 
comes a beneficial gymnastic exercise. 
John Ridlon. 
175 Cocaine. 
Cocaine. 
BEFEBENCE HANDBOOK OF THE MEDICAL SCIENCES. 
drochlorate evaporated to dryness.* At first all co- 
caine made was extracted from the leaves in Europe and 
in this country. The coca-leaves have to be trans- 
ported a long way from the mountain range of Peru and 
Bolivia, on the backs of mules, and farther by railway 
to the Chilean and Peruvian ports. The combined in- 
fluences of heat and moisture to which the leaves were 
exposed during this transportation robbed them of part 
of the amount of the alkaloid they originally contained. 
This circumstance, and the considerable expense of 
transportation of the dead weight, have caused the man- 
ufacture of cocaine to be transferred to the source of 
supply in the Bolivian Mountains, where various manu- 
factories have been established to turn out the crude 
alkaloid. This is exported to Europe and to this coun- 
try in cakes of several inches in diameter and half an 
inch in thickness. It is then refined and converted into 
the hydrochlorate by the process described above. The 
present import duty, discriminating against the crude 
alkaloid (twenty-five per cent, ad valorem against fifty 
cents a pound on the salt), has hampered American man- 
ufacturers, so that almost all cocaine here consumed is 
imported from Germany, where it is manufactured partly 
from leaves, partly from the crude alkaloid. A small 
quantity is made here from leaves, of which 90,000 
pounds are imported per annum. Cocaine salts are used 
in the United States to the amount of 100,000 ounces 
(3,125 kilogrammes) a year (estimate of Messrs. McKes- 
son & Bobbins; Dr. Squibb puts the figure at 1,800 
kilogrammes, giving this as a crude computation based 
on the output of his own factory). 
The annual harvest of coca-leaves in South America 
is estimated to be 10,000,000 kilogrammes, of which 
about five per cent, is exported, either in the natural 
condition or in that of the crude alkaloid, extracted in the 
Peruvian manufactories. The variety best suited for the 
extraction of cocaine is the great-leaved species cultivated 
in Southern Peru (Huanuco, Huanta, Santa Anna), con- 
taining about 0.5 per cent, of the alkaloid. Bolivia fur- 
nishes not very considerable quantities of coca, as the 
price is fifty to eighty per cent, higher than for the 
Peruvian. The so-called Trujillo coca, from Northern 
Peru, is not well suited for the manufacture of cocaine, 
as it contains hardly half as much of this alkaloid as the 
Southern plant, but great quantities of other alkaloids, 
which make the isolation of cocaine very difficult. 
Experiments to raise coca elsewhere have been made 
in the Government of Madras, in the tea-plantations of 
Bengal, in the Island of Ceylon, on Mount Cafe, at San 
Thome in Africa, and in the cinchona plantations of 
Java. The latter ones gave the best results, and the 
coca exported from Java is very similar to Trujillo 
coca (Northern Peru) in aspect and in the amount of 
alkaloid contained. It contains 0.2 per cent, cocaine, 
besides a quantity of other alkaloids that hamper manu- 
facturing. (Information furnished by the firm of C. F. 
Boehringer u. Sohne, Mannheim, Germany.) 
Tests of Purity.-Madagan's test consists in dissolv- 
ing one grain hydrochlorate of cocaine in two ounces dis- 
tilled water and adding one to two drops of ammonia 
solution. If free from amorphous cocaine, on stirring 
the ammoniated solution a few seconds cocaine hydrate 
separates out in crystalline form and falls to the bottom, 
leaving the supernatant solution clear and free from 
opalescence. If at all milky, the presence of amorphous 
cocaine is indicated. (Copied from The [London] Chemist 
and Druggist, March 5, 1887, p. 297.) 
Permanganate Test (Garthier).-When a solution of 
two centigrammes to half a gramme of hydrochlorate of 
cocaine is mixed with one drop of a two per cent, solu- 
tion of permanganate of potash, the resulting fluid 
must assume a red color and remain transparent. On a 
subsequent addition, drop by drop, of the permanganate 
solution, there must appear a red precipitate consisting 
(SUPPLEMENT.) 
of permanganate of cocaine, which becomes brown only 
after heating and that without evolving an odor of bitter 
almonds. When the addition of one drop of the perman- 
ganate solution brings about a brown discoloration or 
brown precipitate, or when on heating the mixture there 
appears an odor of bitter almonds, the preparation is 
impure and unfit for use. (Copied from the London 
Med. Record, 1889.) 
Chemical Constitution.-Cocaine, if heated with 
hydrochloric acid splits into benzoic acid, methyl alcohol, 
and a new alkaloid, ecgonine (C9Hi6NO3), of' not well 
pronounced physiological action. Becent investigations 
have shed light on the manner in which these parts are ar- 
ranged in the cocaine molecule and on the constitution of 
ecgonine (Einhorn, Berichte der chem. Gesellschaft, xxi., 
p. 3029, 3441, vol. xxii.; Stoehr, ibid.). As was to be ex- 
pected, there is an intimate connection between the con- 
stitution of the cocaine molecule and its physiological 
action. There exist quite a series of bodies similarly 
constituted, with analogous physiological action, facts 
that have been studied by Ehrlich (Deutsche med. Woch- 
enschr., 1891, No. 32, p. 717) and E. Poulsson (" Bei- 
trage zur Kenntniss der pharmakologischen Gruppe des 
Cocain," Arch. f. expenmentelle Pathologic u. Pharmako- 
logie, vol. xxvii., p. 301). In ecgonine a group called 
Cocayle, (CH3)NC5H7, whose constitution is methyltetra- 
hydropyridine, is combined with the radical of oxypropi- 
onic acid, thus: 
Place for the benzoyl 
radical. 
Place for the 
methyl. 
Cocaylc (Methyltetrahydro- 
pyridine). 
Oxypropionic acid. 
Ecgonine. 
The side chain in this molecule (oxypropionic acid) con- 
tains a hydroxyl and a carboxyl, with either of which 
different radicals can unite. 
Whenever an alcohol radical is affixed to the car- 
boxyl group, and at the same time an acid radical enters 
the other replaceable hydroxyl group, the resulting 
body in chemical and physiological action closely resem- 
bles cocaine. In this latter methyl (C1I3) and benzoyl 
(C6H6CO?) are the two radicals entering into the oxy- 
propionic rest. The coca-leaves contain various cocaines 
with radicals other than those given above, and by chem- 
ical synthesis a great number of them have been formed. 
So the methyl of the ordinary cocaine has been replaced 
by ethyl, giving rise to coca-ethyl and the benzoyl has 
been substituted by the radicals of baldrian-, cinnamon-, 
or phenyl-acetic acid, thus leading to another series of 
homologous alkaloids. But this does not exhaust the 
possibilities for the formation of bodies similarly consti- 
tuted and with similar physiological action. The radical 
of the oxypropionic acid contained in the ecgonine mole- 
cule can be replaced by other acid radicals, which of 
course must contain one carboxyl and one hydroxyl 
group. . In fact, by oxidizing ecgonin, Einhorn has suc- 
ceeded in composing a body which contains oxyacetic 
acid instead of oxypropionic acid. By introducing the 
benzoyl and the ethyl in this new combination a body 
is obtained which is isomeric with cocaine and possesses 
highly anaesthetic qualities, at the same time surpassing 
cocaine in poisonous effects, as Ehrlich has found. Ex- 
periments with a number of these cocaines and their 
components have shown that the alcohol radical above 
mentioned is essential for the anaesthetic effect, and that 
with its removal from the cocaine molecule the anaes- 
thetizing and poisonous properties disappear (Pouls- 
son, loco citato'). 
* For the information regarding the actual process of manufacture I 
am indebted to Dr. E. R. Squibb's personal communication: it is 
drawn partly also from his journal Ephemeris. The process above de- 
scribed applies only to his factory, but most likely a similar one is em- 
ployed in other establishments. 
176 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Cocaine, 
Cocaine. 
Elementary Action oe Cocaine.-Our knowledge of 
the manner in which cocaine acts as a local anaesthetic has 
been materially promoted by a number of investigations 
on its action on various living cells and tissues. That 
the local anaemia observed upon local application can- 
not be the cause of the anaesthesia, as several authors 
have asserted, must be apparent to everybody, who ap- 
plying it to the eye notices that the anesthesia of the 
cornea precedes the anaemia of the conjunctiva. Several 
facts, as for instance the slight cloudiness and the dotted 
erosions of the corneal epithelium after repeated applica- 
tions of cocaine, pointed to this drug being a general pro- 
toplasma poison, first stimulating and then mortifying 
it. The writer, who in his first experiments noticed the 
haziness of the corneal epithelium, was inclined to con- 
sider it due to evaporation, in consequence of the arrested 
secretion of tears and diminished winking of the lids, 
brought on by the local anaesthesia. When, with the in- 
creasing general use of cocaine as an anaesthetic, reports 
began to come in about opacities of the cornea occurring 
after operations in which cocaine and simultaneously 
solutions of corrosive sublimate had been used (Herschel, 
Bunge), the writer set out to determine this question by 
experiment. Wuerdinger, of Munich (" Experimentelle 
und anatomische Untersuchungen fiber die Wirkung des 
Cocain auf die Cornea," Klinische Monatshefte fur Augen- 
heilkunde, 1886), had come by his experiments and his 
pathological researches to the conclusion that the haze 
was due to dryness of the cornea. In 1886, while in 
Utrecht, the writer conducted a series of experiments 
on rabbits, the results of which, however, were never 
published. Cocaine was instilled into the rabbit's eye 
and the lids carefully closed over it with an artery for- 
ceps, while the other eye was kept open by means of an 
eye speculum. The eye that had been kept open (and 
into which no cocaine had been instilled) showed drying 
and loss of epithelium after several minutes, while the 
cocainized eye showed that by carefully protecting it, 
the hazy appearance and loss of epithelium in it had been 
reduced to a minimum. Evidently, therefore, evapora- 
tion was a factor to be taken into account. [Other 
experiments established the evidence that the corneal 
epithelium is especially prone, when cocainized, to be- 
come hazy by washing the eye with solutions of corro- 
sive sublimate (of the concentration as used in eye sur- 
gery, 1 to 4,000-5,000).] But however careful or how- 
ever often the experiment was made, repeated instillations 
of cocaine would always produce some haziness and some 
dotted defects of the epithelium-a condition, though, 
that would return to the normal within a few hours. It 
was nearly certain, therefore, that cocaine, as such, af- 
fects epithelial cells in their vitality. This probability 
became stronger yet by comparison with the action of 
erythrophleine, an alkaloid extracted from the bark of 
erythrophlaum guineense. This alkaloid, like a number 
of others, has very strong anaesthetic properties, even 
stronger than cocaine. The irritation preceding the 
anaesthesia is much more marked and of longer duration 
than in the case of cocaine, and correspondingly the in- 
road upon the vitality of epithelium and corneal tissue is 
a more vehement one. Two drops of a one-eighth per 
cent, solution instilled into the writer's eye (Koller, 
Wiener medicinische Wochenschrift, 1888, No. 6, and Chi- 
cago Medical Journal and Examiner, April of the same 
year) proved to be sufficient to set up an irritation of 
thirty-five to forty minutes' duration and to produce a 
distinctly visible opacity of the cornea, which took two 
days to disappear entirely. (This property, together with 
the highly poisonous action of the drug, has prevented 
the practical use of it recommended by Lewin.*) The 
initial irritation, the ensuing anaesthesia, and the simul- 
taneous clouding of the epithelium are all proportionate 
in the action of the two drugs and strongly point toward 
an intimate, or rather a causal, connection. 
Extensive researches on the action of cocaine upon the 
vital manifestations of various kinds of cell-elements and 
low animals instituted by Albertoni (Pietro Albertoni, 
(SUPPLEMENT.) 
" Azione della cocaina sulla contractilita del Protoplas- 
ma," Ann. d. Chim., 1890, p. 305) have shown that cocaine 
is a protoplasma poison. According to its concentration 
and the duration of its action it stimulates or paralyzes the 
protoplasma in its vital functions. For instance a0.25 per 
cent, solution applied to the palate of a frog stimulates the 
activity of the ciliated epithelium, so that particles of coal- 
dust are moved along with four times the ordinary veloc- 
ity, while two per cent, solutions slacken the velocity to 
the fourth or sixth part of the normal. Grubs of butter- 
flies and amoebae in a physiological solution of CINa stop 
their movements upon the addition of one-half to two 
per cent, cocaine, and so do the large white blood-cells of 
astacus. Spermatozoids and other ciliated cells stop their 
movements in strong solutions of cocaine or when sub- 
jected to the protracted action of weaker ones. The mu- 
cous glands in the membrana nictitans of frogs lose their 
ability to respond to electrical stimulation. The effects, 
of the electrical current observed in pieces of muscle and 
nerve disappear soon under the influence of cocaine. 
So the experiments of Albertoni have established beyond 
a doubt the view, which was the most reasonable and 
probable one, that the local anaesthesia is the effect of a 
paralyzing influence upon the ends of the sensitive 
nerves. A pathological supplement to this theory is the' 
fact that nerve-fibres in five per cent, solution of cocaine 
look less bright than they do in 0.6 per cent. CINa solu- 
tion (Alms, " Wirkung des Cocain auf die peripheren Ner- 
ven,'' Du Bois Reymond's Archivfur Physiologic, 1886). A 
peculiarly characteristic and deleterious effect is exercised 
by cocaine upon the cells of the liver. The livers of mice, 
which Ehrlich (" Studien in der Cocainreihe," Deutsche 
Med. Wochenschr., No. 32, p. 717) had fed with cocaine 
(0.01 to 0.02 to the " cake," Prince Albert cracker), and 
which had perished within a few days under this diet 
showed considerable increase in volume, and their macro- 
scopic appearance reminded one of the stuffed-goose liver. 
The microscopical examination showed vacuolar degen- 
eration of the cells ; the latter were enlarged, contained 
many vacuoles, and very small remains of protoplasma 
about the nucleus. No glycogen was to be found in the 
cells, nor in fact in the whole liver. The hepatic con- 
nective-tissue showed fatty degeneration and "coagula- 
tions-nekrose ; " the stellated cells and the endothelia 
of the blood-vessels showed also fatty degeneration. 
Action Upon Nerve-tissue.-The action of cocaine 
upon nerve-tissue, therefore, cannot be considered as be- 
ing of a specific kind, but is rather identical with the 
general action of this drug upon protoplasma, the only 
difference being that the nerve-tissue responds more 
readily and more effectively to outside influences. In 
accordance with this view one would expect that all 
nerve-tissue would be similarly affected by it, although 
the action upon the ends of the sensitive nerves is most 
marked and constitutes the most striking property of 
cocaine and its main claim as a valuable therapeutic 
agent. 
In order to test the action of cocaine on other than 
peripheral sensory nerves, the writer devised a series of 
experiments, with the purpose of deciding the question 
whether the terminal apparatus of the higher senses could 
also be paralyzed by cocaine. The field of experiment 
selected was the retina. In two cases in which an enu- 
cleation of the eyeball had to be performed, perception 
and projection of light being still present, cocaine was 
injected into the orbita by means of a hypodermic 
syringe, as near to the eyeball as possible. In one of 
these cases it was apparent that the perception of light 
was affected in that part of the field of vision which cor- 
responded to the place of injection. Continued injection 
in other places around the eyeball blinded other corre- 
sponding parts of the field, until after some time nearly all 
perception of light was lost. The other case did not give 
any satisfactory result, on account of which these exper- 
iments were not published. (The experiments were made 
in Professor Snellen's Eye Clinic, in Utrecht, in 1887). 
Experiments on dogs, undertaken in common with Dr. 
H. Zwaardemaker, in Utrecht, failed, on account of the 
toxic effect of the doses necessary. Later on, Dr. II. 
* Paper read before the Berlin Med. Sec., January 11, 1888. 
177 Cocaine. 
Cocaine, 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Zwaardemaker (" Cocain-Anosmie, Fortschritte der Medi- 
cin 1. Juli, 1889") tested the action of cocaine on the 
sense of smell, and by means of the olfactometer, exam- 
amined the way in which the smell was affected when 
cocaine powder of five, ten, and twenty per cent., was 
blown up the nose. He found that if sufficiently ab- 
sorbed by the mucous membrane of the upper parts of 
the nose, it produces anosmia, preceded by hyperses- 
thesia of smell. The various qualities of smell were 
equally affected. 
Tumass ("fiber die Wirkung des salzsauern Cocainsauf 
die Psychomotorischen Centren." Arch. f. Exper. Path, 
u. Pharmakoi., 1886-7, xxii., 107-126) has shown that 
cocaine has the same paralyzing influence upon the gray 
matter of the cerebral cortex. He experimented on dogs, 
applying from 0.05 per cent, to 4 per cent, solutions to the 
psychomotor centres of the cortex, which had been laid 
bare by trephining. The result was that, after cocaine 
application, stronger currents were necessary to produce 
just noticeable contraction of the corresponding muscles. 
The reduction of irritability lasted fifteen minutes, 
whereupon it slowly increased, but did not reach the nor- 
mal within forty-five minutes. The trunks of thick sen- 
sory nerves were affected in the same way when mois- 
tened with a solution of cocaine ; they could be cut with- 
out the slightest manifestation of pain. Other observers 
obtained the same results. The experiments of Gold- 
scheider (" Wirkung des Cocain, etc., auf die Sinnesner- 
ven der Haut.," Wochenschr f. prakt. Dermatologic, 1886, 
2), Kochs ("Wirkung des Cocain auf Freipraeparirte Ner- 
ven.," Centralblatt f. Klin. Med., 1886, No. 33), and Alms 
(" Wirkung des Cocain auf die peripheren Nerven.," Du 
Bois Reymond's Arch. f. Physiologic, 1886), show that the 
application of cocaine to the trunk of a sensory nerve pro- 
duces peripheral anaesthesia, so that the cocainized part 
of the nerve seems to constitute an impediment for con- 
duction. The same experience can frequently be made, 
when cocaine is applied subcutaneously for surgical pur- 
poses, and the place of application is near a sensory nerve- 
trunk. The action of cocaine upon motor nerve-trunks 
is essentially the same, although the conditions are here 
so complicated as to make that fact less evident than in 
the case of sensory nerves. 
If a cocaine solution is applied to the trunk of a mixed 
nerve of a frog, the limb controlled by that nerve seems 
paralyzed both in its sensory and motor functions; but 
upon further examination it is found that the motor par- 
alysis is only a consequence of the muscular and cutane- 
ous anaesthesia (Vulpian " Comptes Rendus," xcix., p. 
887, and Alms, 1. c.), for reflex-action can be produced by 
irritation of other points of the body in the apparently 
paralyzed muscles. Nevertheless, irritation above the 
cocainized point (experiments made by Alms, on rabbits) 
discloses a marked decrease in irritability, so that co- 
caine acts on motor the same way as on sensory nerves ; 
that is to say, it impedes the conduction of a stimulus. 
The paralyzing action on the terminal apparatus of the 
motor nerves has been demonstrated by Alms. If cocaine 
is injected into the arteria iliaca communis of one side in 
a frog, precautions being taken at the same time to pre- 
vent the cocaine from passing into the general circula- 
tion, the muscles of the leg of that side become com- 
pletely paralyzed ; faradic stimulation of the sciatic does 
not cause contraction, while the muscles retain their di- 
rect irritability. Cocaine applied in this way has exactly 
the same effect as curare has when introduced into the 
blood-circulation. 
The Action of Cocaine upon the Organism de- 
pends of course upon this nerve-stimulating and par- 
alyzing property. A number of more recent investiga- 
tions of the physiological action of cocaine have brought 
to light new facts of great importance. To be complete, 
the following summing up may be in place : 
The central nervous system of all animals is paralyzed 
by cocaine in sufficient doses after a period of excitation, 
which latter in warm blooded animals is characterized 
by general convulsions, while in cold blooded animals 
they are absent. The convulsions are of a general charac- 
ter and of the type of tetanus, and opisthotonus ; they are 
(SUPPLEMENT.) 
certainly of central origin (not reflex-convulsions, as they 
occur at a time when the animals no longer react under 
the strongest stimulants) and their seat is most likely the 
medulla oblongata (Anrep, Tumass). The animals die 
most frequently during these convulsions by suffocation 
due to tetanus of the respiratory muscles-incidentally 
as it were, for, if they survive the convulsions, finally 
paralysis of the entire nervous system sets in, sensibility 
is lost, reflexes disappear, respiration ceases, the heart 
stops beating. After very large doses of cocaine Ibis 
paralysis is developed directly without the intervention 
of convulsions. [According to the statements of Mosso 
Arch. f. Experim. Pathologic u. Pharmakologie, xxiii., 
3-4, 1887), 0.005 per kilogram will sometimes produce 
general symptoms of poisoning, xyhile he puts the fatal 
dose at 0.03 per kilogram. The fatal dose for men 
is about half that amount.] Small doses, 0.03-0.05 
-0.1, produce a decided enhancement of the psychi- 
cal functions, euphoria, and increased capacity for men- 
tal and physical work, as shown by the experiments of 
Freud (" Beitrag zur Kenntniss der Cocawirkung." 
Wiener medic. Wochenschr., 1885, No. 5), and many other 
observers with whom the writer, from his own observa- 
tions, fully agrees. This effect is most likely due to stim- 
ulation of the gray cortical matter. The powerful effect 
large (but not toxic) doses have in altering the psychical 
functions (hallucinations, deliria, irresistible impulse to 
move) is too well known, from Anrep's dramatic descrip- 
tion of his experiments on dogs, to be repeated. It will be 
partly described under the heading, Accidental Poisoning. 
The exciting effect of large doses is not confined to the 
cortex. It includes the great subcortical ganglia, the cere- 
bellum, the medulla oblongata, and the spinal cord, as is 
evident from the forced movements, the vertigo, the con- 
vulsions, and the circulatory and respiratory phenomena. 
Eye.-The action of cocaine, introduced into the gen- 
eral' circulation, upon this organ is very similar to its 
action when applied locally; the pupil is dilated, the eye- 
ball protudes, the eye is opened wider,-symptoms due to 
irritation of the sympathetic nerve. We must look for the 
seat of its action upon the sympathetic nerve (when intro- 
duced into the general circulation) in the nuclei of the 
sympathetic in the cord and medulla, for if the sympath- 
etics is severed in dogs after 0.1 cocaine has been in jected 
into the vena saphena, the above symptoms do not appear 
on the corresponding side (" G. N. Durdufi, zur physiol- 
ogischen Wirkung des Cocain." Deutsche med. Wochen- 
schr.. 1887, xiii., 172-174). The dilatation of the pupil after 
general, just as after local application, must be ascribed to 
the contraction of the iris-arteries, as there does not exist 
another dilater of the pupil in the human eye. 
Respiration.-Cocaine always accelerates the respira- 
tion by stimulating the respiratory centrum. Large doses 
produce very frequent dyspnoic breathing, increasing to 
tetanus of the respiratory muscles. Fatal doses finally 
paralyze respiration. 
Circulation.-In small and medium doses cocaine 
increases the frequency of the heart-beat, small doses ren- 
dering the contraction at the same time more powerful 
(Mosso). The increased frequency is most likely due to 
stimulation of the accelerating nerves of the heart (Dur- 
dufi). Large doses finally paralyze the heart (the action 
is different in frogs, the frequency being diminished in- 
stead of being decreased). 
Vary peculiar and characteristic is the action of cocaine 
upon the blood-vessels. Local application has a powerful 
constringent effect upon the small blood-vessels, making 
the tissue affected almost anaemic,as we can observe every 
day when applying cocaine to the nose or to the eye. 
This action upon the blood-vessels is evidently due to a 
stimulating effect of cocaine upon the nerves af the 
smooth muscular fibres. The contraction resulting is of 
long duration (several hours) and is followed by a relaxa- 
tion. [Again here we find a difference in frogs. Local 
application of even weak solutions (1 : 4000) to the frog's 
tongue, produces considerable dilatation of the blood- 
vessels.] Introduced into the circulation, cocaine has 
the same constricting action upon the blood-vessels, 
and this evidently by means of acting upon the cen 
178 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Cocaine. 
Cocaine. 
ties of the nerves of blood-vessels, as, for instance, is 
shown by the dilatation of the pupil (anaemia of the iris) 
not appearing if the sympathetic nerve has been severed. 
The pressure in the arteries is increased by medium doses 
in consequence of constriction of the small blood-vessels. 
Fatal doses lower the pressure accordingly. 
The, secretion, of urine is materially increased by medi- 
um doses (even to the double of the normal) just on ac- 
count of the increase of pressure in the arteries; very 
large doses diminish and finally stop urine secretion 
(Bignon : " Des Proprietes toxiques de la Cocaine," Bul- 
let. gen. de Therap, 1886, ii.). 
Intestines.-Peristatic movements are increased ; very 
large doses paralyze the intestines, which at the same 
time become very hyperaemic. 
Secretion of saliva and perspiration stops after local 
application, and also when the drug acts by way of the 
circulation, most likely on account of the paralysis of the 
secreting epithelium, and constriction of the blood-ves- 
sels. 
Practical Use.-Eye Surgery.-Cocaine is used for a 
threefold purpose : As an anodyne in painful affections ; 
as a local anaesthetic in eye operations; as a dilater of 
the pupil. 
Owing to the short duration of the cocaine anaesthesia 
(about fifteen to twenty minutes), its use as an anodyne is 
a limited one. Naturally it would be most useful in pains 
caused by superficial erosions, or ulcers of the cornea. The 
weakening effect upon the vitality of cells (as shown in 
the paragraphs devoted to the consideration of its action 
on cell elements) does not make a frequently repeated and 
prolonged action desirable. It is found very useful in 
the examination of an eye, where pain, photophobia, and 
lachrymation would otherwise render such an examina- 
tion almost impossible, as in conjunctival or corneal 
troubles, cases of superficially seated foreign bodies, 
scalding by chemicals, etc. In pains which might pos- 
sibly be of glaucomatous origin the use of cocaine should 
be carefully avoided, as it has repeatedly been found to 
hasten the development of a glaucomatous attack 
previously threatened (Javal). Supra- or infra-orbital 
neuralgia can frequently be successfully combated by 
hypodermic injection. The use of cocaine as a local 
anaesthetic in eye operations is a very extended one, and 
it has reduced the employment of general anaesthesia by 
ether or chloroform to a minimum. The objections 
raised against it in the beginning, of producing sometimes 
opacities of the cornea after cataract operations, have 
been silenced by its more judicious application, by pre- 
vention of evaporation, and by avoidance of the too free 
use of sublimate or other coagulating antiseptics. An- 
other objection raised by several writers, that the cocaine 
anaesthesia renders the eye so hypotonic that the expres- 
sion in operation for cataract becomes difficult, has not 
been heard of in the more recent literature. On the 
contrary, many operators who follow the trend of the 
time by practising cataract extraction without iridec- 
tomy, consider the revival of this more perfect method as 
partly due to the cocaine anaesthesia, the latter being 
instrumental in preventing prolapse of the iris. While 
operations on the conjunctiva and on the cornea can al- 
ways be made perfectly painless by instillation of cocaine 
solutions, such operations in which the iris is touched or 
cut, as iridectomies and operations for cataract, cannot 
always be rendered perfectly painless by instillation, 
owing to the difficulty of making the iris sufficiently 
anaesthetic. In a number of cases one does succeed, in 
another number one does not. The writer has found the 
following to be the most effective method of instillation : 
Begin to instil a four per cent, solution, twenty to thirty 
minutes before the operation (time necessary to reach 
the iris), instilling at intervals of five minutes each. 
During the whole time the eye is kept closed to prevent 
evaporation. The iris can, with certainty, be rendered 
anaesthetic by instilling cocaine into the anterior chamber 
after the corneal section. A David's spoon is inserted 
through the corneal wound into the anterior chamber 
and a drop of cocaine allowed to run into it along the 
furrow of the instrument; the spoon is withdrawn, the 
(SUPPLEMENT.) 
speculum removed, and the eye closed for two to three 
minutes. Although this proceeding complicates the 
operation it has its justification in the great importance 
of complete anaesthesia of the iris for the safety of the 
operation. If prolapse of the iris occurs right after the 
corneal section some of the advantage of this procedure 
is lost. In a proposed iridectomy it is therefore best not 
to allow the whole of the aqueous humor to escape dur- 
ing the corneal section. For operations on the tendons 
and muscles (tenotomies and advancements) instillation 
is never sufficient for a complete anaesthesia, and there- 
fore, as far back as 1885, the writer resorted to subcon- 
junctival injections in these operations. He proceeds 
as follows : After repeated instillation of a four per cent, 
solution, to make the conjunctiva anaesthetic, a speculum 
is inserted, and, by means of a mouse-toothed forceps, a 
fold of the conjunctiva at the point of operation is seized. 
The needle of a hypodermic syringe is inserted into it, 
if possible, as deeply as Tenon's capsule and a few drops 
of a two per cent, solution are injected. Then the eye 
is closed again after removal of the speculum, and the 
artificial oedema of the conjunctiva is given time to dis- 
appear, which it does in five to ten minutes, aided by 
occasional slight rubbing. In this way the operation 
can be performed absolutely without pain. The cocaine 
solution is made aseptic by filtering and boiling, which 
latter does not affect its efficiency. The syringe is 
cleaned with alcohol and rinsed with a two per cent, 
carbolic or three per cent, boracic solution or sterilized 
water. Recently the writer has used these subconjunc- 
tival injections very successfully in cataract operations 
and in iridectomies, following a suggestion made to him by 
Professor Snellen, of Utrecht, in a private communica- 
tion (see also Snellen, " Sur 1'Operation de la Cataracte," 
Annales d'Oculistique, Janvier, 1892). The proceeding 
is the same as that described for squint operations, the 
point of injection to be selected near the place of in- 
tended corneal section. 
The pupil-dilating property of cocaine is of great value 
in ophthalmoscopy. While the dilatation is sufficient in 
the dark chamber to allow a satisfactory examination, it 
does not have the blinding effect of belladonna, the 
pupil all the time responding to light. This is due to 
the fact that cocaine dilates the pupil by constricting 
the blood-vessels of the iris, but leaves the sphincter 
intact. Besides, the accommodation is hardly interfered 
with. The pupil-dilating power of cocaine, if combined 
with that of atropine, is invaluable in cases of iritis. The 
mydriatic effect of this combination is stronger than that 
of any other drug or any combination of drugs ; it coun- 
teracts both forces that contract the pupil-the sphincter 
and the blood-vessels. (Hyperaemia of the iris tends to 
contract the pupil by stretching the tortuous course of 
the iris arteries, while the blood-vessels, when empty, re- 
turn to their tortuous course and so dilate the pupil.) 
The anaemia of the blood-vessels is a strong check to 
the inflammation, the pain ceasing mostly after a few 
instillations, and the duration of treatment being greatly 
shortened. The writer uses a mixture of equal parts of 
a one per cent, solution of sulphate of atropine and a 
five per cent, solution of hydrochlorate of cocaine ; at 
first he instils every ten minutes until the pupil is dilated 
(three to four instillations necessary), then only three 
times a day. The combination of the two drugs is also 
efficient in cases of cyclitis. 
Bhinology and Laryngology.-In the examination 
and treatment of the nasal cavities cocaine has an exten- 
sive field of usefulness. By its power of constricting the 
blood-vessels the mucous membrane recedes and inspec- 
tion of the posterior parts is facilitated; in chronic ca- 
tarrh with hypertrophy a proper inspection without its 
help would be impossible. Medicated applications and 
the actual cautery or caustics can be employed painlessly. 
In reflex neuroses starting from the nose the exact local- 
ity of the trouble can be detected, inasmuch as by appli- 
cation of cocaine to the starting-point the patient is tem- 
porarily relieved (asthma, mimic spasm, etc.). In hay 
fever it affords relief but has no curative power. Pos- 
terior rhinoscopy is facilitated by checking the reflex 
179 Cocaine. 
Cocaine. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
action of the soft palate and the tedious practising of the 
patient is done away with. The solutions are applied 
either as a spray by means of an atomizer or with a cot- 
ton wad on the point of a probe. For spraying, only weak 
solutions (two per cent.) should be used, in graduated bot- 
tles, so that the quantity used is known, to avoid the possi- 
bility of poisoning. Weak solutions applied repeatedly at 
intervals of five minutes will accomplish the same result 
as strong ones ; the first application constricts the blood- 
vessels and the following ones act more strongly on the 
anaemic membrane, while at the same time a too rapid 
absorption, with its poisonous effects, is prevented. For 
application with brush or cotton stronger solutions (five, 
ten, or fifteen per cent.) may be used. Nasal surgery has 
been greatly promoted by the use of cocaine. Operations 
on the septum and the turbinated bones can frequently 
be performed painlessly, although not always so. Laryn- 
gological examination and operation is made easier by 
stopping reflex action of pharynx and larynx ; the prac- 
tising of the patient is done away with. For making the 
vocal cords anaesthetic very strong solutions (twenty per 
cent.) are required ; they are applied with brush or cotton. 
Otology.-Comparatively little advantage has been 
brought to otology by the use of cocaine. The drum- 
head (covered with epidermis) can hardly be rendered 
completely anaesthetic, but the sensibility can be lessened 
by repeated application of a warmed fifteen to twenty per 
cent, solution (Hedinger). In operations in the tympanic 
cavity more can be expected from its anaesthetic effects, 
although, only if the operation is limited to the mucous 
membrane (Kretschmann: "Communication about the 
Experiences made in Schwartze's Clinic," Arch. f. Ohren- 
heilk., xxiii., 4,1886). Catheterization of the Eustachian 
tube is facilitated and made painless ; the air penetrates 
in broader current into the tympanic cavity. Hedinger 
(Wurtemberg. Corr. Blatt., Ivii., 7, 1887) relates favora- 
ble results in cases of inflammation of the middle ear. 
A few drops of a two to four per cent, solution blown 
into the Eustachian tube by means of a catheter were in 
most cases sufficient to stop the pain for several hours. 
Kiesselbach (Monatsschnft f. Ohrenheilkunde, xxiii., 9, 
1889) had good success from insufflation of a few drops of 
a four per cent, solution into the Eustachian tube in cases 
of subjective ear-noises. The insufflations were made at 
intervals of three to five days, the strength of the solu- 
tion being increased to ten per cent. The most various 
noises disappeared entirely; most cases improved. 
General Surgery.-The use of cocaine in general sur- 
gery is very extended, and in minor operations has dis- 
placed general anaesthetics and other methods of local 
anaesthesia. It is injected under the skin or into the 
deeper layers of the skin at the site of the operation by 
means of the hypodermic syringe. Careful distribution 
over the field of operation is necessary for full effect. 
Corning's method of " incarceration " is an important im- 
provement on the simple injection (J. Leonard Corning: 
" On the Prolongation of the Anaesthetic Effects of the 
Hydrochlorate of Cocaine when subcutaneously injected 
-an Experimental Study," New York Medical Journal, 
September 19, 1885, and "Local Anaesthesia in General 
Medicine and Surgery," in book form, Appleton & Co., 
1886). A short time is given to the circulation to distrib- 
ute the drug over the field of operation, then exsanguina- 
tion of the limb and application of a tourniquet (especially 
devised apparatus on other parts) keep the solution in 
place. By this way of proceeding, the anaesthetic effect 
can be prolonged indefinitely, while absorption into the 
general circulation and poisonous effects are prevented. 
At present extirpation of small tumors, extraction of 
foreign bodies, amputations of fingers and toes, operation 
for phimosis, operations for ingrown nail, incision of ab- 
scesses and furuncles, are performed under cocaine anaes- 
thesia. Pernice (Deutsche Med. Wochenschr ift,W>W, 14) re- 
ports more than a thousand cases operated in the Polyclinic 
at Halle, where one per cent, solutions were used, which 
were always found sufficient. One to two syringes were 
injected (0.01-0.02), and thus accidents could with cer- 
tainty be avoided. 
In genito-urinary surgery cocaine is extensively used, 
not only for external and internal urethrotomy, but 
also for operations in the bladder (litholapaxy). As the 
unbroken epithelium of the bladder has hardly any 
power of absorbing, enormous quantities have some- 
times been used (1.00-5.00 ! !). However, genito-urinary 
surgery is especially rich in accidental poisoning, the as- 
sumption of an unabraded epithelium not always being 
correct. 
Dentistry.-To make extraction of teeth painless it is 
not sufficient to brush the solution on the gums, as this 
does not make the alveolus anaesthetic. Even injection 
between gum and alveolus in one place only will fre- 
quently fail. All those who report successful anaesthesia 
(George Viau : " De 1'Anesthesie buccale," Paris, 1886 ; 
Bleichsteiner, Congress of Dentistry, Paris) concur in the 
recommendation to inject the solution under the gum in 
several places on the inside and outside of the alveolus. 
A five per cent, solution is sufficient, and not more than 
0.05 cocaine should be used. Even then the number of 
cases where constitutional symptoms occur is large com- 
pared with its application in other branches of surgery. 
Schlenker ("Ueber Cocain als locales Anaestheticum," 
Tageblatt der 61. Vers. deutscher Naturf. und Aerzte, 
Coin, 1889) had three per cent, of graver and five per 
cent, of minor cases of poisoning. Bleichsteiner had col- 
lapse in five to six per cent, of his cases. 
Gynecology.-Apart from the use in minor operations 
on the vulva, vagina, and the cervix, cocaine is especially 
valuable in the treatment of vomiting in pregnancy, va- 
ginismus, and sore nipples. In cases of vomiting in preg- 
nancy it has been found successful where all other medi- 
cation failed, whether administered by the stomach, hypo- 
dermically, or by application to the os or cervical canal 
(Weiss: Prager Med. Wochenschr., 1884, No. 51-0.004 
internally every half-hour ; Phillips : London Lancet, No- 
vember 26,1887). It is scarcely used any more at present 
in obstetrics ; in the first enthusiasm it was recommended 
to alleviate pain in labor. 
Dermatology.-Cocaine does not have any effect if ap- 
plied to the unbroken epithelium. If the latter is macer- 
ated or wanting, solutions or ointments can be used to 
combat itching as in vesicular eczema, especially in the 
itching eczema of the genitals, in painful ulcers, and after 
cauterizing. In different operations on the skin, and be- 
fore cauterizing, the application is the same as described 
under the heading of General Surgery. Touton reports 
painless treatment by electrolysis of warts or moles, if a 
few drops of a five per cent, solution are injected under 
the little tumor (which fact the writer can confirm). It is 
of theoretical interest that cocaine, like other substances, 
can be driven into the skin by the electrical current if 
applied to the positive pole-cataphoretic action of the 
galvanic current. (Wagner : " Ueber eine neue Methode 
Haut Anaesthesie durch Cocain zu erzeugen," Zeitschr. 
fur Therapie, 1886, No. 6). The anaesthesia thus engen- 
dered may be used for superficial operations. 
In general medicine much has been expected from the 
stimulating powers of cocaine upon the physical func- 
tions. However, it does not seem to be extensively used 
for this purpose, perhaps from exaggerated fear of the co- 
caine habit. From the experiments of Freud, Hammond, 
and others it is apparent that it has a decidedly stimulat- 
ing power upon the psychical faculties, and some writers 
report very good results in neurasthenic patients and in 
melancholic depression (0.02-0.03 internally several times 
a day). According to these observers (Freud : " Bemerk- 
ungen fiber Cocainsucht und Cocainfurcht," Wiener Med. 
Wochenschr., xxxvii., No. 28, 1887) the cocaine habit is 
not to be feared, as persons, unless they are addicted to 
the opium habit, can discontinue the use of cocaine with- 
out any symptoms therefrom. Preparations of coca in 
the form of coca wine are extensively advertised and used 
as a nerve stimulant. 
In whooping-cough applications of two to five percent, 
solutions to the tonsils, pharynx, and epiglottis have been 
used with good result (Schuirer : Arch. fur Kinderheil- 
kunde\ Various neuralgias and the shooting pains in lo- 
comotor ataxia are a field for the subcutaneous applica- 
tion of cocaine. In tabes, 0.02-0.03 twice a day is re- 
180 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Cocaine. 
Cocaine. 
ported to have succeeded in cases where morphine did 
not have the desired effect. Cocaine has also been rec- 
ommended in sea-sickness, however with little success. 
Opium Habit.-The recommendation (Freud : Central- 
blatt fur Therapie, July number, 1884) to use cocaine in 
the cure of the opium habit did not meet with general 
approval, on account of the danger of making the sub- 
jects of the opium habit victims of the cocaine habit in 
addition. As Freud (" Bemerkungen fiber Cocainsucht 
and Cocainfurcht," IFr. Med. W., 1887, No. 28) believes, 
cocaine is a very valuable agent to combat the craving for 
morphine and the collapse incidental to the disuse, pro- 
vided the physician absolutely controls the administration. 
Obersteiner considers the use of cocaine admissible if no 
morphine at all is given. He recommends to administer 
it only internally, the first dose 24-48 hours after the last 
dose of morphine, giving about 0.05-0.1 several times a 
day, and not more than 0.5 per day, gradually diminish- 
ing the quantity and stopping the administration on the 
fifth or sixth day. 
Accidental Poisoning.-It is not surprising that a drug 
which came into such rapid and general use in almost all 
branches of medicine and surgery, should have given rise 
to many and even fatal accidents, partly due to lack of 
acquaintance with the drug, and partly due to reckless- 
ness. The history of cocaine poisoning has already de- 
veloped quite a literature. Its more judicious use in re- 
cent years has greatly reduced the frequency of such 
accidents. Cases of slight poisoning, which are the com- 
moner ones, offer the following objective symptoms: 
Pallor, cold perspiration, frequent pulse, dilated pupils; 
subjectively the patients complain of dryness of the throat 
and the lips, a feeling of heaviness in the limbs, weak- 
ness, or even vertigo. This condition does not last long, 
and after a short time (one-half to one hour) complete well- 
being sets in, although no restoratives are used. In an- 
other class of more serious accidents great mental ex- 
citement, with talkativeness, hallucinations, and even 
delirium, can be present. On the other hand, conditions of 
syncope and collapse can prevail. In the gravest cases 
painful dyspnoic breathing, clonic and tonic convulsions 
occur, which can cause death by tetanus of the respiratory 
muscles. Or death can result from paralysis of respira- 
tion and heart without preceding convulsions. Dr. Paul 
Mannheim, under the guidance of Leyden, has made a 
thorough compilation of the accidents hitherto reported in 
medical literature (" Ueber das Cocain und seine Gefahren 
in physiologischer, toxicologischer und therapeutischer 
Beziehung,' Zeitschrift fur klinische Medicin, xviii., 3 
and 4, pag. 380, 1891). The discussion in the Societe de 
Chirurgie de Paris of a fatal case reported by Dr. Paul 
Berger, is also of great interest and rich in information 
(" Empoisonnement mortel produit par 1'injection d'une 
Solution de Chlorhydrate de Cocaine dans la tunique 
vaginale & la suite de la ponction d'une hydrocele," Bul- 
letin et Memoirs de la Soc. de Chir. de Paris, 1889, pp. 751, 
757, 761, 790). 
Mannheim has collected ninety-nine cases from the lit- 
erature in which the doses used, the symptoms, etc., were 
stated with sufficient accuracy, and the following account 
is based upon these cases. The statement frequently 
made that weak and nervous women are more inclined to 
constitutional symptoms cannot be accepted; sex does not 
show any influence. Idiosyncrasy cannot be proven to 
play a part (the writer fully concurs in this opinion). Al- 
though idiosyncrasy against alkaloids certainly exists as a 
rare exception, it will not do to assume such peculiarity in 
every case where a quantity, harmless to one individual, 
produces constitutional symptoms in another. There are 
other circumstances that should be taken into considera- 
tion, for instance, the velocity with which a given amount 
is thrown into the general circulation. The same quan- 
tity in a more concentrated solution will be more quickly 
absorbed than if dissolved in more water; a tissue richer 
in blood-vessels will absorb faster than a less vascular- 
ized one, etc. For similar reasons it may be that con- 
stitutional symptoms occur with relative frequency in 
operations on the head, which fact has been especially 
emphasized by Wolfler (" Zur toxischen Wirkung des 
Cocain," Wien. Med. Wochenschr., xxxix., 18, 1889) and 
explained by the nearness of the brain). The sitting post- 
ure has been accused as especially aiding the anaemia of 
the brain, supposed to be the chief cause of the weakness 
and vertigo in the minor cases. Out of the ninety-nine 
cases tabled by Mannheim, cocaine was administered 
hypodermically in fifty-one, instilled in the eye in nine, 
in the ear in two, brushed on the mucous membrane of 
the nose in five. Sometimes very small doses produced 
graver symptoms, sometimes very large doses were fol- 
lowed by very slight ones. The time of appearance of 
the symptoms varies, being five to ten minutes on an 
average; sometimes they appeared immediately after ad- 
ministration, or after a few seconds, sometimes only after 
one-fourth or even one-half hour. In the following the 
symptoms of poisoning are given as collected by Mann- 
heim from the various cases. (The seeming contradiction 
in the symptoms is not to be wondered at, if it is taken 
into consideration that cocaine is a poison with first 
stimulating and afterward paralyzing properties, and 
that according to quantity or velocity of absorption the 
first or the second will prevail.-Writer.) 
General Symptoms. -The patients become sleepy and get 
into a soporous condition; they almost lose consciousness 
and faculty to articulate, or they fall within a few min- 
utes into a very deep sleep of comatose character. Severe 
collapse has been observed, preceded by weakness, with 
complete loss of consciousness of long duration and with 
reduced respiration. In other cases the patients become 
very restless and excited, seem dizzy, cry and laugh 
alternately, gesticulate, and are very talkative, not heed- 
ing any questions put to them ; incessantly change their 
position, stand up, sit down ; their gait becomes un- 
steady, like that of a drunken person. This condition 
grows into intoxication, or a feeling of impending death. 
There may be sleeplessness, lasting from thirty to forty 
hours; afterward complete forgetfulness of what has 
happened. 
Central Nervous System.-In mild cases reflexes are 
increased, cerebral irritation and delirium, lasting as 
much as an hour, hallucinations. In severe cases epi- 
leptiform attacks, with general clonic convulsions, lasting 
even five hours, tetanus, opisthotonos, death. 
Peripheral Nenes.-Sensibility diminished. Com- 
plaints of loss of sensation on the whole body or on single 
parts, limbs, or pharynx. Sometimes only numbness, 
sometimes complete anaesthesia. Feeling of intense cold- 
ness in the anaesthesic parts. Various paraesthesias. On 
the part of motor nerves twitching of single muscles (or 
as already mentioned, general convulsions), in other 
cases heaviness or tired feeling in the limbs, sometimes 
aggravated to apparent paresis. Gait staggering or com- 
plete inability to walk. 
Eye.-Pupils dilated, sometimes very contracted ; react- 
ing in some cases, in others motionless. Some patients 
complain of darkness before the eyes, others notice di- 
minished acuteness of vision, complain of mist before the 
eyes ; in some instances complete amaurosis (transient). 
One lady recovered vision only after four hours. 
Other Special Senses.-Buzzing in the ears, various dis- 
turbances of smell and taste. 
Respiration.-Short, whistling, laboring. Paroxysms 
of dyspnoea. On the contrary, the frequency can be 
diminished (even to nine respirations in the minute) and 
may cease, so that death occurs by asphyxia. Sometimes 
Cheyne-Stokes respiration has been observed. 
Circulation.-Pulse very accelerated, often very weak, 
filiform, irregular, at last hardly, or not at all perceptible. 
In other cases, pulse less frequent. Diuresis increased 
according to some writers, diminished and even sup- 
pressed according to others. 
Organs of Digestion.-Numbness of the throat, as- 
tringed sensation and dryness in the pharynx, dys- 
phagia. Burning pain in mouth and stomach (even 
after hypodermic administration). Pain in intestines. 
Rectal and vesical tenesmus. 
Cause of Death.-Paralysis of respiratory and vaso- 
motor centres and heart, whereas in other cases death 
results from tetanus of respiratory muscles. 
181 Cocaine. 
Coeliotomy. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Autopsy showed, in the few cases examined, intense 
hyperemia of the brain and of the inner organs. 
Fatal Dose.-In five of the fatal cases the dose was 
larger than one gramme, whereas only one patient wrho 
had been given one and one-fourth gramme recovered. 
From this Mannheim concludes that one gramme is to be 
considered the fatal dose. 
Of the 99 cases thus compiled, 9 were fatal. Besides, 
there are 100 cases in literature where no symptoms are 
mentioned. Of Mattison's 108 cases, 58 are included in 
Mannheim's table, whereas 50 are not. This makes 
altogether 250 cases with 13 fatal results, so that of the 
accidents reported five per cent, proved fatal. (Consider- 
ing that most of the graver and fatal cases are reported, 
while the much more frequent minor accidents do not 
come to general cognizance, the figure five per cent, is 
certainly too high.-K.) 
Treatment of Cocaine Poisoning.-In the minor cases, 
where weakness and dizziness prevail, horizontal position 
of the patient and administration of stimulants, like 
brandy, coffee, ether, are the reasonable measures to be 
taken. Inhalation of a few drops of amyl nitrite has 
been recommended, and is the measure generally adopted 
to combat the supposed anaemia of the brain. For the 
severe cases, where convulsions occur, Mosso, from his 
experiments on dogs, comes to the following conclusion : 
" If it were necessary to assist a human being poisoned 
with cocaine, one would have immediately to resort to 
ether or chloroform to prevent tetanus of the respiratory 
muscles, which is the most frequent and dangerous cause 
of death. After the first grave and imminent danger has 
passed, chloral can be given. If respiration stops, arti- 
ficial respiration must be resorted to." 
Dose.-Internally 0.02 to 0.05 gramme several times a 
day can be considered a safe dose, and even 0.1 may be 
given. For hypodermic use in operations it is advisable 
to keep under the 0.05 limit. Weak solutions of one per 
cent, and two per cent, should be used, well distributed 
over the field of operation. For spraying (nose, throat) 
weak solutions (two per cent.) should be used in known 
quantity. For operations in nose, pharynx, and larynx, 
brushing with strong solutions cannot be avoided, but in 
these cases the danger is obviously less, because the 
quantities used are small. Careful watching of the pa- 
tient and gradual administration in all cases will increase 
the safety of continued administration. 
Cocaine Habit.-Most subjects of the cocaine habit 
are victims of the opium habit who have taken cocaine 
for the purpose of curing themselves, have not succeeded 
in their efforts, and have consequently become addicted 
to both drugs. It is therefore not easy to state the 
symptoms of the cocaine habit pure and simple. Luff 
(London Lancet, September, 1889) tells of a man who 
used 0.25 gramme daily during three years for nasal 
catarrh, and who, in consequence, was very much reduced 
physically, mentally, and morally. He became unsocia- 
ble, incapable of attending to his business, because un- 
able to come to any decision. Palpitations of the heart, 
obstinate constipation. Bauer (New York Medical Rec- 
ord, November, 1885) tells of a man who replaced the 
use of alcohol by daily injection of 0.67 gramme coca- 
ine. He became very weak, lost all appetite ; had at- 
tacks of delirium ; ultimately complete physical and 
mental decay. 
From all observation it appears that rapid falling off 
in flesh is one of the most prominent somatic symptoms 
of the cocaine habit. Erlenmeyer {Deutsche Medic. Zeit- 
ung, 1886, page 483) reports a falling off of twenty to 
thirty per cent, within a few weeks, without diminution 
of food and with no existing catarrh of the stomach. 
He lays- great stress on the respiratory and vaso-motor 
disturbances caused by the blood-vessel paralyzing prop- 
erties of cocaine : frequent pulse, relaxation of arterial 
system, profuse perspiration, syncope. The psychical 
symptoms are very marked and characteristic, and in 
wTell-developed cases offer the clinical picture of halluci- 
natory paranoia. They consist, according to Obersteiner, 
chiefly of feelings of fright caused by hallucinations, 
especially in the visual and sensory sphere. Either ter- 
(SUPPLEMENT.) 
rible apparitions are seen or great hordes of small 
animals. These latter hallucinations are most likely 
based on itching paresthesias of the skin, giving to the 
patient the impression of the presence of insects or worms 
under the skin and causing him to scratch. There exists, 
an interesting observation of Ehrlich's, in his experiments 
with mice above mentioned, which closely recalls these 
paraesthesias and hallucinations based upon them. One 
of his mice, after three weeks' use of cocaine, began to 
gnaw its limb, so that in the course of the next days the 
whole right thigh down to the knee was entirely denuded. 
Ehrlich's explanation of this remarkable fact is that par- 
aesthesias due to degeneration of the peripheral nerves pro- 
voke the gnawing, while the simultaneous anaesthesia of 
the skin leaves the latter without the protection of sen- 
sation. 
While some writers deny the existence of symptoms 
due to withdrawal of cocaine in cases of well-formed 
habit, others, like Obersteiner and Erlenmeyer, affirm the 
contrary. According to Obersteiner they frequently 
appear only after the lapse of a fortnight and consist of 
sudden collapse and a feeling of impending death. Erlen- 
meyer emphasizes the vaso-motor disturbances as palpita- 
tion, weakness of the heart, dyspnoea, syncope, depres- 
sion of humor, enormous weakening of the will power. 
According to all writers the prognosis of the cocaine- 
habit is not a good one, as patients very readily relapse. 
Carl Koller. 
COCILLANA. A plant belonging to the order Melia- 
ceae, indigenous to tropical America. Its use was advo- 
cated for its expectorant properties by Professor II. H. 
Rusby in 1886. It is obtained from Bolivia, where it is- 
employed as an emetic and purgative. The root is the- 
part used, from which is prepared a tincture, one part in 
six, and a fluid extract. The dose of the former is from 
one-half to two drachms, and of the latter five to twenty 
minims. The powder is not used, as it produces sneez- 
ing, coryza, and irritation of the mucous membrane of 
the nose and throat and pulmonary tract. In over- 
doses it produces emesis, and causes gastric and intes- 
tinal irritation. As an expectorant it acts within half an 
hour, stimulating the secretion of the bronchial mucous 
membrane and producing a free flow of mucus; this 
continues for some hours, and is followed by diminished 
activity of the glands. It has very little action on the skin. 
It has proved of greatest service in chronic and subacute- 
bronchitis when the secretion is scanty and tenacious. 
In such cases it liquefies the secretion and stimulates ex- 
pectoration. The fluid extract, in doses of ten minims 
every three or four hours, seems to have been the 
most serviceable means of securing its effects. In the 
early stages of acute inflammation it should not be.given. 
In bronchorrhcea and in the aged with profuse secretion 
it is not advised, as it does not stimulate the respiratory 
organs, and might produce too free secretion within the 
tubes. In phthisis it has to be used with caution on ac- 
count of its irritant action upon the digestive tract, and 
the danger of producing inflammatory foci in the lungs. 
Beaumont Small. 
CCEL1OTOMY, DRAINAGE AFTER. As early as 1856 
Dr. Peaslee advocated the use, after coeliotomy (laparot- 
omy), of a rubber drainage-tube which should pass from 
the lower angle of the abdominal wound downward and 
through an artificial opening made from the bottom of 
Douglas's pouch into the vagina. He irrigated through 
this tube, from above downward. His success was sat- 
isfactory, but the practice fell into disuse, because a little 
later a glass tube began to be substituted for the rubber, 
although it was allowed to pass in only to Douglas's 
pouch. About this time Lister was teaching us our first 
lessons in antiseptic surgery. The short or long glass- 
tube, as was needed, proved much more useful than the 
rubber had in the earlier attempts at drainage, not be- 
cause of a better principle, but rather because of im- 
provement in the antiseptic methods in doing the work. 
Peaslee's ideas of drainage were correct, as we look 
back at his work to-day. But we know better now how 
182 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Cocaine. 
C celiotomy. 
much to trust to nature and how much to drainage. 
Later still, in 1886, the method of packing any part of 
the abdominal cavity which was denuded of its normal 
peritoneum, with a quantity of aseptic gauze, was advo- 
cated. This practice, without doubt, has served to save 
the lives of many patients. 
There are always possibilities of danger in the use of 
drainage-tubes : (1) In the fact that the operator can, or 
may, do a hasty or an imperfect operation, with the con- 
sciousness that the subsequent use of the drainage-tube 
will avert all danger ; (2) because in the after-treatment 
sepsis may be conveyed directly to the wound by means 
of the tube itself ; (3) because of the extra liability to 
ventral hernia when the tube is used. 
That a drainage-tube, or drainage-gauze, should ever 
be needed is clear proof that surgical work in the abdom- 
inal or pelvic cavity cannot be done after an ideal 
method. Any drainage after an operation means imper- 
fect work. In other words, we have not removed all 
possible sources of sepsis ; we have not checked all bleed- 
ing from small vessels ; we have tied arteries which will 
destroy the vitality of certain sections of tissue ; we 
have broken up adhesions, and have not protected these 
raw surfaces in a kindly manner ; we have left the pedicle 
insecure. 
These indications existing, and with the very best sur- 
gery, it is necessary to reduce the dangerous results of 
such imperfect work to a minimum. To do this we must 
not neglect any precaution which, in our judgment, is 
necessary, or which is well known to be of absolute 
service. The latest method of operating upon a table 
which will easily allow the patient to be placed in the 
Trendelenburg posture, and in a room where a strong 
electric light can be used in the exploration of the cav- 
ity after the tumor has been removed, has rendered the 
subsequent use of a drainage-tube, in many of its pre- 
vious forms, quite unnecessary. For with these methods, 
other things being equal, every bleeding vessel should be 
detected as surely as though it was on the face of the 
patient. 
This ability to see into the cavity thoroughly also ren- 
ders the operator far less likely to rupture, in removal, 
the small or large septic tumor. And so, also, the adhe- 
sions are dealt with more gently when all can be seen by 
the eye as well as felt by the finger ; facilities which the 
new posture and the electric, or strong, light afford. 
To-day, therefore, when the operator is aseptic, the field 
of operation aseptic, and the surgical implements aseptic, 
the table and the light as nearly perfect as can possibly 
be obtained, we have far less need of the drainage-tube 
and are nearing our ideal operation. But, as we have 
not yet attained to this ideal standard, we must, for the 
present, resort sometimes to the best method for drain- 
age. 
The several methods of drainage may be quickly de- 
scribed. The glass tube is the one which has been most 
frequently and most successfully used during the last ten 
years. The tube, if needed at all, should be from three- 
quarters to one inch in diameter and from four to six 
inches in length: it should be open at the distal end and 
have several side perforations near this end. It is not 
necessary for the tube to be curved, as was formerly 
believed to be important. This glass tube should be 
placed so that the distal end will rest very near to the 
probable or possible future location of sepsis, the prox- 
imal end resting in the lower angle of the abdominal 
wound. One suture should always be inserted here, and 
left untied, for the special purpose of closing this track 
as soon as the glass tube is removed. The tube should 
be loosely packed with sterilized gauze, which, at the 
proximal end of the tube, should be covered with a com- 
press of soft, sterilized, absorbent cotton. The tube 
should be dressed from time to time, according to the 
rapidity with which the gauze becomes saturated from 
within, and should be removed just as soon as the fluid 
which escapes is found to be scant and benign in char- 
acter. 
The drainage should take place through iodoform 
gauze in all septic cases, as it will be necessary to retain 
the glass tube in situ for from four to six days. In case 
the packing is only to check a hemorrhage from small 
vessels, and surfaces from which the peritoneum has 
been removed, common sterilized gauze will suffice, as 
such packing can soon be safely removed. 
For pockets beneath the broad ligaments, or low down 
in Douglas's pouch, counter-drainage should be insti- 
tuted through the vagina. The gauze should be from one 
and one-half inch to two inches wide and from tw o and 
one-half to ten yards in length. The distal end should 
be passed through an opening, which can be most easily 
and directly made into the vagina. The opening can be 
made with a trocar, or forceps, or scissors, from above 
downward, the finger in the aseptic vagina indicating 
the locality of the least amount of tissue to be pene- 
trated, care being taken at the same time to avoid the 
ureters and uterine arteries. An iodoform gauze tampon 
should be inserted in the vagina. The proximal end of 
the drainage-gauze should be carefully and methodically 
laid in, fold on fold, or coil after coil; and finally it 
should be crowded into the cavity which is to receive it. 
If it is possible, the slit in the broad ligament, or the 
parts above Douglas's " pouch," should be closed with 
catgut sutures, thus completely shutting off the gauze 
from the abdominal cavity. Of course, after making a 
counter-opening into the vagina there must be a thor- 
ough irrigation, with sterilized water, through the lower 
pelvis and out through the vagina, before the gauze is 
inserted. 
The following are the notes of two of my own cases 
treated in this manner : 
Case 1. Mrs. II., in my service at the Woman's Hos- 
pital, 1891. She had physical and symptomatic evidence 
of a cyst in the true pelvis, under the broad ligament. 
There had been exacerbation and remission of fever, her 
physician informed me, before she entered the hospital. 
I found, on operating, that the left ovary had been dis- 
placed backward, and after being completely covered by 
the broad ligament and an exudate, an ovarian cyst 
had developed, over three inches in diameter. Splitting 
through the exudate, I emptied the cyst with the aspirat- 
ing needle. Its contents w ere purulent. I then enucle- 
ated and cut away the larger part of the cyst, but the lower 
zone was so tightly adherent to the cellular tissue which 
formed its bed, that the question of time for removal of 
all this friable, septic material bad to be considered. As 
there was but a thin wall of tissue between this part of 
the cyst and the vagina, I quickly decided to drain into 
the vagina. I placed, therefore, a long piece of gauze in 
the jaws of a somewhat sharp-pointed pair of forceps, 
and then pushed this instrument through the lowest por- 
tion of the cyst which I had been unable to remove, di- 
rectly through into the vagina just back of the cervix. 
I will mention here that in my service the vagina is al- 
ways made aseptic before coeliotomy. I then irrigated 
through this opening. The remaining gauze I carefully 
laid in the cavity just occupied by the cyst and firmly 
crowded it down. 
All went well for two weeks. At the expiration of 
that time I thought I could safely remove the drainage- 
gauze, and did so. The temperature and pain soon con- 
vinced me that the drainage should be continued for a 
longer period. I therefore inserted a rubber drainage- 
tube for an inch and a half into the sinus, and fastened it 
in situ by means of a silver-wire suture. This was re- 
tained in place, and irrigation was kept up through it for 
nearly four weeks, with the result that the patient at the 
end of that time was discharged cured. 
Case 2. Mrs. M., thirty years of age, in my private 
sanatorium, 1892. A suppurating cyst, three by four 
inches, was found developed beneath the broad ligament. 
The ovary and tube on the same side were 1)0111 dis- 
eased and displaced backward, and covered with an exu- 
date. An incision directly through the broad ligament 
laid bare the tumor. The cyst was so friable that I had 
to remove it in small pieces, and then I could not be 
sure but that some portion had been left. To have 
painted this cavity with a germicide sufficiently strong 
to kill all possible septic elements remaining, or to have 
183 € celiotomy. 
Coelom. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
burned this large surface with the thermo-cautery for a 
similar purpose, would have exposed the patient to a 
greater danger than that which the tumor itself would 
have afforded had it been left undisturbed. 
I therefore passed the points of a pair of scissors di- 
rectly through into the aseptic vagina, irrigated through 
this canal, then pushed the end of the gauze into the 
vagina, and carefully coiled the remaining portion of the 
gauze in the nest formerly occupied by the cyst. The 
tube and ovary on the same side were then loosened up 
and removed in the usual manner. I then turned the 
stump of the pedicle into the incision which I had made 
in the broad ligament on this side, and closed the slit 
with catgut, leaving nothing that could possibly cause 
trouble in the abdominal cavity. The gauze was re- 
moved gradually, a few inches at a time daily, and by 
the tenth day all had been removed. The patient made 
a perfectly satisfactory recovery, the temperature, after 
the first day, never rising above 100° F. 
The necessities for drainage can be grouped under 
four heads : 
1st. Inability to remove the whole of a septic tumor or 
tissue, especially when a ligature has passed through such 
septic tissue. 
2d. A large space of granulating surface after enuclea- 
tion of tumor or separation of adhesions. 
3d. A large number of minute bleeding vessels, 
which, from their location, will require too much time 
to close. 
4th. Fear of secondary hemorrhage. 
This last reason should be, and will be, the excuse 
given only by the timid and inexperienced surgeon. The 
best surgeon will never leave a pedicle so insecure as to 
excite fear of hemorrhage, while his catgut or other asep- 
tic ligature material holds out. This fourth excuse for 
drainage, therefore, may be excluded, and will never be 
put forward by a judicious operator, when it is under- 
stood that any pedicle or ligature can be made absolutely 
secure at the time of the operation, in one-half the time 
it will take to prepare the patient for a secondary opera- 
tion, after the necessity for such operation has been 
demonstrated by the collapsed condition of the patient, 
and the other usual signs of secondary hemorrhage; 
and also when it is remembered that all patients are far 
better able to remain on the operating-table for the five 
or ten minutes necessary to strengthen the original liga- 
ture-or for additional ligatures, or a half-dozen deep 
catgut sutures, introduced with a full-curved, round- 
pointed needle-before a secondary hemorrhage than after 
it has occurred. 
Let us carefully consider the other reasons for drainage : 
1. The necessity for keeping a drainage-tube, or gauze, 
at the site of sepsis will be admitted by all. And we all 
know that sometimes the condition of our patient will 
not allow us to carefully curette every septic cavity, even 
if we were absolutely positive of entirely removing the 
possible source of sepsis ; and in the true pelvis or under 
the broad ligaments we are never absolutely certain that 
we have removed everything septic. Other things being 
equal, time is a great factor in the ultimate results of all 
major operations, especially in abdominal surgery. If. 
however, such septic surface is far from the abdominal 
wound, and near the vagina, drainage through the vagina, 
as described, would be indicated and 
should be preferred. 
But when there is need of. drainage 
because of sepsis, or fear of sepsis, and 
the lowest point of contact for such 
sepsis is not far from the lower part 
of the abdominal opening, a glass 
tube, or a gauze bag, three by six 
inches, filled with sterilized or iodo- 
form gauze, and inserted in the lower 
angle of the abdominal wound, will 
serve best. I am inclined to use the latter method in tu- 
bercular peritonitis and tubercular salpingitis, and when 
a large septic tumor has had to be enucleated from its 
bed near the normal position of the fundus uteri. The 
former method, the glass drainage-tube, is preferable 
where sepsis is feared over only a small space, like the 
condition present when a very badly diseased tube, or 
small ovarian abscess, has been operated upon. 
2. In really non-septic cases, if there are many adhe- 
sions broken up and separated, or when there is a large 
raw surface left in the cavity after enucleating, we must 
expect much sweating of serum, and we always fear ad- 
hesions of the intestines to the bed from which the tumor 
has been removed. In such cases, if we cannot close 
this large raw surface with a few catgut sutures, and 
thus shut it off from the abdominal cavity, and after 
dusting the intestines (when adhesions have existed) with 
aristol powder, we still find the parts too much inflamed 
to warrant our trusting to nature's efforts alone, then we 
must place the bag of gauze in the abdominal wound or 
the gauze in the vagina, choosing the one or the other, as 
may seem most judicious. 
3. In those difficult cases where there is a somewhat 
threatening, or at least a continuous, oozing of blood from 
the lower pelvis, after an enucleation of a solid or semi- 
solid tumor, if these vessels cannot be seen and closed by 
pressure, or the hemorrhage is not checked by hot water, 
nor by dusting with sterilized powdered persulphate of 
iron, then there is nothing to do but to fill the bleeding 
space with gauze. First the gauze bag, then packing 
this bag tightly with gauze from above, and, if we are 
not then satisfied with the state of things, buttressing the 
gauze with a firm tampon in the vagina. 
4. My firm belief, for reasons given above, is that we 
should never drain simply because we fear secondary 
hemorrhage from a large vessel in the pedicle. 
Too much attention to cleanliness cannot be exercised 
in managing the tube. In septic cases, after watching 
the contents of the tube for four or five days, a smaller 
tube may be used, and generally within a week this can 
be removed, and the track of the tube be closed by tight- 
ening the suture. 
When drainage is resorted to for the purpose of remov- 
ing the serum from sweating raw surfaces, within twen- 
ty-four hours the gauze, or the glass tube, should be 
partially removed, and altogether withdrawn by the end 
of the second day. In counter-drainage through the 
vagina a piece of gauze, from three to five yards long 
and from one and a half inch to four inches wide, should 
be used, and should be withdrawn through the vagina, 
little by little, daily, until all is removed. When the 
last is taken away the cavity should be thoroughly irri- 
gated. If there is still evidence of pus a rubber drain- 
age-tube should be inserted into the blind fistula, and 
retained by one of the several methods in general use. 
All tubes and all gauze must be thoroughly sterilized. 
If gauze is to be kept tn situ for a week, sterilized iodo- 
form gauze remains less offensive when in use than plain 
gauze sterilized. But when the gauze can be frequently 
changed, plain sterilized gauze is perfectlv satisfactory. 
Horace Tracy Hanks. 
CCELOM. In all vertebrates the primitive intestine 
forms two sets of diverticula which are destined to be- 
come permanent tissues, (1) one toward the medullary 
groove which forms the chorda dorsalis, and (2) two 
lateral diverticula which form the body cavities. These 
latter are later on subdivided into pleural, pericardial, 
Fig. 100.-Transverse Section through the Posterior Region of a Chick, with Six Pairs of My- 
otoines. (After Waldeyer, from Minot.) Ec., ectoderm; Mes., mesoderm; Ent., entoderm; 
Md., medullary groove. 
peritoneal, and other cavities. A detailed description of 
the theory of the formation may be found in Balfour's 
work, in Hertwig's " Embryologie, " in Minot's " Human 
Embryology," and in Minot's article, " Fcetus," in Vol. 
III. of this Handbook. 
184 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Coeliotomy. 
Coelom. 
When sections are made through very young embryos 
of higher vertebrates, just after the blastodermic mem- 
branes are well formed, a solid mesoderm is present, as 
shown in Fig. 100. Although in lower vertebrates the 
mesoderm is produced by lateral diverticula from the en- 
toderm, which are hollow from the beginning, in higher 
vertebrates the mesoderm is first laid down as a solid 
mass of cells. Soon the cells of the mesoderm on either 
side of the chorda divide into two layers, the somato- 
pleure and the splanchnopleure (Fig. 101, Som. and Sp'.). 
It is from these two lateral cavities that the peritoneal 
cavity is formed. 
(SUPPLEMENT.) 
a cross-section from a chick at this stage, and shows that 
the greater portion of the cavity is now on the outside of 
the body. The cross-piece of the H is immediately on 
the ventral side of the heart, and forms the cavity of the 
pericardium by the heart growing into it. Its communi- 
cation with the remaining coelomic cavity is later on cut 
off in higher vertebrates, while in lower vertebrates it 
may remain open. 
According to Budge two diverticula grow from the 
cross-piece, one on either side of the chorda, toward the 
tail of the body, and form the primitive pleuro-peritoneal 
cavities. Budge's 
paper was published 
from fragmentary 
notes after Ids death, 
and I am sure that 
the above statement 
is not correct. Pro- 
fessor His has placed 
before me Budge's 
specimens, which I 
think show conclu- 
sively that his inter- 
pretations of his in- 
jections are not cor- 
rect. Most of his 
injections were made into the 
amniotic fold as the amnion was forming. Cross-sec- 
tions of embryos show that on either side there is a large 
cavity (Fig. 102, Som.) which communicates freely with 
the pleuro-peritoneal (Coe). Before the amnion is com- 
plete we have lateral cavities on either side of the body, 
communicating with each other only by means of the 
cross-piece on the ventral side of the heart. This is the 
freest portion of the communication, which also com- 
municates most freely with the pleuro-peritoneal cavities 
(Fig. 102, Coe.). In many embryos the injection passed 
from the cross-piece into the pleuro-peritoneal cavity and 
would not extend out into the amniotic portion of the 
ccelom, thus making it appear as if the pleuro-perito- 
neal cavities were, so to speak, diverticula projecting di- 
rectly from the cross-piece or pericardial cavity. Trans- 
verse sections, however, give the picture of Fig. 103. 
Surface views could not decide that these two cavities 
Fig. 103.-Section of a Chick, to 
show that the Pleuro-perito- 
neal Cavity is cut off of the 
Coelomic, leaving a Portion 
in the Amnion. The embryo 
has been injected, but the fluid 
of the two cavities has not 
flowed together. 
Fig. 101.-Transverse Section of a Chick of the Second Day. (After Waldeyer, from 
Minot.) Som., somatic mesoderm; Spl., splanchnic mesoderm; Ec., ectoderm; 
Ent., entoderm : V.C., vein ; W., Wolffian duct; Md., medullary canal ; Ao., aorta ; 
Ch., chorda ; M.S., myotome. 
The more accurate early formation of the pleuro- 
peritoneal cavity, in its relation to the other organs, we 
find carefully studied by Budge, who by means of injec- 
tion followed it in the chick. With a fine hypodermic 
syringe he filled the various spaces of the coelom as they 
appeared, thu^ showing very clearly the extent of this 
cavity in various embryos. The splanchnopleure, ac- 
cording to Budge, may be split into two layers, a dorsal 
or lymphatic and a ventral or vascular. As the first 
blood-vessels are formed, lymph-vessels appear on their 
dorsal side, which flow together to form net-works and 
accompany the primitive veins to the axial part of the 
germinal area. Here the lymphatics form two spaces, 
one on either side of the body, which are soon united by 
a bridge, or rather duct, on the ventral side of the heart. 
In this way, in birds at least, this primitive pleuro-peri- 
toneal cavity appears somewhat as an H, the uprights of 
which are on either side of the body, and the cross-piece 
Fig. 102.-Section through the Body of a Chick of the Third Day. (After Minot.) Ch., chorion ; Am., amnion ; Soni., somatopleure ; v., blood-vessels; 
Coe., coelom ; Spl., splanchnopleure; In., intestine; ao., aorta; Wd., Wolffian duct; Fear., vena cardinalis; Ch.d., chorda dorsalis; My., my* 
otome; Md., medullary canal. 
on the oral side of the sinus venosus. In its further devel- 
opment the sinus venosus grows to the dorsal side of the 
cross-piece, thus reversing the relation of the vascular sys- 
tem to the lymphatic, or rather coelomic system. The 
uprights of the H fall to the outside of the body and are 
swallowed up in the formation of the amnion. Fig. 102 is 
united directly, and these sections were no doubt made 
after the writing of the rough draft of his manuscript. 
Therefore, instead of stating that the two pleuro-perito- 
neal cavities arise as independent diverticula, we must 
say that they are pinched off from the coelomic cavity 
after the amnion is formed. 
185 Coelom. 
Coelom. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
of these sections is the communication between the peri- 
cardial and pleural cavities shown, but sections nearer 
the head contain it. 
A cast of the coelomic cavity of this same embryo is 
given in Fig. 115. There is only a slight communication 
between the pericardial cavity and the pleuro-peritoneal. 
The groove in the cast marked M indicates the position of 
the simple mesentery. Its relation to these organs is bet- 
ter shown in the sections (Figs. 109 to 114). Fig. 116 repre- 
sents a section through a chick at an earlier stage of devel- 
opment, in which the duct communi- 
cating between the pericardial and 
pleural cavities is cut longitudinally. 
Thus it is seen that the heart first 
grows into the primitive pericardial 
cavity, which is nothing else than 
the cross-piece of the H already spo- 
ken of. The heart grows larger and 
larger, at the same time hanging as 
it were over the ventral side of the 
body, and is soon connected with the 
pleuro-peritoneal cavity only by two 
ducts, which later on become closed 
in the higher vertebrates. 
In early embryos the veins enter 
the heart behind, and not in front, as 
is the case in higher animals. The 
heart in its whole development un- 
dergoes a half revolution, and in 
this way the twists, etc., are formed. 
Before the pericardial cavity is shut off from the pleuro- 
peritoneal the large vessels enter from behind. They are 
embedded in a mass of mesoblastic tissue which is en- 
croaching upon the pleuro-peritoneal cavity, and has 
been termed by His the transverse septum. This, by its 
further growth, forms the diaphragm of higher animals 
(Figs. 105, 106, 107). In low7er animals only a rudimen- 
tary diaphragm, or none at all, is present. By the for- 
mation of the diaphragm the pleuro-peritoneal cavity is 
divided into a smaller anterior portion, the pleural, and 
a larger posterior portion, the peritoneal. The lungs 
now grow into the pleural, as shown in an early stage in 
Fig. 116, and in a somewhat later stage in Fig. 109. 
The peritoneal cavity is at first composed of two dis- 
tinct portions, one on either side of the intestine, which 
in lower animals is quite a straight tube, lying in the 
middle line of the body. Soon, however, twro communi- 
cations are found between the two halves, one in front 
and one behind the omphalo mesenteric vessels (Fig. 
115, 0.) These openings enlarge more and more as the 
intestine becomes more convoluted, and soon flow to- 
gether, severing completely the omphalo mesenteric ves- 
sels and duct. A portion of the duct may, however, 
remain in connection with the small intestine to form 
the diverticulum of Meckel. 
As the organs grow the peritoneal cavity surrounds 
them more or less completely, until the condition of 
things as seen in the adult is produced. 
In lower vertebrates the peritoneal cavity remains 
quite simple, but in reptiles, birds, and mammals it may 
become quite complex. Especially is this true regard- 
ing the birds, in which these divisions are greatly com- 
plicated by the growth of the air-sacs from the lungs. 
The first trace of the lesser peritoneal cavity is seen in 
the reptiles. Ravn has shown that in the lizard there are 
twro diverticula from the peritoneum, one on either side 
of the stomach. From the one on the right side the 
lesser peritoneal cavity of mammals arises. In general 
the relations of the lesser peritoneal cavity to the greater 
is much like what is shown in Fig. 105. In the true sense 
of the term there is no lesser cavity, but only the two 
pouches. These are already present in the embryo, and 
in the adult they retain their embryonic appearance. 
In birds the conditions become more complex. They 
appear in the chick during the third day of incubation. 
A section of the chick at this stage is given in Fig. 116, 
G.D., making the lesser cavities, or, as they may better 
be termed, the right and left gastric diverticula. At the 
beginning of the fourth day the gastric diverticula be- 
The coelomic cavities which are so intimately united 
with the lymphatic system, unite and again divide into 
sections, thus forming the various compartments of the 
visceral cavity of higher vertebrates. In all of the verte- 
brates the heart, as it is developing, hangs into the ventral 
transverse portion of the cavity, or the primitive pericar- 
dial cavity. This is shown diagrammatically in Figs. 
104, 105, 106, and 107, P. 
Figs. 104 to 107 show the very early condition of things ; 
the coelomic cavities are united by the cross-piece or the 
Fig. 104. 
Fig. 105. 
Fig. 106. 
Fig. 107. 
Figs. 104, 105, 106, and 107.-Diagrams to Show the Development of the Coelomic Cavity. P.P., 
pleuro-peritoneal cavity; A.P., portion of the coelomic cavity swallowed up in the amnion; P., 
pericardial cavity ; L . pleural cavity; G.N., gastric diverticula, right and left; D., position of 
the diaphragm; L.G.D.. left gastric diverticulum ; R.G.D., right gastric diverticulum or lesser 
peritoneal cavity ; F. IF., foramen of Winslow ; G.P.C., greater peritoneal cavity ; T., tunica 
vaginalis. 
primitive pericardial cavity. The dotted lines (Fig. 104), 
mark what portion of the cavity is taken up in the am- 
nion (A7<), while the remaining middle portion (P.P.) 
becomes the pleuro-peritoneal. Figs. 105, 106 and 107 
show in succession the more advanced stages. In higher 
vertebrates the pericardial cavity is completely closed off 
from the pleuro-peritoneal, but in elasmobranch fishes a 
communication between them exists in the adult. The 
separation of the pericardial cavity from the pleuro-perito- 
Fig. 108.-Reconstruction of a Human Embryo. (Enlarged 16 times, 
viewed from the left side.) P., pericardial cavity; 1, 2, 3, and 4, bran- 
chial pockets; A. D., descending aorta ; A.. auricle; V., ventricle ; L., 
lung: S., stomach ; P., pancreas; AC, mesentery ; A'., kidney: IKD., 
Wolffian duct ; O., openings through which the right and left perito- 
neal cavities communicate. 
neal is aided materially by the heart going over to the 
ventral side of the body, as shown in Fig. 108. Sections 
through various parts of the same embryo, from which 
Fig. 108 is taken, are shown in Figs. 109 to 114. In none 
186 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Coelom-.. 
Coelom. 
come larger, and on tranverse section semicircular. 
Figs. 117 and 118 are from casts of the cavities about the 
stomach of a chick of eighty-eight hours. The right 
is larger than the left and is markedly cup-shaped, 
and connects by means of a narrowed opening with 
the right pleuro-peritoneal cavity (Fig. 117, K W.). 
The two together enclose the proventriculus. On ac- 
count of the relations of the opening of the right diverti- 
culum with the blood-vessels, stomach, and liver, and also 
for reasons which find their basis in comparative anat- 
(SUPPLEMENT.) 
space extends from behind the right gastric diverticulum 
along the dorsal side of this organ, and marks the begin- 
ning of the cavity of the great omentum (0.). Nearly the 
whole of the right diverticulum now lies on the left side 
of the body ; the same position is held by the proventric- 
ulus and the gizzard. 
The domestic fowl possesses three peritoneal cavities, 
completely separated from one another, and from one of 
them the lesser cavity arises. The communication is by 
means of the foramen of Winslow. After the anterior ab- 
Fig. 109. 
Fig. 110. 
Fig. 111. 
Fig. 112. 
Fig. 113. 
Fig. 114. 
Figs. 109-114.-Sections through an Embryo Twenty-six Days Old. (X 25 times.) 0., oesophagus ; 8, stomach ; 7., intestine; P., pancreas ; B., 
bile-duct; A., aorta : C., coeliac axis ; G., right gastric diverticulum ; F., foramen of Winslow ; M., mesentery ; L., liver ; P., portal vein ; U., 
umbilical vein ; H., heart; X., bulb of the aorta. The pleuro peritoneal cavity is colored black throughout. 
omy and embryology, the opening can be nothing else 
than the foramen of Winslow. 
On the left side the gastric diverticulum is much 
smaller, and in older embryos it disappears altogether. 
In a chick of five days and sixteen hours (Fig. 119) the 
right gastric diverticulum has about doubled all its di- 
mensions, while the embryonic foramen of Winslow has 
become much more sharply defined. At this time the 
liver has greatly increased in size, the right lobe being 
larger than the left, both lying anterior to the foramen of 
Winslow. The original position of the liver being behind 
the foramen, its rotation necessarily carries the hepatic 
artery and the portal vein around the foramen of Winslow 
-its adult position. With the growth of the gizzard a 
dominal walls are removed, two ventral cavities are ex- 
posed, separated from each other by a vertical longitudi- 
nal septum. Into each of the cavities hangs a lobe of the 
liver, while into the left the ventral surface of the gizzard 
projects. On the dorsal side of the liver there are, on 
each side, three air-sacs-an anterior, a middle, and a 
posterior. The middle one is the smallest, and the pos- 
terior the largest, extending as it does throughout the 
posterior portion of the abdominal cavity. Each sac 
communicates by means of a special opening directly into 
the lungs. By allowing the sacs to collapse we find that 
a very distinct membrane projects backward from the 
gizzard and cuts off the portion of the abdominal cavity 
containing the intestines. This is the " pseudo-epi- 
187 Coelom. 
Contagion. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
ploon " described by Weldon and followed more exten- 
sively by Bedderd. A similar membrane is present in 
the crocodile. In all respects, this membrane is situated 
in the same position as is the epiploon in mammals, with 
(SUPPLEMENT.) 
upright, only one gastric diverticulum is found. It is on 
the right side in Figs. 109 to 114. which arc taken from a 
young human embryo. In each drawing the coelomic 
cavity is colored black and the position of the section 
can be made out by the organs which are cut across in 
the section. A cast of the' cavity is shown in Fig. 115. 
The portion of the cavity on the right side of the stomach 
and the liver is shown in Fig. 120, which is taken from 
a cast also. Figs. 109, 110, and 111 show sections through 
the gastric diverticulum of Fig. 120, Fig. Ill being 
through the foramen of Winslow. 
Fig. 115. - Corrosion Preparation of the Pleuro-peritoneal 
Cavity of an Embryo Twenty-six Days Old. (X 22 times.) 
P, pericardial cavity; A, opening for the aorta; V, 
opening for the vein ; L, space over the liver ; M, slit 
for mesentery ; W. B, space for Wolffian body. 
Figs. 117 and 118.-Corrosion Preparations of the Right and Left Gastric Diverti- 
cula of a Chick Eighty-eight Hours Old. (X 33 times.) P.P., pleuro-peritoneal 
cavity; R.G.D., right gastric diverticulum; L.G.D., left gastric diverticulum; 
L., position of lung ; F. W., foramen of Winslow. 
the difference that it is adherent to the abdominal walls 
along its free border. On the dorsal side of the gizzard 
the air-sacs till all the space, thus closing off the com- 
munication between the cavity 
in which the intestines lie and 
the ventral cavities. 
When the anterior and mid- 
dle air-sacs on the right side are 
separated from the posterior sac 
on the same side, a slit is shown 
which extends anterior and dor- 
sal to the hepatic veins. Here 
it communicates by means of a 
round opening, about one centi- 
metre in diameter, with a large 
cavity lying on the median and 
dorsal side of the proventriculus 
and extending to the spleen. 
The cavity does not extend on 
the dorsal side of the gizzard. 
In all respects it corresponds 
with the right gastric diverticu- 
lum of embryos and with the 
lesser peritoneal cavity of mam- 
mals. 
The relation of the embryonic 
omentum with the '' pseudo- 
epiploon" is as yet unknown. 
However, I think it probable 
that the one is changed into t*he 
other, and that the ''pseudo- 
epiploon " will prove to be the 
true epiploon homologous with 
the same in mammals. We 
must only imagine the embry- 
onic omentum attaching itself 
on the sides of the abdomen fol- 
lowed by a loss of the epiplobnic cavity. A subsequent 
growth of the air-sacs backward from the dorsal side of the 
stomach will produce the condition found in the adult. 
In mammalian embryos, while the stomach is still 
The general form of the cavities is shown in Fig. 120, 
which is taken from a reconstruction of a human em- 
bryo. The peritoneal cavity surrounds the Wolfflan 
body, intestine, omphalo-mesenteric vessels, stomach, 
liver, and lungs, with the addition of the right gastric 
diverticulum. 
In lower mammals, according to Ravn, there are two 
diverticula ; so the symmetrical arrangement of these 
Fig. 116. - Section through 
the Region of the Heart of 
a Chick of Seventy Hours. 
(X 35 times.) The section 
strikes the oral end of the 
gastric diverticulum G.D , 
and the tips of the pul- 
monary buds, Z. A few 
sections deeper the gastric 
diverticula communicate 
with the pleuro-peritoneal 
cavity. H., heart; D.C., 
ductus Cuvieri; B.A., bul- 
bils aortse. 
Fig. 119.-Corrosion Preparation of the Right Gastric Diverticulum 
from a Chick of One Hundred and Thirty-six Hours. (X 15 times). 
P.P., pleuro-peritoneal cavity; F. W., foramen of Winslow ; L., posi- 
tion of right lung ; P., position of proventriculus ; O., omental cavity 
(position of gizzard). 
cavities in reptiles is still indicated in the mammals. It 
is so insignificant, however, that we need not take it into 
consideration. 
The fate of the right gastric diverticulum of mammals 
has been studied in the dog, and it has been found that it is 
converted directly into the lesser peritoneal cavity, much 
as is shown in Figs. 106 and 107. In a dog's embryo, six 
millimetres long, the diverticulum is much like what it 
188 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Coelom. 
Contagion* 
(SUPPLEMENT.) 
is in the human embryo of about the same size (h ig. 120). 
A dog embryo, ten millimetres long, shows a picture more 
advanced, much like what is seen in the chick of five days 
(Fig. 119). In a later 
stage (Fig. 121) the stom- 
ach has been twisted 
about, holding in great 
part the adult position. 
The liver, which before 
lay on the ventral side of 
the stomach, now lies in 
front, and to a great ex- 
tent on the dorsal side of 
it. A model of these 
parts from a ten-milli- 
metre embryo, simply 
rotated to throw the 
stomach away from the 
mouth, gives the condi- 
tion of things as they ex- 
ist in the embryo thir- 
teen millimetres long. 
Fig. 121 shows the 
lesser peritoneal cavity as a cast stuck in behind the 
stomach. The intestine is composed of two loops, one 
from the stomach, extending into the pelvis, and the 
omentum (Fig. 121, 0.). The general shape of the lesser 
peritoneal cavity is shown in transverse section in Fig. 122, 
which can be compared with Fig. 111. The S-shaped 
loop of intestine is cut across three times, and the lesser 
peritoneal cavity with the foramen of Winslow is shown 
throughout its whole extent. 
The omentum from now on rapidly grows over the 
whole ventral wall of the abdominal cavity, and in man 
adheres to the colon as first described by Meckel. 
A resume of the subject is given in Figs. 104 to 107. 
Franklin P. Mall. 
COLBERG. An important watering-place in Pome- 
rania, Germany, near the Baltic Sea. It is also a seaside 
resort. 
Access.-Colberg is a railroad station, and can be 
readily reached from any European city. 
Analysis.-The waters of Colberg are saline, and are 
chiefly used for brine baths, although they are also ad- 
ministered internally after dilution with carbonated water. 
The principal springs are the Zillerbergsoole, Marktsoole, 
and Salinensoole. In 1,000 parts of Salinensoole there 
are contained: 
Chloride of sodium 48.63 parts. 
Chloride of calcium 4.37 " 
Chloride of magnesium 2.18 " 
Sodium bromide 0.04 part. 
Carbonate of iron 0.08 " 
Indications.-The place is much frequented owing to 
the advantages it possesses for sea-batning, alternating 
or combined with a course of brine baths. It has been 
found beneficial in cases of scrofula, anaemia, tedious 
convalescence after acute diseases, and neurasthenia. 
Female complaints are successfully treated at Colberg. 
Accommodation.-Good hotels and modern bathing 
establishments are found here. 
Edmund C. Wendt. 
CONTAGION. The progress of knowledge of the 
spreading diseases, in the past six or seven years, has en- 
larged the sphere of contagion as a factor, and in like de- 
gree has diminished that of heredity. (See article on He- 
redity, in this volume.) At the same time the agency 
of bacteria in their dissemination has gained greatly in 
importance with increased research. 
Under the present title, in Vol. II. of the Handbook, 
allusion was made to the ptomaines in connection with 
bacteria. The study of the animal alkaloids has been 
actively pursued by the German pathologists, with refer- 
ence to their origin, development, and agency in disease. 
They are distinguished as ptomaines when they attend 
fermentation or putrefaction of a dead animal body, and 
leucomaines when found in living tissues. They result 
from retrograde metamorphosis, and resemble in com- 
position and character the vegetable alkaloids. The al- 
leged alkaloid of tetanus, for example, has the formula 
CuHaoNaOi. They are highly unstable compounds in a 
chemical sense, and consequently difficult to manipulate. 
Some are toxic ; others not so ; most are acrid. They are 
to be regarded as the consequence, but never the cause, 
of bacteria; and there is good reason to suppose that path- 
ogenic bacteria largely operate through these secondary 
products. 
Brieger and Frankel (1890) have obtained a ptomaine 
from the bacillus of diphtheria, which produced in the 
animals experimented on precisely the same symptoms 
which follow inoculation with pure cultures of the 
same bacillus. Its activity was destroyed by a heat of 
140° F. Brieger gives a list of the animal alkaloids iso- 
lated up to 1889, amounting to forty-one in all. Wurg 
has demonstrated (1889) the presence of leucomaines in 
normal blood, and further researches may prove them to 
be habitually present. Obviously they are not patho- 
genic, but experiment might show them to be transfera- 
ble from one healthy individual to another by appropriate 
culture and inoculation. 
8. 8. Herrick. 
Fig. 120.-Corrosion Preparation of 
the Gastric Diverticulum of a Hu- 
man Embryo, 7 mm. long. (X 35 
times.) P.P.^ pleuro-peritoneal 
cavity; F. W., foramen of Win- 
slow ; G.D., gastric diverticulum. 
Fig. 121.-Corrosion Preparation of the stomach, Intestines, and Lesser 
Peritoneal Cavity of a Dog, 13.5 mm. long, Viewed from the Left Side. 
(X 15 times.) The lesser peritoneal cavity has been filled with metal. 
B.D., bile-duct; pancreas; C., caecum; O., omentum; F.W., 
foramen of Winslow ; L.8., position of lobus Spigelii. 
other from the ctecum into the umbilical cord. The 
rapid growth of the large intestine has thrown the caecum 
as high as the stomach and to the right of it. The fold 
Fig. 122.-Section through the Foramen of Winslow and Lobus Spigelii 
of a Dog, 13.5 mm. long. (X 36 times.) A., aorta ; A, stomach ; P., 
portal vain ; V., umbilical vein ; L.S., lobus Spigelii; O., omental 
cavity ; L.T., large intestine. 
of mesogastrium coming from the dorsal side of the 
stomach passes, over the large intestine to form the 
189 Contrexeville. 
Cranial Nerves. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
CONTREXEVILLE. This spa, being the most impor- 
tant one of the group in the Vosges district, and being now 
frequented by many English-speaking invalids, it may be 
well to give some additional information concerning it. 
.(See also Vol. II. of the Handbook.) 
That the waters are the chief point of attraction is not 
doubted, although the pure invigorating air, the pleasing 
scenery, as well as the good walks and drives, all con- 
tribute to make the place popular and even fashionable. 
The new railroad has brought Contrexeville to within an 
eight hours' ride from Paris. Large sums of money have 
been recently spent upon the thermal establishments, 
which are now modern and complete in every detail. 
Although the Source du Pavilion is the spring most 
generally employed, there are six other springs, all of 
.tried efficacy in the particular line of maladies here treated. 
The Source le Clerc, Source du Prince, Sources Mongeot, 
and Source du Quai, deserve to be mentioned. All these 
waters are diuretic, aperient, and at the same time tonic. 
They disturb the stomach less than the more highly min- 
eralized springs, and have been named "amisde I'estomac," 
in consequence. A statistical table published by Dr. 
Debout d'Estrees show's that of every hundred patients 
visiting Contrexeville, on an average thirty-seven suffer 
from gravel (uric acid, oxalic, or phosphatic), twenty-two 
from gout, nineteen from vesical catarrh, cystitis, etc., 
nineteen from gouty diabetes, seven from hepatic colic, 
and the remaining ten from other chronic diseases of the 
kidneys, the bladder, the liver, or the stomach (Wolff : 
" The Watering-places of the Vosges ''). 
The waters of this spa are taken in larger quantities 
■than at the resorts having stronger springs. Patients at 
Contrexeville are at times directed to take as much as 
twenty-five glasses a day, which produces a veritable in- 
ternal Hushing. Mr. Wolff summarizes the rules for 
drinking in this way : "You rise early, to dispose of the 
prescribed quantity of liquid in good time and with req- 
uisite ease. Five or six o'clock sees all the little bathing 
world assembled round the bubbling spring attractively 
housed in a neat and roomy pavilion. You drink your 
tumbler and then take a quarter of an hour's walk-that 
or thereabouts. Then comes another glass-another w'alk, 
and so on. For rainy weather the administration has 
■provided convenient covered walks, sheltered by trans- 
parent walls and roofs of glass. In fine weather there 
4S the well-kept little " park," with its gravel walks and 
its tastefully laid-out turf, and bosquets, and shrubs." 
After lunch comes exercise, then perhaps a bath or a 
■moderate potation. Another walk, or lounge, fills up the 
-afternoon, and then comes the six o'clock dinner. In 
the evening the ordinary amusements are provided, and 
everybody retires at an early hour. It is in the strict en- 
forcement of regular habits and a suitable regime that 
the European spas excel our own, and for this reason the 
therapeutic results seem so much better there. Mr. 
Wolff notes that the first effect of the water, which is 
readily assimilated, is to stimulate generally all animal 
functions. There is a notable acceleration of both pulse 
•and respiration, and a marked diuretic action. All this 
is not unpleasant. But after a period, in most cases after 
-about a fortnight, but sometimes much sooner, comes the 
" crisis," rather a trying ordeal. It does not as a rule 
last beyond from one to three days. Whatever its dura- 
tion, it makes the patient most decidedly uncomfortable. 
In regard to hotel accommodation and lodgings, Con- 
trexeville is now on a level with the better class of 
^French resorts. The season lasts from the middle of 
May to September. Edmund C. Wendt. 
CONVALLAMARIN. This glucoside is recommended 
to replace the other preparations of convallaria majalis, 
as its dose is more definite and its action more certain 
and prompt. It possesses all the desired properties as a 
heart tonic, and is devoid of any irritant action on the 
bowels and stomach. Convallarin, the other principle 
of the plant, contains the irritant properties and has 
been employed for its purgative action. Convallamarin, 
the chemical composition of which is C23H44O12, is a 
whitish, bitter, amorphous powder, soluble in water and 
alcohol. Its dose is from one-half to one grain, to be cau- 
tiously increased. When administered its action is di- 
rected to the muscular structure of the heart ; it renders 
its action more slow by prolonging the period of dias- 
tole, which period of rest is followed by a forcible con- 
traction and more thorough emptying of the cavities. 
When death is produced the heart is arrested in systole. 
As a cardiac tonic it proves of greatest service in cases 
where there is a failure of circulation due to organic 
heart disease ; it is indicated where the arterial pressure 
is reduced, the veins full, and the right side of the heart 
and lungs are engorged. By the more forcible contrac- 
tions which its use produces the arteries are filled and 
the equilibrium of the circulation regained. Where the 
heart trouble is far advanced, with extreme dilatation 
and loss of muscular power, the remedy must be given 
cautiously and its action carefully watched, as the ex- 
hausted heart may not be able to maintain the increased 
effort. The drug is excreted by the kidneys, and at the 
same time it exerts a direct diuretic action which is sup- 
plemented by the increased tension in the vessels, which 
must also be attributed to the action of the drug. Its ad- 
vantage over digitalis as a diuretic is its promptness of 
action, in which it resembles caffeine, and probably it 
occupies a position intermediate between the two. Al- 
though very much praised, it does not prove as efficient 
in cardiac therapeutics as digitalis, and in no sense super- 
sedes the more used drug; it, however, often proves of 
value to replace digitalis when it has been given for a pro- 
longed period, and may always be given when digitalis 
has failed or for other reasons cannot be administered. 
Beaumont Small. 
CORFU. The most important of the Ionian Islands 
(Greece), and a popular winter health-resort. Corfu can 
be reached by way of Trieste in fifty-three hours, and 
from Brindisi, Italy, in twelve hours. The steamers are 
moderately comfortable. The climate of Corfu may be 
considered as typical of the whole group of Ionian Islands. 
It is a warm place, having a mean annual temperature of 
65° F. But the winter months, which represent the 
invalids' season, average 53° F. Corfu has a moist, 
marine climate, although when the wind blows from the 
north extreme dryness may be the temporary result. 
Rain falls in almost every month, but during the seven 
cooler months only eighty rainy days occur on an aver- 
age. 
The capital (26,000 inhabitants) of the island is also 
called Corfu. It is well sheltered. According to Brad- 
shaw': "The bay is open to the full south and south- 
east winds, and consequently well protected against all 
northerly winds. The Bora is not felt here. Northwest 
and northeast winds are tolerably frequent, though the 
latter are objectionable only as being cold. The atmos- 
phere is never stagnant, owing to a sea-breeze which 
blows up to three o'clock, after which the land-breeze 
sets in. Rapid atmospheric disturbances, such as are 
met with on the Riviera, occur but seldom, and there is 
almost complete immunity from dust and high winds. 
" The climate, though warm, is bracing. At the end of 
January and in February hyacinths, roses, and almond 
trees begin to blossom. By March, spring has set in, 
and in April cherries are ripening. The temperature 
rarely falls to freezing-point, and still more rarely 
below' it. Fogs occasionally occur and last some time. 
" The town itself offers many attractions. It is a link 
between the East and the West. Its streets are very live- 
ly. Close to the town on a small hill is a villa belonging 
to the King of Greece. The esplanade and the Strada 
Nuova are the centre of Corfu life. The environs are 
mostly covered with olive groves. The interior of the 
island offers a fine field for excursions and sports. Naples 
has been called the El Dorado of Hypochondriacs, and 
Corfu may claim the same honor. The drinking-water 
and the means of communication are excellent." 
The class of cases sent to Corfu comprises many mor- 
bid states, and many tourists of the semi-invalid class 
spend more or less time there. Scrofula, chloro-ansemia, 
neurasthenia, protracted convalescence after severe ill- 
190 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Contrex6 ville. 
Cranial Nerves. 
ness, catarrhal affections of the upper air-passages, dys- 
pepsia, gout, and incipient phthisis are all said to be 
benefited by a winter residence on this pretty island. 
There are fair hotel accommodations at moderate prices, 
postal and telegraph facilities, an English church, etc. 
The Hotel St. George is one of the principal 
■establishments. Edmund C. Wendt. 
CRANIAL AND SPINAL NERVES. The 
account of the development of the cranial and 
spinal nerves given in a previous volume of the 
Handbook must now be considerably enlarged 
by reason of recent discoveries. 
It is well known that the first trace of the 
nervous system is the formation, in the middle 
of the blastodermic area, of a longitudinal band 
of cells called the medullary plate; and that 
this plate, by the inversion of its edges caused 
by cell proliferation, is converted first into a 
groove, the medullary or neural groove, and 
afterward into a canal, the neural canal. 
The epithelium forming the inner wall of the 
tube is, of course, derived from the ectoderm. 
Its cells show, even at an early stage when 
■composed of but a single layer, a differenti- 
ation into two kinds that differ in shape, func- 
tion, and subsequent history. One form, the 
spongioblast of His, is columnar, with oval 
nuclei, is passive in character, and constitutes 
the sustentacular portion of the 
tissue ; the other, the germ-cell 
of His, is round, with a large 
nucleus which usually has kary- 
okinetic figures indicating rapid 
proliferation, and is evidently 
more active in character. (See Fig. 123.) 
The cell-body of the spongioblast soon 
differentiates into two distinct substances, 
a clear, hyaloplasmic, non-stainable por- 
tion, probably of fluid consistency, and a 
dark, metaplasmic portion that is readily 
stained and becomes arranged in a re- 
ticular manner. This latter at first ex- 
tends throughout the entire cell-body, 
but finally disappears at one end, and a 
columnar process is 
formed by the appo- 
sition of the walls 
of two contiguous 
cells, while at the 
other the basket-like 
reticulum remains. 
(See Fig. 124, A.) 
At the ends of the columns the 
original boundaries of the cell remain 
defined by a ring of metaplasm, and a 
section parallel to the surface shows 
a flat sheet of lace-like net-work. (See 
Fig. 124, B.) Sooner or later the hyal- 
oplasmic material disappears, leaving 
the nuclei with the columns stretch- 
ing toward the free inner or ventricu- 
lar surface of the medullary canal and 
the basket-work forming the external 
boundary of the original plate. (See 
Fig. 124, U.) This external boundary 
or reticulum becomes important, as it 
limits the migration of the active ele- 
ments hereafter to be described. It is 
accordingly called by His the " border 
veil," for which Hill has proposed the 
equivalent term, velum confine. 
By means of this arrangement of the spongioblasts there 
is laid down a trabecular framework with the trabeculae 
disposed radially about the ventricular cavity of the neu- 
ral tube. The system is termed the myelospongium, and 
is afterward developed into the neuroglia, which is, 
therefore, a purely ectodermic tissue correlative with the 
other nerve-elements, and not, as was formerly supposed. 
(SUPPLEMENT.) 
a mesodermic or true connective tissue. At an early 
stage the trabeculae appear to anastomose. (See Fig. 125.) 
This is due to the adherence of the metaplasmic walls of 
contiguous cells. 
Origin of Nerve-cells and Nerve-fibres.-Even when 
Fig. 124.-Details of the Spongioblasts. A, spongioblast in which the reticulum is 
forming at one end while the other has become columnar. B, arrangement of the 
inner ends of the spongioblasts to form the membrana limitans. Surface view. C, 
radial arrangement of the spongioblasts ; a, membrana limitans ; 6, columnar layer; 
c, nuclear layer ; d, velum confine. After His. 
the epithelium of the medullary plate is constituted by 
only a single layer, there are found here and there among 
the columnar cells the round-celled elements ■which have 
already been referred to as germ-cells. They occur in 
varying numbers, sometimes diffused at considerable in- 
tervals, sometimes quite closely packed. In the region 
of the neck they develop earlier than elsewhere. It is not 
yet known whether they develop from the spongioblasts, 
or exactly by what steps both are derived from the com- 
mon, embryonic, ectodermal cells. They are found at first 
Fig. 123.- Ecto- 
derm from the 
Medullary Plate 
of the Rabbit. 
A, A, supporting 
epithelial cells or 
spongiobl a s t s ; 
B, ger m - c e 11. 
After His. 
Fig. 125.-Formation of Neuroglia. Section from the spinal cord of a human embryo of about three 
and a half weeks, l.m, membrana limitans; N, germ-cell; ngl, neuroglia ceils; Ruch, velum 
confine. After His. 
in the so-called germinal area of the medullary tube, that 
is to say, quite near the ventricle or lumen of the tube, be- 
tween the rod-like processes of the spongioblasts (see 
Fig. 126, (r), or in rare cases extruding through the meshes 
of the membrana limitans and projecting into the ventri- 
cle. 
Soon these cells begin to grow. At first spherical, they 
191 Cranial and 
Spinal Nerves. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
become pointed and then pear-shaped, lengthening out 
into a conical process. They are then called neuroblatts, 
as they are the primitive nerve-cells, and the process is 
the beginning of a nerve-fibre. (See Fig. 126, N.) At this 
period they are evidently movable, as they migrate from 
the situation where first found, near the membrana limi- 
tans, and pass outward, following the radial interspaces of 
the spongioplasm, to become collected near the velum 
confine in a sheet, known as the mantle layer, which be- 
comes the foundation of the gray matter of the cord. The 
(SUPPLEMENT.) 
formation of nerves, is now called the nerve process (axis 
cylinder process of Deiters), may, as already stated, pass 
out to become a constituent element of the anterior or 
Posterior Root. 
Ganglion. 
Anterior Root. 
Fig. 126.-Development of Neuroblasts. From a section of the medulla 
oblongata of a human embryo. G, germ-cell; y, neuroblast; ngl, 
neuroglia cell. After His. 
Fig. 128.-The Formation of the Nerve-roots. Section through the spi- 
nal cord of a human embryo. The condition of the anterior root 
corresponds to the development at the fourth week, that of the pos- 
terior to about four and a half weeks. Combined by Edinger from 
representations by His. • 
processes have now become striated and extend for a con- 
siderable distance peripherally. (See Fig. 127,/,/'.) 
At the end of each growing process a slight enlarge- 
ment occurs, and upon this there may be seen minute ele- 
vations or papillae. The enlargement is called by Ramon 
y Cajal the cone of growth. The direction which these 
primitive fibres take differs somewhat in different regions 
of the cord. In the dorsal half the nerve processes turn 
so as to run vertically along the velum confine and paral- 
lel to the surface ; in the ventral half they proceed directly 
outward, pierce the velum confine in compact bundles, 
and become the anterior or ventral roots of the spinal 
nerves. (See Fig. 128.) 
The rounded head of the neuroblast usually undergoes 
motor root of the spinal nerves. It passes to the pe- 
riphery and there becomes associated with the muscular 
elements. Afterward the process becomes provided 
with a medullary sheath derived from the connective tis- 
sue of the mesoblast, the process itself being the axis 
cylinder of the nerve-fibre. Thus we see that we must 
no longer consider the fibres of the nervous system as 
elements distinct from the cells with which they are con- 
nected, but rather as integral parts of such cells. In the 
adult human body the cells of the anterior horn of the 
spinal cord send prolongations to the extremities of the 
Fig. 127.-Neuroblasts forming Nerve-roots. Section from the spinal 
cord of an embryo cat. N, neuroblasts; f.f, their processes combin- 
ing in bundles to form the anterior roots of the spinal nerves. After 
His. 
a further modification. Around its circumference small 
buds begin to appear which push outward in the same 
manner as the primitive process did, and develop into 
the so-called protoplasmic or dendritic processes of the 
nerve-cells. These are seen therefore to be of precisely 
the same character as the others, only differing in the 
time of their development. Lenhossek has shown, by 
observations upon the earthworm (Lumbricus), that there 
is originally no morphological difference between these 
processes. All the processes are dendritic in this animal, 
one set passing out to communicate with the periphery, 
another to convey impulses to other cells. 
The primitive process which, because it assists in the 
Fig. 129.-The Formation of the Neural Greet. Sections through the cer- 
vical region of a human embryo of 14 to 16 days. Ec, ectoderm ; mes, 
mesoderm ; Gl, beginning of the spinal ganglion, first known as the 
neural crest; nul, medullary plate. After Lenhossek. 
limbs. The growth of the nerve-process is at first quite 
rapid, but afterward decreases. 
It seems at first difficult to understand how these pro- 
cesses can pass from the spinal cord and traverse so un- 
erringly such a vast extent of the body (comparatively 
192 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Cranial and 
Spinal Nerves. 
speaking), and arrive at their destination in the group of 
muscle-cells to which they belong. Yet it should be re- 
membered that the distance traversed is, at the stage of 
embryonic life at which this growth occurs, but a few cen- 
timetres at most ; and further, it is noticed that the neu- 
roblasts have a tendency to unite together in groups, 
sending out their processes together as a single bundle 
(see Fig. 127) which appears to be directed to a correspond- 
ing bundle of muscle-fibres, so that an exact adjustment 
of each neuroblast to a special myoblast does not appear 
to be necessary, the adjustment taking place rather be- 
tween the grosser elements formed by the separate 
groups. It is not impossible that in this group-like ar- 
rangement of the primitive elements there may yet be 
found the key to a true morphological arrangement and 
classification of the muscles. 
It will be noted that the foregoing account relates only 
to the origin of the anterior roots. The development of 
the posterior roots is no less instructive. 
In Fig. 129 there are shown sections across the inedul- 
(SUPPLEMENT.) 
cells of the neural crest assume a spindle shape before 
they become detached from the medullary canal. They 
are then termed ganglioblasts (Lenhossek). The ends of 
the spindle finally lengthen out into processes running 
in opposite directions, and a bipolar cell results. (See 
Fig. 130, also A of Fig. 132.) 
In these cells the oval nucleus is placed to one side, so 
that the fibres run directly through opposite to each 
Fig. 131.-The Stages of Unipolarization of Ganglion Cells. (Lenhossek.) 
A, oppositipolar cells; R, geminipolar cells; C, unipolar cells. 
other. The cells have accordingly been termed oppositipo- 
lar (Courvoisier). They resemble greatly at this stage the 
cells found in the ganglia of most adult fishes. The con- 
dition remains permanent in man only upon the ganglia 
connected with the auditory nerve, viz., the ganglion of 
Scarpa, found upon the vestibular nerve within the in- 
ternal auditory meatus, near its origin from the auditory, 
and the ganglion spirale, found upon the cochlear nerve 
within the walls of the cochlea. In other situations the 
processes change their relations to the cell-body, for the 
axis of the ganglion being more and more invaded by 
nerve-fibres, the cells are pushed to the sides and the pro- 
cesses are so displaced as to be given off close together 
from one side of the cell, which 
is then called geminipolar. Fin- 
ally the processes unite to form 
a single one, and the cell is then 
unipolar, the cell-body standing 
at some distance from an appar- 
ently continuous fibre attached 
as by a pedicle. The stages of 
the process are shown in the an- 
nexed diagram, Fig. 131. 
It seems unlikely that this 
modification in the arrangement 
of the processes of the cell 
should make any material dif- 
ference in its functions. The 
evidence that we have in regard 
to the functions of cells shows 
that the principal seat of activity 
is in the central protoplasmic 
mass, and especially in the nu- 
cleus of that mass. It seems, 
therefore, almost certain that 
the influences received from the 
periphery must travel up to the 
body of a unipolar cell, and 
thence out again toward the cord. 
The appearance of the adult 
ganglion-cell is shown in Fig. 
132, B, where it is contrasted 
with the earlier form. The bi- 
furcating fibres characteristic of 
these cells are known as the T 
fibres of Ranvier. 
From a morphological point of view ganglioblasts may 
be regarded as cells of special sense, formerly situated at 
the periphery of the body, and now withdrawn to the 
edges of the medullary plate. In invertebrate animals, 
as, for example, in lumbricus (Lenhossek), such cells ex- 
ist at the periphery and receive impulses like other sen- 
sory cells upon special collecting processes situated im- 
mediately under the epidermis. These impulses they 
transmit to the central nervous system by means of a 
Fig. 130.-Ganglioblasts. Group of cells from the spinal ganglion of a 
human embryo. After His. 
lary groove taken at different nerve-levels. At A the 
groove is widely open, the ectoderm exterior to it is seen 
as a thin layer which becomes thicker by the addition of 
some spherical cells, Gl, just at the edge of the groove. 
At B we see the groove nearly closed, and at C the closure 
completed. The spherical cells have united on the mid- 
dle line to form a longitudinal band known as the neural 
crest. This at first occupies a median position and shares 
the segmentation which, though but slightly shown in 
the cord, is well marked in all accessories belonging to 
the nerves. It then becomes displaced on either side to 
form the ganglia situated on the posterior roots of the 
spinal nerves. It will thus be seen that the spinal 
ganglia are not, as they seem, integral parts of the nerves 
exterior to the cord, but detached portions of the original 
medullary plate, and should be regarded as displaced 
segments of the spinal cord. Therefore their cellular 
elements may well be of the same general nature. 
This is found to be actually the case. The rounded 
Fig. 132.-Cells from Spinal 
Ganglion. A, from hu- 
man embryo of four and 
a half weeks ; B, from an 
adult rabbit; ax, axis 
cylinder; M, nuclei of the 
medullary sheath ; R, node 
of Ranvier. After His and 
Schiefferdecker. 
193 Cranlal and 
Spinal Nerves. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
fibre. Such cells agree in general form with those of the 
anterior horn of the spinal cord, the collecting processes 
of the one corresponding to the dendritic processes of the 
other. When the cells are withdrawn to a more central 
situation, the connection with the collecting processes is 
made by a lengthened, secondary fibre, which becomes the 
peripheral pole of a bipolar cell. Other matters con- 
nected with the development of the ganglia of the cranial 
nerves tend to show that the ganglia may properly be 
considered as sense organs that have been withdrawn 
from the surface. 
Thus it is found that both the anterior and posterior 
nerve-roots are formed of processes of cells situated, 
for the anterior roots, within the gray matter of the 
spinal cord, for the posterior roots, within the spinal 
ganglia. 
This discovery is due almost entirely to the researches 
of His. It strildngly confirms the results obtained by 
section of the nerve-roots. . It is well known that if the 
anterior root is cut the nerve-fibres degenerate from the 
section toward the periphery of the body, and that if the 
posterior root is cut between the ganglion and the cord 
the fibres do not degenerate, while if cut beyond the gan- 
glion the fibres affected are speedily destroyed. (See 
Fig. 133.) 
This was formerly ascribed to a supposed " trophic in- 
(SUPPLEMENT.) 
change these names. The first class are now known as 
dendritic processes, the second as nerve-processes. 
Gerlach, in his excellent article on the spinal cord, pub- 
lished in Stricker's " Handbook of Histology " (1871-72), 
attempted to show that all cells are not provided with 
nerve-processes, that those so characterized are typically 
represented in the anterior horn of the spinal cord, and 
are probably motor, as they appear to be connected with 
the motor roots of the nerves, that the cells not so char- 
acterized are found in large numbers in the posterior 
horn of the spinal cord, and that their dendritic processes 
are united together to form a fine reticulum with which 
he believed the posterior roots to connect. This, there- 
fore, was characteristic of the sensory nerves. Gerlach's 
views have prevailed until quite recent times, his " reti- 
cular formation " being mentioned as an anatomical fact 
in text-books now in general use, as for instance, Macal- 
ister's "Human Anatomy," 1889, and in Obersteiner's 
" Anatomy of the Central Nervous Organs," translated 
by Hill, 1890. 
It is not at all surprising that those views should be 
held when the technical methods in use are considered. 
Every advance in histology has been heralded by some 
improvement in microscopic or in technical manipulation, 
and it is not always realized that our knowledge of mi- 
nute anatomy is so recent. Schwann's researches on cells 
FIG. 133.-Deg< aeration of Nerve-fibres after Section. A, section of entire trunk beyond ganglion; B, section of anterior root; C, section of pos- 
terior root (a few fibres are shown as degenerating beyond the section) ; I), excision of ganglion. 
fluence" which was thought to reside in the anterior 
horn of the spinal cord for the anterior roots, and in the 
spinal ganglion for the posterior roots. Since it is recog- 
nized that we are merely cutting off cell-processes, the 
results become intelligible. 
Central Connections of Cells and Fibres.-The investi- 
gation of the central organs has long been singularly un- 
satisfactory from an anatomical point of view. The 
ganglion-cells in the spinal cord were first discovered by 
Ehrenberg in 1833, and described by Valentin in 1836. 
Those in the brain were discovered by Purkinje in 1838. 
In the same year Remak noticed that some processes of 
cells in the sympathetic nervous system appeared to be 
continuous with medullated nerve-fibres. Kolliker first 
noticed that such fibres arise from the unipolar cells of 
spinal ganglia. That these cells are usually bipolar in 
fishes was noticed in 1847 by several observers, inde- 
pendently, viz., Bidder and Reichert, Charles Robin, 
and R. Wagner. In 1851 Wagner, in examining the 
electrical organ of the torpedo, noticed that but one, or 
at most two, of the processes of the nerve-cells were con- 
nected with nerve-fibres. This was verified by Remak 
in the spinal cord of the ox in 1854. Special attention to 
these facts was, however, first drawn by Deiters in 1865, 
who noted that the greater number of the processes of 
the nerve-cells are short and break up immediately into 
fine arborescent forms that he called " protoplasmic " pro- 
cesses, but that among the others there was frequently 
found one that appeared to run without division. This 
he assumed to be continuous with the axis cylinder of a 
nerve-fibre, and therefore called it the axis-cylinder pro- 
cess. Recent discoveries have made it advisable to 
were not published until 1839, it was not until 1842 that 
Stilling invented the method of cutting thin sections in 
series, Gerlach first stained tissues in 1858. The wide 
extension of this method is now well known. 
The preparations by which Gerlach sustained his views 
■were prepared with the greatest care and are marvels of 
patient skill. He admitted, however, that he had never 
been able to trace a nerve-process into a nerve-fibre, nor 
had he actually demonstrated the connection of nerve- 
fibres with the plexus of dendritic processes. The con- 
nections of the fibres rested therefore upon hypothesis 
rather than upon any actual anatomical demonstration. 
The special obstacle in the way of progress was the 
great complexity of the interlacing fibres and pro- 
cesses that made it absolutely impossible to follow 
the connections of the cells for any distance. It 
seemed of no use to further pursue the subject by this 
method. 
This being the case, attempts were made to obtain fur- 
ther knowledge of the connections of the cells by their 
behavior under pathological and embryological condi- 
tions. Waller, in 1852, discovered that when a nerve was 
cut its peripheral end degenerated. It was soon sur- 
mised that this same law governed certain degenerations 
found in lesions of the spinal cord and other portions of 
the central nervous system ; and since the researches of 
His it is definitely known that degeneration occurs along 
the entire course of a nerve-fibre when it is severed from 
the cell from which it originally grew. Ample illustra- 
tion of this is shown in Fig. 133. Since degenerated fibres 
can be readily distinguished in serial sections, it became 
possible to investigate the course of fibres or groups of 
194 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Cranial and 
Spinal Nerves. 
(SUPPLEMENT.) 
fibres by means of experimental lesions made in different 
portions of the spinal cord. 
By observing degenerations, whether artificially pro- 
duced or the result of pathological processes, it was soon 
found that the central connections of the cranial and 
spinal nerves were not arbitrarily arranged, but that they 
followed a certain definite plan. A knowledge of this 
was often assisted by the study of malformations in 
which special tracts of the central nervous system were 
found to be wanting. 
Another discovery also greatly aided investigation. In 
the early embryo the only nerve-fibres found are those of 
the non-medullated variety, the myelin being afterward 
added. Flechsig (1872-76) found that this process of mye- 
lination does not occur at the same time in all parts of 
the nervous system, but seems to follow certain definite 
laws. Certain of the tracts already made out by the 
study of degenerations were found to myelinate at a dif- 
not to send fibres to the root of the same side, but to com- 
municate through the anterior gray commissure with the 
anterior root of the opposite side. 
The fibres of the posterior root were not considered to 
be connected with cells, but rather with the plexus of 
Gerlach. An exception was made, however, with regard 
to certain cells found in the column of Clarke, each of 
which was believed to have two processes, by one of 
which it was connected with the fibres of the posterior 
column. It was, however, acknowledged that many of 
the fibres of the posterior root did not enter the plexus at 
all: some turned inward and upward passing toward the 
brain, first in the column of Burdach, then in the column 
of Goll ; others passed into the lateral column where their 
subsequent course was unknown. 
The idea generally prevailed that the transmission of 
nervous impulses could only be explained by assuming a 
continuity of structure. The fibres and the cells must 
Fig. 134.-Former Theory of the Connections of the Nerve-roots with the Spinal Cord. A, unipolar cell of the spinal ganglion sending process to the 
column of Burdach ; B, same sending process to lateral column ; C, same ending in Gerlach's plexus of the posterior horn ; D, fibre of posterior 
root passing to a bipolar cell in the column of Clarke ; E, the other process of the same cell passing to the cerebellar lateral tract; F, large motor 
cell of the anterior horn ending in a nerve-process G, that passes into the anterior root; H, nerve-process from a cell of the anterior horn of the 
other side of the cord that passes through the anterior gray commissure : I, K, cells that form the plexus of Gerlach by anastomoses of their den- 
dritic processes ; L, nerve-process from one of these cells passing to the anterior root. 
ferent period from others, and thus their connections 
could be made out, confirming and amplifying the data 
already obtained. 
It would be beyond the scope of this article to give a 
complete account of the researches made under these dif- 
ferent heads. It will be necessary, however, to give a 
short summary of the principal results obtained with re- 
gard to the central connections of the cranial and spinal 
nerves at the date of the publication of the Handbook in 
order to make intelligible the recent discoveries. (See 
Fig. 134.) 
In the gray matter of the cord certain rather ill-defined 
clusters of cells were made out which were thought to 
have certain definite, relations to the nerve-roots. The 
anterior or motor root was composed of fibres arising 
from cells in ihe anterior and lateral horns. Those in 
the anterior horns are in three groups, described by Wal- 
deyer as the antero-medial, antero lateral, and postero- 
medial. The large cells of the lateral horn are considered 
by themselves and termed by Waldeyer the postero- 
lateral group. The postero-medial group was believed 
be continuous with other fibres and cells in order to pro- 
duce the so-called nerve-paths by which these impulses 
travelled. Thus the ordinary reflex acts which physiol- 
ogists found to occur within the spinal cord were be- 
lieved to be produced by the transmission of sensations 
through the posterior roots to the plexus of Gerlach, from 
which they were transferred either to a motor cell or to 
nerve-fibres formed by the union of the fibrillae of the 
plexus. The act was thus made clear and intelligible. 
It did not, however, rest upon any actual demonstra- 
tion. 
A short notice should be given to the views which 
have been advanced by Gaskell upon the nature of cranial 
and spinal nerves. 
On section of a nerve stained with osmic acid, it is 
noticed that the fibres involved are by no means all of 
the same calibre, or provided with the same thickness of 
medullary sheath. Nerves that supply the voluntary 
muscles appear to have a large proportion of large, dark- 
bordered fibres, while those supplying involuntary mus- 
cles and viscera have a great majority of small, fine me- 
195 Cranial and 
Spinal Nerves. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
dullated, or so-called "leucenteric" fibres. (See Fig. 
135.) 
Gaskell showed that these leucenteric fibres pass out of 
the spinal cord at certain definite levels, corresponding to 
cury, and then placing it in a silver solution. After suit- 
able maceration in this it is found that a fine deposit 
occurs along every nerve-fibril, distinctly marking it out. 
This deposit is probably a chromate or chloride of silver 
precipitated in exceedingly-delicate crystals. The prep- 
aration of material by this method is by no means easy. 
It must be perfectly fresh ; the solution must be of a 
certain definite strength ; the exposure is long, weeks 
and even months being required for some results, and cer- 
tain precautions in handling and keeping are absolutely 
necessary. The section must be mounted in Canada bal- 
sam without a cover glass. 
The results obtained are truly astonishing. For the 
first time every detail of the cell-processes is clearly made 
out, marked with the precision of a line of black upon a 
white page. It is no longer necessary to deal with nerve- 
cells that have been mutilated and displaced from their 
natural connections by teasing, their processes appearing 
C and D 
Ascending 
Ascend- 
ing 
V 
Fig. 135. - Sections across Parts of the Roots of Various Nerves of 
the Dog, to show the Variations in Size of their Constituent Fibres 
(Gaskell). The nerves were stained with osmic acid and the sections 
are all drawn to one scale. A, from one of the upper roots of the 
spinal accessory ; B, a rootlet of the hypoglossal ; C, from the first 
cervical anterior root; D, from the second thoracic anterior root. 
Vaso motor. 
the exit of the fibres going to the splanchnic nerves and 
other trunks of the sympathetic nervous system. He 
thus divided the nerve-fibres into two classes, the somatic, 
supplying the somatopleuric portion of the mesoderm, 
and the splanchnic, supplying the splanchnopleuric por- 
tion. These he again separates into efferent and affe- 
rent subdivisions. 
He also assigned to certain definite cell-groups in the 
spinal cord the function of presiding over these separate 
nerve-fibres. The somatic efferent nerves he connected 
with the large cells of the anterior horn; the splanchnic 
efferent with those of Clarke's column ; the cells of the 
lateral horn with the solitary cells at the base of the pos- 
terior horn. 
No special groups for cells are assigned to the efferent 
nerves. 
He considers that in the system of cranial nerves certain 
of these groups have a tendency to break up and form 
special nerve-strands. His application of the theory will 
be seen on examining Figs. 137 and 138. 
To an Italian anatomist, Camillo Golgi, of Pavia, is due 
the discovery of methods of staining nerve-fibres which 
has led to most important practical advances in our 
knowledge. This is essentially an impregnation of the 
tissue with either a chromic salt or bichloride of mer- 
Fig. 137.-Schematic Cross-section of the Medulla Oblongata. (Gaskell.) 
A, cells corresponding to those of anterior horn ; B, cells correspond- 
ing to those of lateral group of anterior horn ; C, cells corresponding 
to Clarke's column ; D, cells corresponding to the solitary cells at base 
of posterior horn ; E, cells corresponding to those of lateral horn ; a, 
somatic efferent fibres ; b, somatic afferent fibres; c, splanchnic non- 
ganglionic efferent fibres ; d, splanchnic ganglionated efferent fibres ; 
e, splanchnic afferent fibres. 
as bare stumps, and all fine details of structure swept 
away. Another advantage is that, for some reason not 
yet clearly understood, certain cells of the section stain 
sooner than others, so that by adjusting the time of 
maceration it is possible to obtain only a few cells stained 
at a time, and thus to follow out the complicated ramifi- 
cations of a single cell without having it confused by the 
details of the other cells in its immediate neighborhood. 
By varying the procedure slightly it is possible to stain 
the neuroglia without affecting the other elements. 
Golgi was at once able to settle definitely certain im- 
portant matters. The connections of the nerve-roots be- 
came no longer matters of surmise and hypothesis, but 
reached the realm of actual ocular demonstrat ion. He 
was able to show that the prevalent theory with refer- 
ence to the cell-processes was incorrect. Not only do all 
nerve-cells possess a nerve-process-that process invari- 
ably branches at a greater or less distance from the cell. 
It can, however, be distinguished from the den- 
dritic processes by its manner of branching and its 
comparatively simple course. 
There exist two types of cells, dis- 
tinguished by the behavior of their 
nerve-processes: First, those in which 
the nerve-processes preserve their in- 
tegrity for a considerable distance, 
always giving off, however, some col- 
laterals, passing finally into a nerve- 
fibre and breaking up at its termina- 
tion ; 2d, those in which the nerve- 
process after a short course divides 
and subdivides within the gray sub- 
stance of the nervous centres, form- 
Fig. 136.-Cross-section of the Spinal Cord, to show Gaskell's Views. (Hans Gadow.) A, cells 
of posterior horn : B, cells of Clarke's column; C, cells of the lateral horn ; D, cells of an- 
terior horn ; E, solitary cells at base of posterior horn; a, somatic afferent fibres; b, 
splanchnic ganglionated efferent fibres ; c, splanchnic non-ganglionated efferent fibres for 
visceral and enteric muscles ; d, somatic efferent fibres ; e, splanchnic afferent fibres. 
196 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Cranial and 
Spinal Nerves, 
ing thus the plexiform arrangement described by Gerlach. 
The nerve-processes of these cells never contribute to the 
formation of nerve-fibres. (See Fig. 139.) 
Golgi was not able to fully disembarrass himself of 
the old ideas with regard to the anatomy of the nerve- 
centres. As the cells with long nerve-processes are found 
(SUPPLEMENT.) 
of a single specimen. Then, too, it is found that the em- 
bryonic tissues are particularly susceptible to this method 
of investigation. 
In studying by the new method the cerebellum of the 
embryo of birds and mammals, Ramon y Cajal arrived at 
certain conclusions with reference to the nature and re- 
lations of nerve-cells that were considerably at variance 
with the scheme of Golgi, and which profoundly affected 
the whole question of the structure of the nervous sys- 
Fig. 138.-Diagram of the Arrangement of the Cranial Nerves. (Gaskell.) 
mostly within the anterior horn of the cord, he concluded 
that they must necessarily be motor cells. He also as- 
sumed that the great part of the cells of the second type, 
that is to say, those with short nerve-processes, were to be 
found in the posterior horn, and must therefore be con- 
sidered as sensory cells. In fact, his view differed but 
very slightly from that of Gerlach, as will be seen by 
contrasting the two diagrams in Fig. 140. The difference 
was merely one which affected the processes by whose 
ramification the plexus was made up. While Gerlach 
assigned this rile to the dendritic processes, Golgi con- 
sidered that it was effected by the collateral branches of 
tem. Continuing Ins observations to tne investigation oi 
the spinal cord, he was able to show, first, that the nerve- 
cells are entirely independent, and never anastomose 
either by their dendritic or by their nerve-processes ; 2d, 
that every nerve-process, whether long or short, ends 
either simply or by ramifications which may either be 
within the motorial end-plate of a muscle-fibre, as in the 
cells of Golgi's type I., or in protoplasmic expansions in 
contact witli the body or processes of other cells; 3d, 
that these latter establish by contact alone communi- 
cations as effectual for the transmission of impulses 
as the continuity of structure formerly supposed to 
exist; 4th, that the dendritic processes of cells are 
probably also conducting elements, and not merely 
for the purpose of imbibing nutriment, as heretofore 
thought. 
Anastomosis of the processes of one nerve- 
cell with another is absolutely denied. Each 
cell is a special structural unit that remains 
functionally and anatomically distinct. This, 
it will be noted, agrees entirely with the em- 
bryological evidence produced by 
His; for each cell, with its den- 
dritic and nerve-processes extend- 
ing perhaps a distance of several 
feet, is the result of the growth of 
a single neuroblast. Waldeyer has 
given to each of the units so 
formed the name of neuron. The 
entire nervous system is a combi- 
nation of neurons, independent in 
structure, and combined for func- 
tional purposes by the juxtaposi- 
tion of their processes. Each neu- 
ron may be considered as composed 
of three portions: the cell-body, 
the nerve-fibre, and the fibrillary 
arborescence in which the fibre ter 
minates. The appearance of the connec- 
tions of the nerve-roots with the spinal cord, 
as demonstrated by Golgi's method in the 
embryo chick, is shown in Fig. 141. 
The minute elevations noted on the 
" growth cone " at the end of each growing 
process, referred to in the first part of this 
article, are apparently the budding terminal 
fibrillae of the fully developed neuron. The power of 
peripheral extension appears by no means to be confined 
to foetal life. It is probably by such extension, from al- 
ready existing cells and fibres, that nerves are renewed 
after section. There appears indeed to be a general ten- 
dency for fibres to extend until arrested at the periphery. 
When cut, as in amputations, they still continue to grow, 
causing the well-known convoluted growths (traumatic 
Fig. 139. - Types of Nerve-cells as shown by 
Golgi's Method. A, cell with long nerve- 
process, Golgi's Type I., also called a Deiters 
cell; B, cell with short nerve-process, Golgi's 
Type II., also called a Golgi cell; *, *, nerve- 
processes. 
the nerve-processes, and that reflex phenomena 
take place through this plexus in essentially the 
same way as imagined by Gerlach, and that by 
its connections with other nerve-roots different 
levels of the cord are excited and associated for 
co-ordinate movements. 
The method of Golgi was soon taken up by other 
histologists and applied to a wide range of research. It 
has been especially fruitful in the hands of the well- 
known Spanish investigator, Dr. Santiago Ramon y Ca- 
jal, Professor in the University of Barcelona. Great 
advantage is obtained by applying it to embryonic tissues, 
as the field is much smaller and the elements fewer, 
so that it is possible to bring an area corresponding to a 
considerable extent of the adult tissues within the limits 
197 Cranial and 
Spinal Nerves. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
neuromata) found in stumps after healing, His suggests 
that it is by a similar extension of growth of fibres within 
the central organs that one portion of the brain is enabled 
to assume vicariously the functions ordinarily belonging 
to another part, after such part has been destroyed or 
become disabled. The growth of fibres is by no means 
But in 1889, at the meeting of the Anatomical Society at 
Berlin, he exhibited specimens which convinced the 
most sceptical. The discoveries were immediately taken 
up and fully confirmed by von Kdlliker, of Wurzburg ; 
Waldeyer, of Berlin ; Lenhossek, of Basel ; and van Ge- 
huchten, of Louvain ; all of whom have published im- 
portant papers on the subject. 
The fibres of the posterior root, according 
to these observers, are of two varieties, centrip- 
etal and centrifugal. The former, by far in 
the majority, do not enter the gray substance 
as undivided fibres, according to the prevalent 
view, but immediately bifurcate, Y-like, one 
limb ascending, another descending. These 
limbs run longitudinally in the posterior col- 
umns of the cord, which are almost wholly 
made up of these continuations of the posterior 
roots. (See Fig. 142.) 
rapid-weeks and even months being required for them 
to reach their ultimate destination. 
The cells belonging to the spinal ganglia, hi some cases, 
end peripherally without bifurcation, and become envel- 
oped by special sheaths of connective tissue, as in the 
corpuscles of Pacini or of Krause ; in others they divide 
into fibrillte that end freely in the intercellular spaces. 
What, now, are the central connections of the fibres de- 
rived from the posterior roots ? Already, in 1885, Nan- 
sen had demonstrated that in Myxine glutinosa, one of the 
lowest fishes, those fibres bifurcate upon reaching the 
white substance of the cord. Golgi also had seen such 
Fig. 142.-Entrance of the Posterior Roots of the Spinal Nerves. (Ram6n 
y Cajal.) A semi-diagrammatic, longitudinal section of the posterior 
column of the cord, taken parallel to the entrance of the posterior 
nerve-roots. A, posterior root; B, white substance ; C, gray sub- 
stance ; D, cell of the posterior horn whose nerve-process bends up- 
ward ; E. cell with bifurcating nerve-process: F. cell whose nerve, 
process bends downward ; G, H, and I, final ramifications of nerve- 
processes : K, K, K, final ramifications of collaterals; a', collateral 
from the ascending branch of a nerve-fibre of the posterior root; b', 
collateral from the main trunk of a fibre of the posterior root. 
Fig. 141.-Transverse Section of the Spinal Cord of a Chick at the Ninth 
Day of Incubation. (Ramon y Cajal.) V.r, axis cylinders of anterior 
root-fibres issuing from the large cells of the anterior horn, N; Dr, 
posterior root-fibres passing from the bipolar ganglioblasts of the spinal 
ganglion, Gl, into the posterior column of the spinal cord, where they 
bifurcate and send collaterals that penetrate the gray matter. 
These latter fibres give off, at right angles to their 
course, delicate collateral branches (a', Fig. 142) which 
penetrate the gray substance and terminate by free rami- 
fications (K) that surround the nerve-cells. Collaterals 
may also be given off from the trunk-fibre before its di- 
vision (b"). A slight thickening is observed at the point 
where these collaterals arise, and their origin is always, 
as in the division of the single pole of an adult ganglio- 
blast (Fig. 132, B), at a node of Ranvier. 
The ascending and descending limbs of the bifurcating 
fibre probably end by bending sharply at a right angle, 
taking a course like the collaterals, and breaking up in a 
similar manner. Their full extent has not been com- 
pletely demonstrated. In the embryo the course of the 
fibres has been followed for a distance of several milli- 
bifurcations, as appears from publications made by him 
in 1881. These observations were, however, fragmentary 
and without special result. It was reserved for Ramon 
y Cajal to clearly unravel the central connections. His 
first publications were received with the same incredulity 
as those of his predecessors, and the text-books of Obcr- 
steiner, Edinger, and others, on the anatomy of the ner- 
vous centres, although published some time after his 
discoveries had been made, yet give no account of them. 
198 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Cranial and 
Spinal Nerves. 
metres, and it lias been estimated by Kolliker that this 
corresponds to a distance of from six to seven centimetres 
in the adult. From clinical and experimental evidence 
it is believed that they extend much further. It is known 
that after section of the posterior roots an ascending de- 
generation occurs, reaching as far as the medulla ob- 
longata to the nuclei found in the columns of Goll and 
Burdach, or perhaps even higher. Also, that a certain 
amount of descending degeneration occurs, not extending, 
it would appear, for any very great distance. 
As the fibres of each successive nerve-root divide, the 
ascending and descending limbs push those coming up 
from a lower level toward the middle line, so that their 
ascending course is slightly oblique rather than vertical, 
and at last they are displaced from 
the column of Burdach to the 
column of Goll. This accounts for 
the fact already noted by physiolo- 
gists, that lesions of the latter 
column are usually found to be as- 
sociated with the leg rather than 
the arm ; and also explains the rea- 
son why that column is usually 
composed of finer fibres. Contain- 
ing the terminals of the fibres that 
enter on much lower levels than 
those in the column of Burdach, 
they would naturally be smaller. 
The fibres of the column of Goll 
also acquire their myelin sheaths 
at a later date. (Flechsig.) 
The course and ultimate distribu- 
tion of the collaterals within the 
^ray matter of the cord is, it 
will be seen, of considerable 
Iidorncf a a it maar ho ovnoofod 
are conveyed to the ganglioblast at d, and thence to the 
cord, where by'the bifurcation at e they may extend 
either upward or downward, and affect different levels 
supplied by the collaterals h, h, h, which in their turn 
communicate by contact with the motor cells a, a, that 
convey impulses through the anterior root, and by termi- 
nal ramifications to the muscle-fibre c. It will be noticed 
that but two neurons are involved in this act. 
II. Another bundle of collaterals passes to the column 
of Clarke from the middle region of Burdach's column. 
The fact that such a path existed was already demon- 
strated by Flechsig (" Leitungsbahnen," Plate xviii., 
Fig. 123), as shown on Fig. 134, D. The fibres break 
up within the column, surrounding the cells with a rich 
net-work. The fibres are provided with a medul- 
lary sheath much farther than usual, and this is 
thought to be the reason why Clarke's column has 
such a markedly fibrous appearance when colored 
by haematoxylin (Lenhossek), and why it is one of 
the first areas to show degeneration in tabes. 
III. A few collaterals pass from the fibres of 
the posterior root through the gray posterior com- 
missure, to break up into tufts in the posterior 
horn of the opposite side, in front of the sub- 
stantia gelatinosa of Rolando. (Fig. 144, 3.) 
Unilateral section of the cord, as is well known, 
abolishes tactile sensation on the opposite side be- 
low the lesion. The decussating fibres here de- 
scribed are, however, evidently insufficient to 
fully account for this phenomenon. These decus- 
sating fibres are much more marked in the dog, 
rabbit, and guinea-pig than in man. 
IV. A great number of the collaterals from the 
fibres of the posterior root penetrate the posterior 
horn, passing through the substantia gelatinosa 
and breaking up in the gray matter immediately 
beyond. These are the fibres that have been 
hitherto noticed by anatomists streaming through 
the gelatinous substance in arcades like meridians 
of longitude on the surface of the globe. The ter- 
minal filaments are unusually fine and numerous, 
and being readily stained, produce the appearance 
which Waldeyer has called the nucleus of the 
posterior horn. 
As to the elements of the posterior nerve-roots 
which have been spoken of as centrifugal, it is 
noticed that when the roots are cut a small num- 
ber of fibres degenerate peripherally. (See Fig. 
133.) These have no connection with the cells of 
the spinal ganglia. Lenhossek thinks that in the 
spinal cord of the chick, on the fifth day of incu- 
bation, he has been able to demonstrate that these 
fibres arise from cells in the anterior horn. Their 
function is unknown. If their existence in all 
vertebrates is ascertained, it will be a very in- 
teresting exception to the well-known law of Bell, 
by which the posterior roots are held to be ex- 
clusively centripetal. 
It will be evident from this sketch of the be- 
havior of the posterior roots, that an account of 
them will be incomplete without some notions of 
the cells of the cord with which they are anatomi- 
cally related, and to which they probably trans- 
mit their impulses. Upon the right-hand side of 
Fig. 144, the principal groups of such cells are diagram- 
matically indicated. \/ 
Radicular Cells.-Those are the cells already referred 
to that send processes to the nerve-roots. (Fig. 144, a, a.) 
They are confined to the anterior and lateral portions of 
the anterior horn, and send their processes to the anterior 
root already adverted to. The passage of fibres from cells 
of one anterior horn to the anterior root of the opposite 
horn (Fig. 133, h) is positively denied by all recent ob- 
servers. 
Commissural Cells.-These are cells that send a nerve- 
process to the opposite side of the cord by the way of 
the anterior commissure. (Fig. 144, c, d.) Ramon y Cajal 
finds them distributed throughout the gray matter in all 
parts of the cord. Lenhossek describes a special group 
Fia. 143.-Scheme of Simple Reflex Action. (Lenhoss6k.) A, motor ceil of anterior 
horn ; b, its nerve-process extending through the anterior root ; c, its termina- 
tion by ramifications upon striped muscular fibres ; d, a single ganglioblast situ- 
ated in the ganglion of a posterior root and sending into the cord a centripetal 
fibre that bifurcates at e into an ascending limb,/ and a descending limb, (/; h, h, 
collaterals that reach by their ramifications the motor cells of the anterior horn ; 
i, the peripheral origin of the other process of the ganglioblast from ramifica- 
tions ending free in the epidermis ; A', from a l'acinian corpuscle. 
to throw light upon the physiological processes in which 
the cord takes part. We may divide them into several 
categories, as follows: 
I. A large number of the collaterals belonging to the 
posterior roots unite in a bundle which crosses the pos- 
terior horn and breaks up into terminals that ramify 
about the cells of the anterior horn. (Fig. 144, 1.) There 
is thus established the reflex-path imagined by Gerlach 
and Golgi (see Fig. 140), there being, however, this 
difference in the new conception, 1st, that the path is 
not made directly by the fibres of the posterior roots, but 
by their collaterals ; 2d, that the terminals do not anas- 
tomose with the cell-processes of the anterior horn. 
On consulting Fig. 143, it will be seen that sensations 
taken up from the skin by the nerve-filaments i and k, 
199 Cranial and 
Spinal Nerves. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
of these cells on the medial side of the anterior horn, and 
these are the ones which were formerly supposed to send 
fibres to the anterior root of the opposite side. Commis- 
sural cells are usually smaller than the radicular cells, 
and their nerve-processes may spring either from the 
cell-body or from one of the dendritic trunks. The axis 
cylinder may (1) break up at its termination into the 
usual arborization ; or (2) divide into two branches, one 
of which breaks up, the other proceeding to the adja- 
cent white matter ; or, (3) after bifurcating, both 
branches may pass to separate portions of the white mat- 
ter. The branches proceeding to the white columns may 
either bend simply upward, or divide T-like, sending 
branches upward and downward. This affords an in- 
teresting anatomical explanation of the simultaneous as- 
cending and descending degenerations sometimes found 
after lesions of the opposite side of the cord. Occasion- 
ally lateral branches may be seen given off from the 
nerve-process in its course. 
It will be remembered that, in considering the distri- 
and also communicate through the tegmental region with 
the cortex of the brain. After removing the parietal lobe 
of the cat, Monakow found that the lemniscus tract de- 
generated, and could be traced to the nucleus of Goll's 
column of the opposite side. 
Column Cells (celulas de los cordones, Ramon y Cajal). 
-These pass from the gray substance into the surround- 
ing columns of gray matter of the same side. (Fig. 144, c.) 
They are scattered without order in nearly all parts of 
the cord, but are especially abundant in the middle zone 
of the gray substance, that is to say, the region between 
the anterior and the posterior horns. They are usually of 
median or small size. They may either divide into as- 
cending and descending branches, or simply turn up 
without division. Sometimes their nerve-processes di- 
vide within the gray matter and send two or even more 
divisions into the columns at a distance from each other, 
which divisions comport themselves like a single fibre 
(celulas multicordonales, Ramon y Cajal). Most of 
these cells send their processes to the anterior and lateral 
Fig. 144-Scheme of our Present Knowledge of the Relations of the Cells and Fibres of the Spinal Cord. (Lenhoss6k.) The right side of the figure 
shows the cells of different classes found in the cord with their processes. The left side shows the processes of cells whose bodies are either 
beyond the cord or at other levels, with the distribution of their collaterals, a, a. Motor cells of anterior horn ; c, commissural cells; d, Golgi com- 
missnral cell: e, e, columnar cells of antero-lateral column ; f, f, columnar cells of posterior column ; g, Golgi cell of posterior horn ; f, fibres of pos- 
terior root forming the antero-posterior reflex tract; 2, fibres passing to column of Clarke ; 3, commissural fibres of posterior root; 4, fibres that 
enter the posterior horn ; k, k, collaterals of antero-posterior column ; I, I, collaterals from the pyramidal tracts. 
bution of the collaterals of the posterior nerve-roots, it 
was found that but a very small number penetrate to the 
opposite side of the cord, and that these were insufficient 
to explain the phenomena of crossed, tactile sensations. 
The discovery of the commissural cells makes the matter 
clear. They appear to constitute neurons of the second 
order, that serve to transmit to the opposite side of the 
cord impulses received from the periphery. It should 
also be noted in this connection that those fibres that as- 
cend from the posterior roots in the columns of Goll and 
Burdach are interrupted, when they reach the medulla 
oblongata, by the nuclei found in those columns, and there 
transfer their impulses to neurons which decussate like 
the commissural cells of other levels of the cord. These 
nuclei then are in fact local collections of such commis- 
sural cells. 
In a former volume of the Handbook (VIII., p. 186) 
it was noted by Spitzka that it is probable that the lem- 
niscus tract of the brain is composed of fibres that take 
up impulses from the nuclei of the posterior columns, 
columns. These processes quite frequently show an in- 
crease of calibre during their course. Among the inter- 
esting cells of this class are those of the column of 
Clarke, whose processes pass outward and turn toward 
the brain in the cerebellar lateral tract. The existence of 
a path of this kind has been known since Gerlach and 
Flechsig, and it is sometimes called Flechsig's bundle. 
(See Fig. 134, K) It has been hitherto supposed that the 
cells of the column of Clarke were many of them bipolar. 
(See Mott, Obersteiner, p. 182, and Fig. 107.) This is now 
shown to be an error. They are all multipolar cells 
with extremely rich dendritic processes. These are 
sometimes given off from two stems arising at opposite 
ends of the cell, and as the processes are for the most part 
torn away in the preparations ordinarily made, the cells 
then appear as bipolar. 
The collaterals that were mentioned above as passing 
to the column of Clarke, surround these cells with an 
interlacing basket-work of processes. From clinical evi- 
dence it is believed that the impulses here conveyed are 
200 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Cranial and 
Spinal Nerves. 
not those that relate to tactile sensation, but rather those 
which concern co-ordination of movements. The cells 
constitute neurons of the second order, communicating 
with the cerebellum. It is well known that disorders of 
the cerebellum produce inco-ordination of movements, 
and also that when a sclerosis is set up about the cells of 
Clarke's column and the elements atrophy, as in tabes 
dorsalis, that inco-ordination is one of the prominent 
symptoms. There is no ground for the hypothesis ad- 
vanced by Bechterew, that these cells communicate with 
the column of Goll. 
But few cells are found that send nerve-processes into 
the posterior columns. Lenhossek has found some such 
in the posterior horn behind the column of Clarke. 
Cells occupying the area of the posterior horn known 
as the substantia gelatinosa of Rolando, send their pro- 
cesses for the greater part to the area at the tip of the 
posterior horn, which, since Lissauer's description, has 
been known as the zona terminalis. The cells of the sub- 
stantia are large and spindle-shaped, and were formerly 
(SUPPLEMENT). 
matter tneir terminals. inese would produce whal 
Kolliker has designated as the " indirect reflex path" bj 
which the motor cells of different levels of the cord can 
be correlated in special groups (see Fig. 145); 2d, the col- 
laterals may belong to nerve-processes of cells situated at 
levels entirely above the cord, in the cortex of the brain, 
in the cerebellum, or in the medulla oblongata. There 
seems to be some reason to think that this is the case. 
The so-called pyramidal tracts connect, as is well known, 
the motor area of the cerebral cortex with the cord. 
The result of degenerations shows that they are divided 
into two portions, the direct pyramidal tract, situated in 
the anterior columns, and the crossed pyramidal tract 
situated in the lateral column near the tip of the poste- 
rior horn. From each of these columnar areas collaterals 
pass in considerable numbers to ramify about the large 
cells of the anterior horn. It is interesting to note that, 
by the group of commissural cells situ- 
ated on the medial side of the anterior 
horn, connection may be made with 
Fig. 146.-Nuclei of the Cranial Nerves. (Edinger.) The medulla ob- 
longata and the pons are represented as if transparent. 
the direct pyramidal tract of the opposite side, and that 
thus may be explained the fact, already demonstrated 
clinically, that lesions of this tract affect movements of 
the opposite side of the body. 
Upon examining by the same method the nerves at a 
higher level than the spinal cord, we find that the same 
general structure is found. Some of the results obtained 
are most striking, and throw a flood of light on the gen- 
eral constitution of the nervous system. 
The existing knowledge of the situation of the nuclei 
of origin of the cranial nerves is shown in the following 
diagram. (See Fig. 146.) 
Olfactory Nerve.-In Fig. 147 there is diagrammatically 
shown an antero-posterior section of the olfactory bulb. 
In the olfactory mucous membrane are found two 
kinds of cells, the epithelial, ec, and the nervous, be, the 
latter being bipolar, presenting one process to the surface 
for the reception of impressions, while the other passes 
centrally and breaks up into the usual ramifications, 
forming the well-known glomeruli of the olfactory bulb, 
which have caused so much speculation. In these glo- 
meruli they come in contact with the peripheral processes 
of another set of cells, called mitral cells from their 
shape, they having a large body and two processes given 
off nearly together. The peripheral process receives the 
stimulus from the olfactory glomeruli, and it is trans- 
mitted to the brain by the other process, which is directed 
horizontally. This shows in a striking manner that the 
hypothesis'of Golgi, that the dendritic processes are for 
the purpose of absorbing nutriment, is incorrect. Each 
of the nervous elements or neurons is in fact independent, 
and each probably serves as a transmitter of stimuli. 
Optic Nerve.-Here the sensory cells appear to be the 
large ganglion-cells of the retina. By their short processes 
they communicate with the special receptive elements, 
the rods and cones and the spongioblasts. Their long 
processes go to make up the principal mass of the optic 
nerve-fibres (see Fig. 148), and break up into the usual 
arborescent filaments that become associated with fila- 
ments of short-process cells situated within the central 
ganglia (corpus geniculatum, optic thalamus). The 
white radiations observed in the corpora geniculata are 
composed of such, fibres. His has shown that in the em- 
bryonic retina there exist neuroblasts whose processes 
Fig. 145.-The Indirect Reflex Path. (A. v. Kolliker.) a, Ganglioblast 
sending into the cord a fibre, b, which divides into ascending and 
descending limbs, c, d. and gives off collaterals, e, which embrace the 
cell / with their terminal filaments. This in turn sends off a nerve- 
process, g, which divides into ascending and descending limbs, A, i, 
provided with collaterals, j, j, that embrace with their filaments the 
motor cells k, k, from whose nerve-processes, I, I, the anterior roots 
are formed. 
supposed to be connected either immediately with the pos- 
terior roots, or with Gerlach's plexus. (See Fig. 134, K.) 
Cells with Short Nerve-processes (Golgi cells).-It was 
held by Golgi that these cells were confined to the pos- 
terior horn. This is found not to be the case. Still 
there is one locality in that horn, near Clarke's column, 
in which they are especially numerous. (Fig. 144, g.) 
They are also found near the anterior commissure, send- 
ing their processes across to the opposite side of the cord. 
(Fig. 144, d.) 
Collaterals of the Columns.-We have hitherto consid- 
ered only the collaterals given off by the ascending and 
descending limbs of the vertically-branching fibres of the 
posterior roots. These are by no means the only ones. 
A longitudinal section of the white columns in any por- 
tion of the cord shows that all the vertical fibres have the 
same disposition to give off to the gray substance collat- 
erals that end by arborescent divisions. -Kolliker could 
find no exception to this rule. 
It is evident that these collaterals may arise from two 
sources : First, they may belong to column cells that have 
divided at higher or lower levels into their ascending and 
descending branches, and are sending back into the gray 
201 Cranial and 
Spinal Nerves. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
grow centrally into the optic nerve. There are also in 
the optic nerve certain fibres that belong to cells situated 
in the corpora quadrigemina anteriora, and also probably 
some from cells in the occipital lobe of the cortex. 
The question has been often discussed whether the 
fibres of this nerve between their real and apparent origin 
Weigert and Pal, the latter that of Golgi. They find that 
in the duck, at least, there is a partial decussation of fibres 
derived from both the dorsal and ventral portions of the 
nuclei. The crossed fibres pass principally into the 
internal or median part of the peripheral nerve. The 
fibres of the posterior longitudinal bundle give off 
numerous collaterals that come in contact with the 
protoplasmic processes of the cells of the nuclei. 
Starr divides the cells of the nucleus into groups 
which innervate special muscles, as follows : 
Sphincter iridis. 
Levator palpebr®. 
Rectus superior. 
Obliquus inferior. 
Ciliary muscle. 
Rectus internus. 
Rectus inferior. 
Median 
Line. 
Gaskell lias put forward a theory that a ganglion 
formerly existed upon the third and fourth cranial 
nerves, and as evidence therefor shows a consider- 
able mass of connective tissue, apparently the re- 
Fig. 147.-Structure of the Olfactory Filaments and Bulb. (Ramon y Cajal.) be. Bi- 
polar cells of the olfactory mucous membrane ; sm, submucosa ; ethm, cribriform 
plate of the ethmoid ; og, olfactory glomeruli; me, mitral cells ; ep, epithelium 
of the olfactory ventricle ; ec, epithelial cells of the olfactory membrane. 
Fig. 149.-Transverse Section through a Rootlet of the Third 
Cranial Nerve of Man, to Show Degenerated Ganglion. 
undergo a decussation either total or partial. Duval held 
that the fibres of the nerve proper do not decussate, but 
that there are mingled with them certain fibres from the 
posterior longitudinal bundle, probably derived from the 
nucleus of the abducens, that undergo decussation. This 
view was adopted and figured by Testut in his " Anato- 
mic Humain," 1891. 
Gudden showed, however that in the rabbit, and prob- 
sult of degeneration, through which some of the rootlets 
of the nerve pass. He holds that the arrangement and 
appearance of these roots, as shown on section through 
this mass, is precisely that which would appear in a sec- 
tion through a ganglion. (See Fig. 149.) 
He considers that this degenerated ganglion belonged 
to the sensory root of the nerve, and that this sensory 
root has disappeared because of the great changes that 
have taken place in the vertebrate head and brain. He 
also thinks that the substantia nigra of the crura cerebri 
is a degenerated nucleus from w hich arose certain lost 
fibres belonging to the third and fourth nerves. 
He thinks the ciliary ganglion is a vagrant ganglion 
belonging to the small-fibred portions of the oculo-motor 
nerve. 
Patheticus Nerve.-The evidence that the fibres of the 
fourth cranial nerve decussate completely has not in any 
way been shaken. Gaskell thinks that a small vagrant 
ganglion will be discovered in connection with it, as he 
believes it to belong to his efferent ganglionated splanch- 
nic class. 
Trigeminus Nerve.-Gaskell considers the motor-root 
of the trigeminus as a complete segmental nerve, that has 
its small-fibred ganglionated portion in the fibres that go 
to the spheno-palatine ganglion and whose sensory fibres 
have degenerated. The sensory root of the trigeminus 
he considers to belong to several of the segmental cranial 
nerves. 
Abducens Nerve.-A novelty with reference to the ori- 
gin of the sixth nerve is the discovery of a small and 
Fig. 148.-Connections of Fibres of the Optic Nerve. (Romon y Cnjal.) 
Section through the corpus geniculatum laterale of the cat. .4, fibres 
of the optic nerve ; b, b, their ultimate filaments entwining with Golgi 
cells. 
ably in man, the nucleus of the oculo-motor nerve is com- 
posed of two parts, one ventral, sending fibres to the 
nerve of the same side, one dorsal, sending fibres to the 
nerve of the opposite side. 
Kolliker and van Gehuchten have recently studied the 
question anew, the former observer using the methods of 
202 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Cranial and 
Spinal Nerves. 
easily overlooked bundle of fibres that turns toward 
the middle line ventrally from the nucleus and enters 
the abducens nerve of the opposite side. A connection 
has been described between the abducens nucleus and the 
superior olive. Edinger suggests that this connects the 
abducens with the auditory nerve and correlates the move- 
ment of the eyes with orientation in space. The connec- 
tion of the fibres of the facial nerve with the nucleus of 
the sixth is definitely disproved by the researches of 
Gudden. 
Facial Nerve.-Fibres from the facial nucleus are now 
known to decussate. The " superior facial nucleus" de- 
scribed by some authors as supplying fibres for the 
orbicularis oculiand frontalis muscles is now discredited. 
It is believed that these fibres, which do not degenerate 
in central disease of the facial nerve, are probably derived 
from the posterior longitudinal bundle. 
Auditory Nerve.-A considerable addition has been made 
to our knowledge of the origin of the auditory nerve. It 
seems clear that we have here to deal with two nerves, 
one for the supply of the cochlea and one for the semi- 
circular canals. Many physiologists hold that this latter 
nerve has nothing to do with hearing. The roots of these 
nerves lie on opposite sides of the restiform body and are 
therefore distinguished as lateral (superficial, inferior, 
posterior) and medial 
(deep, superior, an- 
terior). The lateral is 
connected with the coch- 
lear nerve, the medial 
with the vestibular. 
The lateral root springs 
from a collection of cells 
lying partly outside the 
brain substance, like a 
ganglion on a nerve- 
trunk. In some verte- 
brates and in the embryo 
it is wholly detached. 
It is sometimes termed 
therefore the auditory 
ganglion. It produces 
the eminence in the me- 
dulla oblongata known 
as the acoustic tuber- 
cle. 
The medial root arises 
chiefly from a large nu- 
cleus lying near the 
median line known as 
the chief auditory nu- 
cleus, also from a collec- 
tion of large cells lying 
more externally, termed 
Deiters's nucleus. 
By the method of Golgi, Retzius has shown that the 
endings of the auditory nerve are essentially the same 
as those described for other sensory nerves. Both in 
the organ of Corti and in the acoustic crest of the semi- 
circular canals exist the terminals of bipolar cells situ- 
ated in the ganglion spirale (cochlear nerve) and ganglion 
of Scarpa (vestibular nerve), which terminals break up 
into numerous branches situated between the epithelial 
cells. The epithelial hair-cells represent, then, the same 
elements as the rods and cones of the retina, and are 
agents for carrying to the nerve-cells the sonorous vibra- 
tions. This arrangement will be seen in Fig. 150. The 
epithelial expansion of this bipolar cell corresponds ap- 
parently to a dendritic process, while the central com- 
munication is an axis cylinder. Frank Baker. 
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per le Malattie nervose, Anno 18, 1881. 
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nervoso. Milano, 1886-86. 
His, W. : Ueber die Anfiinge des peripherischen Nervensystems, Archiv 
f. Anat. u. Physiol., Anat. Abth., 1879. 
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fasern am Riickenmark menschl. Embryonen, Archiv f. Anat. u. 
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wurzeln, Abh. d. K. Sachs. Ges. d. Wissensch., mathem.-phys. Klasse, 
1886, Bd. xiii., No. vi. 
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Embryo. Uebersichtliche Darstellung um die morphologische Betracht- 
ung der Koptnerven, Archiv f. Anat. u. Physiol., Anat. Abth., 1887. 
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1887. 
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Ges. d. Wisensch., mathem.-phys. Klasse, 1888, Bd. xiv., No. vii. 
His, W. : Die Neuroblasten und deren Entstehung im embryonalen 
Mark, Abhandlungen der koniglichen sachsichsen Gesellschaft der 
Wissenschaften, mathem. physische Klasse, 1889, Bd. xv., No. iv. 
His, W. : Histogenese und Zusammenhang der Nervenelemente, Archiv 
fiir Anatomic und Physiologic, anatomische Abtheilung, 1891, Supple- 
ment-band. 
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Nervensystems durch anatomische Untersuchungen bewiesen. Zurich, 
1844. 
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Zeitschrift fiir wissenschaftlichc Zoologie. 61 Band, 1890. 
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anatomischen Gesellschaft in Munchen, vom 18-20 Mai, 1891. 
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en, Sitzungsberichte d, Wurzb. phys. med., Gesellschaft, 30 Juli, 1892. 
Lenhossek, Mich. v. : Der feinere Bau des Nervensystems im Lichte 
neuester Forschungen, Fortschritte der Medicin, 1892, No. 44 et seq. 
Marie, Pierre : Lefons sur les maladies de la moelle. Paris, 1892. 
Monakow, C. v. : Neue experimentelle Beitriige zur Anatomie der 
Schleife, Neurol. Centralblatt, Jahrg. 1885, S. 265. 
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Elements of the Centra) Nervous System, Bergens Museums Aars- 
beretning for 1885. Bergen, 1886. 
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and Disease. Translated, with Annotations and Additions, by Alexan- 
der Hill. London, 1890. 
Obersteiner, H. : Die neueren Anschauungen uber den Aufbau des 
Nervensystems, Naturwissenschaftliche Rundschau, 1892, vii., 1 and 
17. 
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Barcelona, 1889. 
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meduia embnonaria, Gaceta Sanitaria de Barcelona, 1890, ii., 413. 
Ramon y Cajal: Notas preventivas sobre el gran simpatico y retina de 
los mamiferos, Gaceta Sanitaria de Barcelona, 1891, iii., No. 16. 
Ramon y Cajal, S. : Pequehas contribuciones al conocimento del sistema 
nervioso. Barcelona, 1891. 
Ramon y Cajal, S. : El nuevo concepto de la histologia de los centros 
nerviosos, Revista de Ciencias Medicas de Barcelona, 1892, Nos. 16, 
20, 22, and 23. 
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glionnaires, Comptes-rendus de 1'Academie des Sciences, 1875, Ixxxi., 
1274. 
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holm, 1892. 
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No. 687 ; 1848. No. 733. 
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Gaceta Sanitaria de Barcelona, 1890, ii., 282 et seq. 
Fig. 150.-Collecting Filaments of the 
Vestibular Branch of the Auditory 
Nerve. (Ramon y Cajal.) Trans- 
verse section of the semicircular 
canal of a mouse. A, lumen of the 
canal : B, acoustic crest ; C, bundle 
of nerve-fibres containing bipolar 
cells ; D, a similar bundle supply 
ing the top of the canal ; a, b, and c, 
varieties of bipolar epithelial cells. 
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(SUPPLEMENT.) 
Wagner, R. : HandwOrterbuch der Physiologie. Bd. iii., Abth. 1, S. 377. 
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1891, No. 44 et seq. 
CREASOTE. Discovered in 1830 by Reichenbach.it 
early acquired a reputation for being of service in pul- 
monary troubles, and has always been used to a greater 
or less extent in such diseases. Its recent revival, how- 
ever, dates from the communications of Professor Julius 
Sommerbrodt, of Breslau, Fraentzel, Guttman, and others 
in 1887 and 1888. Ten years previously Drs. Bouchard 
and Gimbert had given the results of their experience 
with the drug, and had recommended that it should be 
more extensively used in pulmonary phthisis, as it had 
proved of decided value in their hands. During the 
intervening years many physicians tried the remedy, but 
it was not until Professor Sommerbrodt corroborated the 
statements of Bouchard and Gimbert, and claimed for it 
even greater curative properties, that it received the atten- 
tion which it appeared to deserve. Sommerbrodt's experi- 
ence appears to have embraced many thousand cases and 
to have extended over a number of years ; as a result he is 
very decided in his views, and claims that it is not only 
a very useful drug for the relief of the numerous trouble- 
some symptoms, but that, by its power of checking the 
progress of the disease, it appears to possess almost spe- 
cific properties. In a later paper, in reviewing some five 
thousand cases of tubercular disease, he states that definite 
recovery has been attained in a much greater proportion 
than by any other method of treatment, and in the great 
majority of cases decided benefit could be traced to its 
use. The fever, night-sweats, cough, and expectoration 
were lessened, the general health of the patient improved, 
and in the cases where no curative effect followed or 
was to be expected, the livps of the patients were pro- 
longed and rendered more comfortable. He dwells par- 
ticularly upon the importance of an early diagnosis where 
curative results are to be expected, and insists upon the 
drug being administered in full doses and for a prolonged 
period. In his early cases he considered five to eight 
minims a day to be sufficient, but he now advises that as 
much should be given as the patient can bear, his rule 
being that the more creasote can be introduced into 
the system the greater will be its beneficial action, lie 
now advises that twenty to twTenty-five or thirty minims 
a day should be given, and this dose continued for many 
months or even years. His mode of administering it is 
to commence with one minim three times a day and in- 
crease the dose by one minim each day for eighteen days, 
until such an amount is reached as the patient can bear, 
and then continue that quantity for an indefinite period. 
He gives the drug with a few drops of cod-liver oil or 
oil of sweet almonds in capsules,-never on an empty 
stomach, but after the three principal meals. The purity 
of the drug he considers of the greatest importance, and 
advises that only the best beech-tar creasote be used. If 
these points are observed no difficulty should be experi- 
enced by the patient, as any ill effects-such as eructations 
and belching of wind-never continue for any length of 
time. The antiseptic action improves the condition of 
the digestive tract and a decided improvement soon fol- 
lows its use, not only relieving the digestive disturb- 
ances but increasing the appetite and promoting assimila- 
tion and the general well-being of the system. Another 
advantage that he claims for this treatment is, that it is 
simple and devoid of danger and does not prevent the 
adoption of further methods of combating the disease. 
Sommerbrodt's purpose in administering the drug so 
freely is based upon the researches of Guttman, who 
found that the bacillus of tuberculosis would not live in 
a solution of greater strength than one part in four thou- 
sand. He points out that if about twenty grains could 
be introduced into the blood of an ordinary man it would 
represent a solution of such a strength. He considers it 
possible to produce such a condition by giving it in 
large quantities, as it is not likely to be changed or 
excreted as rapidly as it is introduced. He has given as 
much as sixty minims a day, and Freudenthal has pushed 
it to one hundred and fifty minims in the twenty-four 
hours. 
How creasote acts or in what way it produces its bene- 
ficial action has not been determined. It is admitted that 
the improvement in digestion and nutrition that follows 
its use places the system in a better state to resist the 
disease, but beyond this nothing is known. Creasote 
does not exist in the blood in a free state, and this would 
seem a serious objection to Sommerbrodt's theory, but it 
is supposed to enter into combination with certain albu- 
minoids in the blood, and this combination he considers 
still possesses the properties of the crude drug. Very 
recently Seifert and Hoelscher have formulated a theory 
which favors this view : they conclude that the products 
of creasote circulating in the blood render innocuous the 
ptomaines which have been formed by the bacilli and 
afterward absorbed. In this way it eliminates from the 
system these toxic compounds before they produce any 
of their deleterious effects. 
Such experiments as have been made on animals to test 
the efficacy of creasote upon tuberculosis have not sup- 
ported the views of those who consider it of so much 
value. The disease always progressed steadily, and no 
effect was apparently produced by the drug. Sommer- 
brodt, however, points out that artificial tuberculosis in 
animals is very different from the disease in man, and 
that many animals are particularly susceptible to the 
influence of the poison. 
In using creasote much difficulty has been found in 
administering the large doses that are advised without 
producing gastric disturbance and causing the patient to 
rebel. How far this may be due to the quality of the 
drug is hard to estimate, but it may also be, to a certain 
extent, due to the preparation or the manner in which it 
is given. Mixed with the oil and enclosed in capsules is 
probably one of the simplest, as well as easiest ways of 
taking the drug. When the cod-liver oil is not well 
borne, the more bland oil of sweet almonds or olive-oil 
may be employed. In addition to the nutritive proper- 
ties of the oil, it is supposed, to a certain extent, to con- 
vey the drug into the intestines before being acted upon. 
Freshly prepared capsules are always to be preferred, as 
it has been found that a chemical reaction occurs when 
the oil and creasote remain in contact for any length of 
time. Dissolved in spirits is a common way of prescrib- 
ing the drug, and tincture of gentian has been favored as 
a means of disguising the taste. A combination of Bou- 
chard, which has given rise to many modifications, was 
as follows : Creasote, 15 minims ; tincture of gentian, 40 
minims ; rectified spirits, 6 drachms ; white wine, to 
make 3 ounces. Milk is recommended as a good vehicle 
for the drug, either in its purity or when in solution. 
Malt extract, or malt extract and emulsion of cod-liver 
oil, are very highly praised as a means by which it may 
be administered. The following emulsion is said to dis- 
guise the taste and supply the beneficial properties of the 
constituents : Malt extract and emulsion of cod-liver oil, 
8 ounces ; creasote, 80 minims ; oil of bitter almonds, 4 
minims ; oil of lemon, 6 minims. 
Many pills containing creasote are prepared and form a 
convenient vehicle, but the insolubility of many of these 
pills must not be forgotten. A coating of keratin, resin, 
salol, collodion, and substances not acted on in the stom- 
ach, is now prepared, and the creasote is only liberated 
when the pill reaches the alkaline fluids of the intestine. 
The hypodermic injection of creasote has been advo- 
cated as an excellent means of introducing it into the cir- 
culation, the great advantage being that it does not cause 
any derangement of the digestive organs. A ten per cent, 
solution in oil of sweet almonds is used, and the treat- 
ment begun by injecting small amounts, which are grad- 
ually increased. Local irritation, however, has frequent- 
ly followed, and the internal administration is generally 
preferred when possible. Deep pulmonary injections 
have been used. Specially prepared long needles are 
employed, and the creasote carried through the chest- 
wall directly to the diseased tissue. Eight minims of a 
204 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Cranial Nerves. 
Cresol. 
three per cent, solution in oil is the quantity used. A 
modification of this is the intra tracheal injection of the 
drug. A five per cent, solution in oil of almonds is used, 
and thirty-one minims (two grammes} injected into the 
trachea twice a day. The oil descends into the lungs 
and gradually enters the alveoli. It is said that no bad 
effects follow this use of the drug, and on the affected 
part a beneficial local action is exerted. 
Inhalation is, of course, a valuable way of acting di- 
rectly on the diseased organ, and forms an important 
adjunct to the internal use. The following combination 
is most efficient: Creasote, eucalyptus, and turpentine, 
each 5 drachms ; iodoform, 7| grains ; dissolved in sul- 
phuric ether, 1| drachm. 
In a paper published by Professor Sommerbrodt with- 
in the past year the application of creasote is specially 
advocated in the glandular enlargement and other dis- 
eases arising from a tuberculous condition in children. 
With him the results of such treatment have been most 
favorable, and he urges others to adopt it in their prac- 
tice. The dose for children above six years of age is 
from 7 to 12 minims per day, beginning with one minim 
and increasing it daily, as in his former directions for 
pulmonary disease. He also takes advantage of the oc- 
casion to insist upon the importance of a full dosage, and 
reiterates his faith in its value. 
In this paper he records the first instance of profound 
intoxication by the drug that has been brought to his no- 
tice. A patient of Dr. Freudenthal, of New York, who 
was taking, with benefit, from 30 to 45 grains a day, 
took about 150 grains (9 or 10 grammes) within two 
hours. She became unconscious, and gave the impres- 
sion of one narcotized ; pulse, 128 ; respiration, 30; in- 
tense trismus, lips cyanotic, pupils contracted, sensory 
and reflex action annulled. After nine hours the patient 
recovered without any ill effects following, and continued 
the regular use of the drug. 
Although it is now very evident that no toxic effects 
are to be dreaded during proper medication, there are 
some symptoms that must not be disregarded. The dis- 
coloration of the urine, when it occurs during large doses, 
calls for a diminution of the quantity, or its stoppage for 
a short period ; but if it follows small doses, or occurs fre- 
quently, the drug must be given very cautiously. Ver- 
tigo, intoxication, and signs of stupor must not be disre- 
garded, and malaise, prostration, sweating, cephalalgia 
are also signs of intolerance of the drug. 
Beaumont Small. 
CREOLIN is a proprietary article, the name being 
registered by the manufacturers in Hamburg. Commer- 
cial creolin, however, varies much in appearance and 
properties, and many preparations are sold under that 
title. It is obtained from the product that remains after 
carbolic acid has been removed during the fractional dis- 
tillation of coal-tar. The cresols form the active ingre- 
dients. The following analysis of the German compound 
is furnished by Dr. Bernard Fischer : Cresols, 20 parts ; 
naphthalene, 18 parts ; other hydrocarbons. 20 parts ; and 
non-volatile matter, 42 parts. It is quite free from car- 
bolic acid and other poisonous ingredients, and should 
not possess any toxic properties. Creolin is prepared 
by treating these insoluble hydrocarbons with resin 
and caustic potash, which form a resinous, soapy emul- 
sion. When added to water and agitated the ingredi- 
ents remain suspended as an emulsion. In appearance 
it is a dark, resinous liquid, neutral to test-paper, not 
caustic. Its odor resembles creasote. It mixes with 
oils. 
It possesses powerful antiseptic and disinfectant prop- 
erties, and is recommended as a substitute for carbolic 
acid, to which it is said to be superior, as it does not con- 
tain any poisonous ingredients. It is very extensively 
employed, and numerous reports speak in its favor in all 
conditions where carbolic acid is indicated. 
For surgical purposes two solutions are employed, one 
containing two per cent, of the drug, the other one-half 
per cent. The stronger is used for disinfecting the 
hands, the instruments, and surfaces of the body ; the 
(SUPPLEMENT.) 
weaker solution is used for irrigation, moistening dress- 
ings, saturating tampons, etc. 
For suppurating and sloughing -wounds, and where 
discharges are offensive the parts may be cleansed and 
disinfected by the pure drug, and the effect maintained 
by a weaker solution. To irrigate the bladder, urethra, 
nose, pharynx, and other mucous surfaces, a solution of 
one part in a thousand is sufficiently strong. 
The objections to its use are, the uncertainty of its action 
on account of the numerous preparations, and being unc- 
tuous .it renders the hands and instruments slippery and 
difficult to handle. Beaumont Small. 
CRESALOL. This is the cresylic ether of salicylic 
acid, and bears the same relation to cresylic acid that sa- 
lol does to carbolic acid. It is analogous to betol and 
salol, and has been introduced by Nencki, the originator 
of the other two compounds. It is prepared by treating 
cresylate of sodium and salicylate of sodium with per- 
chloride of phosphorus. Three salts are formed, accord- 
ing as the ortho-, meta-, or para-cresylic acid is used. All 
three possess the same properties, but the para-cresalol is 
the one usually prepared. The chemical formula is 
C.II4OHCOC8H4CH3. 
Cresalol is a white, crystalline powder, without taste ; 
odor somewhat resembles salol. It is insoluble in water, 
slightly soluble in alcohol. The dose is given as from 
three to thirty grains daily. It possesses antiseptic prop- 
erties similar to salol, and, like that salt, is not acted 
upon by the secretions of the stomach. It is used for in- 
testinal antisepsis, and is said to be more efficient than its 
analogues. In the system it is decomposed into cresol 
or cresylic acid and salicylic acid, and its advantage is 
the freedom of these acids from any toxic properties. 
Beaumont Small. 
CRESOL, CRESYOL, CRESYLIC ACID. This con- 
sists of ortho-, meta-, and para-cresylic acid in variable 
proportions, having a general formula of C6H4, CH3, 
OH. It is a higher homologue of carbolic acid or phe- 
nol, and differs from it by the replacing of one atom of 
hydrogen by the methyl group CH3. It is present in 
coal-tar, with carbolic acid, and is obtained during the 
process of fractional distillation. The fractional distilla- 
tion of coal-tar consists in the separation of groups of 
products according to their volatile properties. Up to 
80° C. about four percent, is separated, consisting of car- 
bon bisulphide, ammonia, amylene, benzene, and other 
very volatile compounds. From 80° to 210° C. what is 
termed the light oil is removed ; this is made up of ben- 
zene and its homologues. Between 210° and 400° C. the 
heavy oil is formed, consisting of phenol, naphthalene, 
cresols, and other hydrocarbons. The residue is pitch, 
about fifty per cent. The phenol, cresol, and naphtha- 
lene, and other constituents of the heavy oil, are sepa- 
rated by further distillation. It forms the greater part 
of the crude carbolic acids of commerce, which might 
more properly be called crude cresols. 
It is a colorless, strongly refractive liquid, boils at 397° 
F., is strongly caustic ; its odor resembles creasote. It is 
insoluble in water, soluble in alcohol, glycerine, and 
ether. The cresols are powerful antiseptics and produce 
some of the most active preparations of the aromatic series. 
According to the investigations of Jaeger and Ohlmuller, 
of the Board of Health, and Fraenkel, of the Berlin Hy- 
gienic Institute, it has been shown that when dissolved 
in sulphuric acid the most active of such antiseptics is 
formed. Being insoluble in water it is difficult to obtain 
a solution that is stable and applicable to surgical pur- 
poses. 
Many methods have been devised and numerous prepa- 
rations have been introduced into commerce under a vari- 
ety of names : creolin, lysol, solveol, solutol, and others, 
are all preparations of this kind. Some contain other 
hydrocarbons in addition to the cresols. Resin and alkali 
soaps form a favorite means of retaining the active in- 
gredients in solution, but when added to water they pro- 
duce milky and greasy fluids, very objectionable for 
surgical uses; the antiseptic properties are, however, 
205 Cresol. 
Death, Origin of. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
effective as deodorizers and disinfectants. Cresotate of 
soda has been found to retain cresol in solution. For 
therapeutic purposes a one and one-half percent, solution 
is sufficiently strong, free from irritant or caustic proper- 
ties, and equal to a five per cent, solution of carbolic acid. 
Cresol is also dissolved in a concentrated solution of sa- 
licylate of sodium, which allows of free dilution ; no de- 
composition occurs, a neutral solution of cresol being 
formed. Lime is recommended as a means of rendering 
a solution which forms a cheap and active disinfectant; 
one part of lime is treated with four parts of water, and 
five parts of cresol are added ; the resulting liquid con- 
tains fifty per cent, of cresol and is miscible in water in 
all proportions. 
For internal administration the preparation cresalol has 
been introduced and is highly recommended. 
Beaumont Small. 
CRESOTIC ACID (Cresotinic Acid, Homosalicylic 
Acid). This is a higher homologue of salicylic acid, to 
which it is allied both in chemical and in physiological 
properties. Its formula is C8H3OHCH3COOH, which 
is that of salicylic acid, CeHLOHCOOH, with one atom 
of II replaced by the methyl group CII3. It is obtained 
by the action of carbon dioxide on sodium and cresol; 
the product, when treated with hydrochloric acid, yields 
a solution of cresotic acid, from which it is separated 
by evaporation. It crystallizes in long, white, pris- 
matic needles, which dissolve with difficulty in cold 
water, more readily in hot -water, and are very soluble in 
alcphol, ether, and chloroform. Three isomeric acids are 
formed-the ortho-, meta-, and para-cresotic acids,-corre- 
sponding to the ortho-, meta-, and para-cresols. They dif- 
fer in their melting-points, by which they may be distin- 
guished, that of the ortho being 160° C.; the meta, 177° C.; 
and the para, 151° C. Their aqueous solutions are col- 
ored violet by ferric chloride, and in many other reactions 
they correspond to salicylic acid. They are now most 
readily separated from this acid by the fractional crys- 
tallization of their lead salts from alcoholic solutions. 
The three acids are generally present in the salicylic acid 
of commerce, which is prepared artificially, as much as 
8.10 per cent, of the para-cresotic acid having been de- 
tected in some specimens. They are never present in 
the natural acid prepared from the oil of wintergreen. 
These acids were brought to the notice of the profes- 
sion in 1890, as dangerous ingredients of the salicylic 
acid of commerce, by the researches of Professors Char- 
teris and Dunstan, of Glasgow, which were published in 
the Pharmaceutical Journal and Transactions of Novem- 
ber 22d. It had long been known that very alarming symp- 
toms often followed the use of the artificial salicylic acid, 
and in 1878 two bodies had been separated which had 
been shown to account for the toxic symptoms, but which 
at the time were not identified. These were now demon- 
strated to be ortho- and meta-cresotic acids, and the third 
acid was also found to be present in large quantities. 
The meta-cresotic acid was known to be inert, but it was 
now claimed that both of the other two possessed a power- 
ful depressant action on the heart, and in comparatively 
small doses would produce fatal effects when given to 
animals. These statements, particularly in regard to 
para-cresotic acid, were important, as this acid was sup- 
posed to be less toxic than salicylic acid, and had been 
recommended to be used in medicine as a substitute. To 
verify those statements further experiments were made 
by Professor Charteris, and the results were published in 
the British Medical Journal for March 28, 1891. 
His experiments proved that both acids were active 
poisons, and rapidly caused death when administered to 
animals by means of an hypodermic injection. His 
conclusions are that the lethal dose of the para-cresotic 
acid is about three grains per pound-weight of the animal, 
and that one grain of the ortho-cresotic acid would have 
the same effect. These doses were fatal within three hours, 
the toxic symptoms following immediately upon the use 
of the drug, and he considers that much smaller doses 
would also prove fatal, but after a more prolonged inter- 
val. Further experiments were made by combining the 
two acids, and it was found that the fatal quantity was 
less than when they were administered separately. The 
acids were also used when added to pure salicylic acid, 
and this combination added to the toxic power of the cre- 
sotic acids. One grain of para-cresotic acid and one grain 
of the ortho-cresotic acid were dissolved with twenty 
grains of salicylic acid, and experiments showed that one- 
quarter of a grain of each cresotic acid, with four and 
one-half grains of salicylic acid, proved fatal to an animal 
weighing two pounds. 
Chemical experiments were also made which led to im- 
portant results, and proved bow essential the degree of 
crystallization and the melting-point are as means of 
indicating the purity of salicylic acid. He found that 
when either of the cresotic acids was added to pure 
salicylic acid, dissolved and recrystallized, the departure 
from the large and beautiful crystals of the latter was in 
direct ratio to the degree of contamination, and when 
the amount of impurity was great, an amorphous powder 
was the result, and the acids had to be redissolved several 
times before crystals could be obtained. 
The practical conclusion to be drawn from this is, that 
the difference in degree of crystallization allowed by the 
Pharmacopoeia between the natural and artificial salicylic 
acid allows a certain percentage of the cresotic acid to be 
present. With regard to the melting-point, it was also 
shown that 156.8° C., allowed by the British Pharmaco- 
poeia, was too low, and permitted the same impurities to be 
retained. The experiment showed that an artificial acid 
could be prepared as pure as that obtained from the nat- 
ural sources, and it was urged that in the revised Pharma- 
copoeia these tests should be insisted upon and the stand- 
ard of purity raised. The following is a tabular state- 
ment of the results of experiments made to determine 
the melting-point of the various mixtures : 
Natural salicylic acid of commerce 157.0° C. 
Artificial salicylic acid of commerce 156.0° C. 
Equal parts of salicylic acid and other cresotic acid, dissolved 
and crystallized ' 136.0° C. 
Equal parts of salicylic acid and para-cresotic acid, dissolved 
and crystallized 128.5° C. 
Twenty grains salicylic acid and one grain ortho-cresotic acid, 
dissolved and crystallized 152.5° C. 
Twenty grains salicylic acid and one grain para-cresotic acid, 
dissolved and crystallized 152.0° C. 
Sixty grains salicylic acid and one grain ortho-cresotic acid, dis- 
solved and crystallized five times 156.0° C. 
Sixty grains salicylic acid and one grain para-cresotic acid, dis- 
solved and crystallized six times 154.5° C. 
Ninety-seven grains salicylic acid, two grains para-, and one 
grain ortho-cresotic acid, dissolved and crystallized 155.0° C. 
The only preparation of these acids that has been pre- 
pared for therapeutic purposes is the para-cresotate of 
sodium. It is a white, fine, crystalline powder, with a 
slightly bitter taste, soluble in twenty-four parts of warm 
water. It is said to possess antipyretic and antirheumatic 
properties similar to those of salicylate of soda, but in a 
lesser degree. It, however, has the advantage of not dis- 
turbing the digestive organs. Although it has been 
shown that the acid base has such decided toxic proper- 
ties, this salt is said to be quite harmless, and may be 
given in doses of forty-five grains a day, for several days 
in succession, without any ill effects. The dose recom- 
mended is, according to the patient's age, from one and 
one-half grain to twenty-three grains, repeated three or 
four times a day. It is also reported to be of use as an 
antipyretic in pneumonia and typhus fever. In children 
it has been used in gastro-intestinal catarrh as an intes- 
tinal antiseptic. Beaumont Small. 
DAWLISH. A popular and pleasant seaside resort in 
Devonshire, England. It is about equidistant from Ex- 
mouth and Teignmouth. The English patronize the 
place at all seasons, but its chief attraction is a fine beach 
which is used in summer. The climate is not as equable 
and mild as that of Torquay, nor is the place as fashion- 
able and expensive. Dawlish rests on gravelly soil, 
which, in view of the large amount of rainfall, is obvi- 
ously a great advantage. It is cooler in summer than 
the resorts nearer London. The climate is humid, and, 
206 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Cresol. 
Death, Origin of. 
while sedative, is rather relaxing. The indications are 
the usual ones for healthy seaside resorts ; and the place 
is especially to be recommended for those conditions 
which a too bracing climate might injuriously affect. It 
is not an international resort, being visited by the British 
only. Edmund C. Wendt. 
DEATH, ORIGIN OF. Physiological Theories.- 
Living things, in the forms most familiar to us, at least, 
all grow old and die. We infer that this fate is universal 
with something of the same certainty with which we 
prophesy that a stone thrown into the air at any spot what- 
soever will fall back again to the earth's surface. On the 
other hand, it is equally a commonplace of observation 
that the death of the individual does not mean the death 
of the race, and, inasmuch as every living thing is directly 
sprung from a preceding form,-omne vivum e vivo,- 
we may assume that the continuity of life has never been 
interrupted, and never will be. If the environment re- 
mains as favorable in the future as it has been in the 
past, living things will continue in unbroken succession 
for all time. From this stand-point we may speak justly 
of living matter as possessing immortality, or, at least, 
potential immortality, since it has unlimited powers of 
propagation. It is one of the final aims of biological 
speculation to reconcile these two apparently paradoxi- 
cal properties of living matter ; to furnish a satisfactory 
hypothesis which shall explain the occurrence of old 
age and death in the individual, and at the same time ac- 
count for the possibility of unending existence for the 
race, which is implied in the fact of reproduction. 
In speculations of this character we must, moreover, 
keep clearly in mind that forms of living matter are not 
stable, in the same sense that forms of dead matter are. 
A given animal exists for a period of five years; but we are 
all perfectly well aware that no portion of the living 
substance of this animal has remained actually the same 
throughout this time ; i.e., the atoms of C, H, O, N, S, 
P, which constituted the living matter in the beginning, 
were replaced very early by others brought in with the 
food. What has remained unchanged through the indi- 
vidual's life has been, on the physiological side, a form 
of activity, and, on the morphological and chemical side, 
a material substratum of a practically definite composi- 
tion. However familiar this fact may be, it is, after all, 
the great distinctive feature of life-or rather, of living 
matter. We express in the single word assimilation, or 
nutrition, that property which separates living matter 
from dead. As long as any particle of matter is in the 
living form, just so long has it the creative power of con- 
verting dead food into living substance like itself. 
Throughout its period of existence there is a steady 
stream of dead matter coming to it to be rearranged into 
the living form, and an equally continuous outflow of 
dead material from it which had once been in the living 
form. Nothing can make this conception clearer than 
Huxley's simile of the whirlpool at Niagara,-which fits 
so well as an illustration of the ever-changing particles 
which make up the unchanging form of life. From this 
point of view we may say that living matter is never 
actually the same, yet it must be evident that, in respect, 
of any given mass of that body which we call protoplasm, 
it can only reproduce itself in its offspring by transmit- 
ting a portion of its actual substance. The formation of 
a new organism from this transmitted germ is therefore, 
from a chemical stand-point, no more a creation of a new 
being or of new living material, than is the continued ex- 
istence of the parent form throughout its period of nat- 
ural life. 
As far as the mere external phenomena of senility are 
concerned they may be observed and recorded. In the 
human being this has been done with more or less care. 
The coming on of the signs of old age in the different 
tissues, the rate of its normal development, and the con- 
ditions which hasten or retard its development, are known 
to a certain extent, though they have not been investi- 
gated with the carefulness of detail which scientific ex- 
actness requires. We cannot expect any solid advance 
in our knowledge of the development of old age until the 
(SUPPLEMENT.) 
statistics, which may be determined by experiment and 
observation, have been recorded. The superficial signs 
of old age are spoken of usually in the text-books of 
physiology. In the old, the bones become more brittle 
because of a continually increasing excess of deposits of 
inorganic salts; the cartilages become more rigid and cal- 
careous for the same reason ; the elasticity of the lens of 
the eye decreases, bringing on imperfect accommodation ; 
the muscles atrophy and lose their physiological mobility, 
as shown by the lessened vigor of their contractions and 
their diminished elasticity ; the hairs lose their pigment, 
etc. It is important to notice that these signs of dete- 
rioration in the machinery of life do not make their 
appearance first during or after the period of maturity, 
but begin to develop from the time of birth, or possibly 
before. At ten years of age the near point of distinct 
vision is 7 ctm. from the eye, at twenty it has lengthened 
to 10 ctm., at forty years of age it is 22 ctm., at sixty 
years it is 100 ctm., and so on. The long-sightedness 
of old age begins to develop in early childhood, and 
results physiologically from a continual diminution in 
the elasticity of the lens. We obtain similar facts if we 
measure the rate of growth of the body throughout life. 
According to the somewhat unreliable statistics of Quete- 
let, the average male child weighs at birth 6| pounds. 
At the end of the first year it will weigh 18| pounds, a 
gain of 12 pounds. At the end of the second year it will 
weigh 23 pounds, a gain of only 4| pounds. And so on to 
full maturity the rate of increase each year falls rapidly. 
If we measure the rate of growth by the increase in 
height instead of by the increase in weight, we find that 
in the first year the gain is 148 mm., in the second year it 
has fallen to 93 mm., in the third to 72 mm., from the 
twentieth to the twenty-fifth year it averages 12 mm., 
and from the twenty-fifth to the thirtieth year only 0.8 
mm., while in extreme old age it becomes a negative quan- 
tity. In a recent paper Minot has given the results of a 
laborious research upon the growth of guinea-pigs, which 
show much more clearly and accurately the same gen- 
eral fact of a decrease in the rate of growth beginning 
shortly after birth. Minot bases his figures upon observa- 
tions taken daily. He defines the term "rate of growth " 
with an exactness not hitherto employed, in that he calls 
attention to the fact that usually, in considering the rate 
of increase, the actual increment at different periods is 
given instead of the proportionate increment. In other 
words, if an animal in successive periods gains in absolute 
quantities only the same amount in weight or height, its 
rate of growth is in reality decreasing, since proportion- 
ately to the weight of the whole animal the increase has 
been less and less. Making use of his short periods of 
twenty-four hours, and expressing the rate of growth 
as the fraction of weight added during that period, he 
finds that, after the animal recovers from a short post- 
natal retardation of growth, the rate of growth dimin- 
ishes during life, at first rapidly, and afterward more 
slowly. It follows from these facts, that what we may 
call the creative power of growth, or better, the creative 
power of assimilation, which measures the capacity of 
living matter to form matter like itself, decreases steadily 
from birth. Like a stone projected upward, the initial 
velocity begins to fall from the outstart. As the height 
to which the stone travels may be taken as a measure of 
the force with which it was thrown, so the length of life 
in any individual may be taken as a measure of the power 
or capacity of assimilation with which the germ of that 
individual started its career. When the power of assimi- 
lation is insufficient to replace the wastes of nutrition then 
death for that tissue is at hand. Whatever may be the 
internal causes which lead to this diminution, and thus 
serve to bring on old age, we are safe in saying that they be- 
gin to make themselves felt in the very first years of post- 
natal life. The curve of vitality-to use a much-abused 
but convenient word-does not rise from birth, reach its 
maximum in the vigor of maturity, and fall in old age, 
but begins to fall steadily, though not uniformly, from 
the beginning of life. 
To mankind as individual organisms old age and death 
are inevitable, but it is interesting to inquire what may 
207 Death, Origin of. 
Death, Origin of. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
be considered as the longest possible life under the most 
favorable conditions this world is likely to afford. We 
can answer this only by searching the records. If we 
put aside the oldest accounts on the ground of uncer- 
tainty as to the unit of time, and make our estimates on 
the basis of comparatively modern statistics, we may put 
the maximum age as lying somewhere between one hun- 
dred and twenty and one hundred and eighty years. 
Perhaps the most celebrated case of longevity is that 
of Thomas Parr, an account of whose life, together with 
the results of a post-mortem examination made by Har- 
vey, may be found in the third volume of the " Philo- 
sophical Transactions," p. 886. The account relates " that 
he was a poor countryman of Shropshire, whence he 
was brought up by the Right Honorable Thomas, Earl 
of Arundel and Surrey, and that he died after he had 
outlived nine princes, in the tenth year of the tenth of 
them, at the age of one hundred and fifty-two years and 
nine months." Other interesting extracts from the let- 
ter of Harvey are as follows : " The cartilages of the 
sternum were not more bony than the others, but flexile 
and soft." " The cause of his death was imputed chiefly 
to the change of food and air ; forasmuch as coming 
out of a clear, thin, and free air, he came into the thick 
air of London, and after a constant, plain, and homely 
country diet, he was taken into a splendid family where 
he fed high and drunk plentifully of the best wines." 
" He was able, even to the hundred and thirtieth year of 
his age, to do any husbandman's work, even threshing 
of corn." It is also stated that he married a widow when 
one hundred and twenty years of age, and from her own 
statement had frequent sexual intercourse with her. In 
an essay by Pfliiger on macrobiotics, he refers to other re- 
corded cases of unusual longevity. H. Jenkins, a native 
of Yorkshire, died, in 1670, at the age of one hundred 
and sixty-nine. It is related that on one occasion, when 
brought before a justice to testify with reference to an 
event which had occurred one hundred and forty years 
before, he appeared accompanied by his two sons, aged 
one hundred and two and one hundred years, respec- 
tively. A more remarkable case still is that of Kentigern, 
or Saint Mungo, founder of the Cathedral of Glasgow, 
who reached an age of one hundred and eighty-five, if 
we may trust the accounts of his life on record. Among 
the exceptional cases recorded some are stated to have 
been unusually temperate in their habits of life, while 
others paid no regard to such precautions. In this last 
category Pfliiger mentions one Brawn, who reached an 
age of one hundred and twenty, although his tomb- 
stone records the fact that he was a confirmed drunkard. 
Outside of such evidence as this, it is evident that excep- 
tional longevity cannot be referred solely to careful ob- 
servance of hygienic conditions. We must explain it, in 
general terms, as due to an unusual power of assimila- 
tion in the living substance composing the tissues, and 
that this tendency to long life is inherited may be ac- 
cepted as demonstrated by the statistics of life insurance. 
At the present day we have numerous cases of persons 
passing the hundred-year mark by a few years, so that 
this age cannot be regarded as very unusual. 
However, leaving aside the reproductive cells, death 
sooner or later comes to the rest of the cells of the body, 
no matter how favorable the environments of life may 
be. It is not altogether hopeless to inquire into the 
causes which bring this about, though naturally any 
such investigation is largely made up of speculation of a 
very general character. We may define death as a cessa- 
tion of life. In order, therefore, to arrive at even a gen- 
eral conception of its cause one must first define as clearly 
as possible what is meant by life. Spencer's definition is 
perhaps the one most familiar to educated persons. Ac- 
cording to him life is the continual adjustment of inter- 
nal to external relations. When properly analyzed the 
definition includes a great deal, and it is difficult to criti- 
cise it justly. But the physiologist will certainly object 
to it, because it attempts to present, in the most general 
terms, only the ensemble of properties manifested by liv- 
ing matter without pretending to trace these properties 
in any causative way to the physical substance which 
manifests them. It is as though one defined light by 
enumerating its chemical and physiological effects in- 
stead of referring it to vibrations of the ether. For the 
physiologist an adequate definition of life must be one 
which connects its phenomena with the chemical struct- 
ure of living matter. As the chemist may deduce the 
chief properties of a salt from a knowledge of the struct- 
ure of its molecule, so the physiologist believes that a 
scientific explanation of life-that is, of the phenomena 
of assimilation and reproduction-can only be obtained 
by discovering the essential chemical structure of the 
living molecule. To this end all biological work tends. 
The adjustment of internal to external relations, and 
the interaction of the different organs which brings about 
this adjustment, should be deducible from the chemical 
structure of living matter in somewhat the same way 
that the adjustments or reactions of benzine to different 
external conditions may be foretold from a knowledge of 
its molecular structure. That this kind of explanation 
of life is not inconceivably remote is demonstrated by the 
fact that several chemical theories have been seriously pro- 
posed and applied in some detail. Pfluger, for example, 
suggests that the essential difference between dead and 
living albumin lies in the grouping of the nitrogen in the 
molecule. In dead albumin it may exist in the form of 
an ammonia compound, while in albumin which is living 
it occurs in part, at least, in the cyanogen grouping. 
As something approaching scientific evidence for this 
view he asserts that the oxidation products of dead albu- 
minous bodies-that is, as far as the nitrogen is concerned 
-are always ammonia compounds, amines, or amido- 
acids, while the end products of the oxidations of living 
substances may be classed among the cyanogen bodies. 
Moreover, the cyanogen compounds are characterized 
by their instability, and this is likewise one of the most 
prominent phenomena exhibited by living substances; 
it is doubtless the chemical cause of what is known as 
the irritability of living things. Cyanogen compounds 
also exhibit, in a striking way, a tendency to polyme- 
rize, and Pfltiger suggests that this property of polymeri- 
zation may be the essence of what we speak of in general 
as assimilation or nutrition, by which the living mole- 
cule takes into itself the molecule of dead albumin. In- 
deed, says Pfluger, we may may look upon the molecule 
of cyanic acid as showing properties intermediate between 
those of living and dead matter, as a half-living sub- 
stance. In a similar way Loew and Bokorney attempt to 
explain the peculiar properties of living matter on the 
supposition that its molecule contains an aldehyde group. 
They find that living protoplasm, in certain plant-cells 
at least, has the property of reducing silver nitrate from 
alkaline solutions, while dead proteid has no such action. 
They infer that this reducing power is caused by the 
presence of an aldehyde group, and they give a scheme 
showing that formic aldehyde, by union with ammonia, 
may produce aspartic aldehyde, and this, by condensation 
and reduction, with the addition of S, will give, or might 
give, a compound of the molecular formula of proteid, 
which as long as it retained the aldehyde grouping would 
be living proteid, and would form the basis of living 
protoplasm. Latham attempts to combine the theories 
of Loew and Pfluger by supposing that living proteid is 
composed of a chain of cyan alcohols, united to a benzine 
nucleus, thus explaining the irritability or instability of 
living proteid, as well as its reducing action. However 
inadequate and premature such hypotheses may seem at 
present, they at least serve to demonstrate the fact that 
the physiologists and chemists are looking forward to a 
definition of life based upon a knowledge of the chemical 
structure of the substance through which it is made 
manifest. 
Proceeding from his conception of what constitutes 
life, Spencer defines natural death as a want of corre- 
spondence between the internal and external relations. 
Perfect correspondence would mean eternal existence. 
If the organism could adapt itself to every change in 
its environment, old age and death would be impossible. 
It is difficult to understand the full significance of Spen- 
cer's language. Taken literally it seems to assert noth- 
208 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Death, Origin of. 
Death, Origin of. 
ing more than that death is a cessation of life. It adds 
nothing at all to our knowledge of the causes leading to 
this cessation, nor does it indicate any fruitful line of in- 
vestigation. If, however, Spencer means that the fatal 
want of correspondence may come from without ; that 
is, from changes in environment to which no adequate 
adaptation can be made by the organism, and in many 
passages this seems to be implied, then his view is op- 
posed to that accepted by most physiologists. They, the 
physiologists, believe in general that although the environ- 
ment were perfect and unchangeable, yet by virtue of in- 
herent changes in the organism itself the assimilative 
powers would inevitably grow weaker and finally cease 
with death. In want of a more exact knowledge of the 
structure of the living molecule and the changes in struct- 
ure which come on in old age, the physiologist expresses 
his ideas of the general nature of these changes by 
similes and metaphors more or less apt. We may com- 
pare the living organism to a clock, the mainspring of 
which is so constructed that in consequence of slowly 
developing molecular changes it suffers a gradual loss of 
elasticity. In such a mechanism there will come a time 
when "winding the clock up" will no longer make it 
run, since energy can no longer be stored in the spring. 
We may imagine this loss of elasticity to develop grad- 
ually, giving stages that may be roughly compared to 
the periods of life. To carry out the simile, it is the food 
we eat and the oxygen we breathe which take the place 
of the winding force. In consequence of a slowly de- 
veloping molecular change in the organism, this energy 
is less efficiently utilized as the individual grows older. 
The clock runs more feebly and needs relatively 
more frequent winding, until at last the elasticity 
is gone, the power of assimilation is insufficient, and 
we have what we call natural death. In complex 
organisms like ourselves this failure of assimilation may 
come first to some one organ, such as the heart or the 
nervous system, and through its collapse the organism as 
a whole ceases to exist. In the nature of the case natu- 
ral death cannot come to every organ of the body at the 
same time, so that the death of a portion, perhaps from 
the stand-point of weight, the larger portion of the body, 
must always be accidental, as, for example, from a shut- 
ting off of the blood-supply due to natural death of the 
heart. But this consideration does not affect the general 
conception of the liability of all the organs to a similar 
fate. Rightly or wrongly, it is, or has been, a well- 
nigh universal belief that every organism and every bit 
of living matter in an organism has only a limited dura- 
tion of life, no matter how favorable the external condi- 
tions may be. 
In striking opposition to this view, Weissmann, in a 
recent series of essays upon the duration of life, has at- 
tempted to demonstrate the essential immortality of liv- 
ing matter, or, in other words, to show that death is not 
an inherent necessity of life, but an acquisition or adap- 
tation on the part of living things. These essays have 
aroused a wide-spread interest and discussion among 
biologists, and are probably the most important specula- 
tions of recent times upon the origin and meaning of 
death. Weissmann carries the problem back to the low- 
est forms of life, the unicellular organisms or protozoa. 
Whatever in this regard is true of them must be looked 
upon as being or as having been true for living things in 
general, since modern biological doctrines trace the evo- 
lution of life from these forms, and modern morphology 
has demonstrated that all complex forms of life are in fact 
mere colonies or collections of unicellular organisms. If 
we study one of the protozoa, the amoeba for instance, 
which has always been taken as the archetype of life, 
we find that it is a complete cell ; that it feeds, and as- 
similates, and excretes ; that it increases in size, and 
finally reproduces by simple fission, forming two new in- 
dividuals, or daughter-cells. In this last process we 
have the disappearance of one old individual and the for- 
mation of two new ones, nevertheless there is no death. 
To speak of the disappearance of the parent cell as an 
example of death, as some have done, is a mere figura- 
tive use of language. There is no death in such a 
(SUPPLEMEN I'.) 
change, because, as Weissmann puts it, there is no 
corpse. If we consider the two daughter-cells produced 
by the fusion, we find not only that they are similar mor- 
phologically, but that each of them , has possibilities of 
growth and reproduction equal to those shown by the pa- 
rent form ;-there is apparently no reason why such a pro- 
cess should not go on indefinitely. Amoeba?, as we find 
them under the microscope, show no signs of old age ; 
the daughter-cells are not less capable of reproduction 
than the parent cell. Il is permissible to suppose that if 
a single amoeba were given a favorable environment it 
would in time produce an infinite number of descendants, 
each of them possessing in turn the same unlimited possi- 
bilities of multiplication. This is precisely the hypothe- 
sis which Weissmann makes when he says that living 
matter is potentially immortal. It is an alternative hy- 
pothesis to the one usually adopted, and Weissmann's 
contribution to the subject comes not so much from his 
adoption of this view as from the application he makes of 
it in considering the higher forms of life in which death is 
an indisputable reality. Weissmann's theory of the origin 
of death among the metazoa is developed directly from 
his hypothesis that living matter was originally incapa- 
ble of natural death. His direct statement that the sim- 
plest unicellular forms of life to-day probably retain this 
primitive constitution of protoplasm has not, however, 
passed unchallenged. Maupas has made an experimen- 
tal test of the statement in some very interesting observa- 
tions. He set himself to observe certain unicellular ani- 
mals throughout an extended period, when placed under 
the most favorable conditions for growth and multiplica- 
tion. The infusoria were chosen for experiment. After 
making careful observations upon the best conditions 
of temperature and food, an individual was selected, 
placed upon a microscopic slide in a suitable moist 
chamber, and kept under the most favorable conditions 
possible for propagation. A faithful record was kept 
each day of the increase in number through multiplica- 
tion by division of the specimen chosen for study. After 
the increase had reached some hundreds of individuals, 
one of them was again isolated and allowed to multiply, 
and so on until unmistakable signs of what he calls a 
senile degeneration became apparent in the offspring. 
His experiments lasted for a variable time. In no case 
were the observations carried over less than fourteen 
days, and in the case of stylonichia pustulata, upon 
which the most careful experiments were made, the 
successive progeny were cultivated for nearly five 
months. 
The rate of growth in some of the species was incredi- 
bly fast. He estimates that in six and one-half days a 
single stylonichia, at a temperature of 25° to 26° C., might 
produce by repeated fissions a body of protoplasm weigh- 
ing one kilogramme, and in thirty days a mass of pro- 
toplasm a million times larger than the sun. He was 
able to observe that after a certain number of generations 
the progeny began to show signs of a physiological de- 
cline. The new animals formed were smaller than nor- 
mal, seemed weaker, were not so well provided with 
cilia, and the nuclei contained within them gave micro- 
scopical evidence of pathological changes. Maupas looks 
upon this result as proof of a genuine senility which 
would have resulted-had the process of isolation been 
continued sufficiently long-in the natural death of all the 
descendants, despite the most favorable conditions for liv- 
ing. After a colony began to show signs of old age he 
found that if one of the animals was taken out and mixed 
with another lot having a different ancestry, conjugation 
took place. The weakened infusorian united sexually 
with one of the more youthful forms, and rejuvenes- 
cence was thereby secured. The descendants of this 
pair multiplied again with the original vigor and gave 
rise to normal healthy offspring. Weissmann takes 
exception to these experiments. The infusoria are the 
most highly developed of the unicellular animals, show- 
ing a marked degree of specialization of structure. Fur- 
thermore they are known to conjugate at certain periods 
in their life history. A pair will come together and ex- 
change a portion of their nuclear material, after which 
209 Death, Origin of. 
Death, Origin of. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
each begins to multiply by simple fission with renewed 
vigor for a certain undetermined period. It may be that 
in so highly a differentiated form the primitive reproduc- 
tive power of protoplasm has been specialized in a particu- 
lar structure of the cell, as in the higher animals it has 
been reserved only to the germ-cells ; so that in this re- 
gard the infusoria might be classed with the metazoa 
rather than with the protozoa. Moreover, it may be 
doubted whether Maupas really kept his captive infusoria 
under perfectly normal conditions. Possibly the experi- 
ment could be made with greater certainty of success in 
this particular by using bacteria. Granting, however, 
that no exception can be taken to the experiments as 
made by Maupas, and that his results are correct, 
Weissmann contends that in the more primitive forms, 
in which reproduction is always by simple fission and 
anything approximating sexual conjugation is unknown, 
his fundamental hypothesis must still be true-death 
can occur only by accident, and not by natural decay. 
In the amoebae, bacteria, and similar forms of life no con- 
jugation has been discovered. While the conditions of 
life are favorable, growth and multiplication go steadily 
on. When the conditions of life are unfavorable-e.g., 
when moisture is withdrawn-forms like the amoeba 
may become encysted and cease to show the properties 
of living matter until more favorable conditions pre- 
vail. Gbtte has seized upon this process .of encystment 
as the equivalent of death, but we will speak of the 
theory of this author after Weissmann's theory has been 
stated. 
Let us assume that Weissmann is right in his fundamen- 
tal hypothesis, and that the first forms of life were poten- 
tially immortal, as the simplest forms of life are to-day. 
What, then, has become of that immortality in organisms 
like ourselves ? What was the origin of death ? Weiss- 
mann makes the supposition that in the higher animals 
we have two kinds of living matter, one composing the 
mass of the body, which unquestionably is subject to a 
natural death, and one composing the reproductive cells, 
which is evidently possessed of potential immortality, 
since if fertilized and kept under proper conditions it 
will give rise to . an infinite number of descendants. 
The former, the mortal, he speaks of as somatoplasm, 
the latter, the immortal, as germ-plasm. Furthermore, 
he supposes that the germ-plasm, constituting the re- 
productive cells in any individual, is directly derived 
from the fertilized ovum from which that individual 
developed. The fertilized ovum is a single cell; by cell 
division it multiplies a billion-fold and more to make 
the body. Of this infinite number of cells those which 
make up the muscles, skin, etc., although directly de- 
rived from the ovum, have become specialized physio- 
logically as well as morphologically to fit them for the 
performance of their special functions, and at the same 
time they have lost the potential power of immortality 
which characterized the germ-plasm of the ovum. But 
among this infinite number of cells there are always cer- 
tain ones which do not undergo specialization ; they re- 
main like the ovum from which they were formed ; they 
retain a portion of the germ-plasm with its powers of im- 
mortality, and these cells become the ova and spermato- 
zoa from which new organisms may be developed in turn. 
If we carry back this conception through the line of an- 
cestral forms from which man has been developed, it in- 
volves the idea that the germ plasm has been actually 
continuous throughout the history of living things, and 
that it represents the immortal protoplasm of the unicel- 
lular forms from which the metazoa were evolved. This 
is the doctrine which goes by the name of the " continuity 
of the germ-plasm," and in the form in which it is pre- 
sented makes one of the most original contributions given 
to biology within recent years. The question as we have it 
before us now may be stated in this way : The unicel- 
lular forms arc potentially immortal; the many-celled ani- 
mals contain an immortal germ-plasm and a mortal soma- 
toplasm, and yet the many-celled animals have been 
directly derived from the unicellular forms. In the first 
many-celled animals produced, the different cells must 
have had similar properties ; they must all have been 
(SUPPLEMENT.) 
equivalent to reproductive cells. But subsequently, 
after specialization of structure and physiological divis- 
ion of labor had become established, it happened that the 
vast majority of the cells of the body, all those in fact 
that had undergone differentiation in structure and func- 
tion, lost the power of perfect nutrition, and became sub- 
ject to old age and death. Upon what biological grounds 
can we explain this variation ? Weissmann refers it to 
the operation of the law of natural selection and states 
his theory briefly in saying that death is an adaptation, 
acquired because of its utility to the race on th? one hand, 
and, on the other hand, because, after the beginning of 
a differentiation in function among the cells, the posses- 
sion of immortality by all the cells was no longer any 
value to the race, and therefore was not brought under 
the preserving influence of natural selection. 
With reference to the first of these reasons, the utility 
of death to the race, it must be borne in mind that the 
operation of the law of natural selection is directed en- 
tirely toward the perpetuation of the species. Anything 
that endangers this perpetuity will be discarded, and the 
duration of life of the individual is a point worth fighting 
for, or against, only in so far as it influences the struggle 
for existence of the species. If natural death had not 
appeared, and creatures could have been destroyed only 
by fatally adverse changes in their environment, then we 
may imagine that every species would have been bur- 
dened in its fight for existence by individuals whose 
physical value had been impaired by previous minor ac- 
cidents, such as loss of limbs, etc. There would have 
been, from the pitiless stand-point of natural selection, 
many useless mouths to feed. Weissmann was inclined in 
his first essays to lay great stress upon this point, but in 
later years he has emphasized chiefly the second of the 
reasons given above, namely, that immortality was lost to 
the non-reproductive cells because, being of no direct value 
in the perpetuation of the species, they were not acted 
upon and preserved by natural selection. This tendency 
of structures to retrograde and disappear when their 
value to the species becomes nil, even though they may 
not be actively injurious or burdensome, because natural 
selection no longer acts to preserve them, is something of 
a new idea in biology. Weissmann attaches great im- 
portance to it, and has coined for it the term panmixia. 
A simple example of its action is seen in the absence of 
eyes in the cave-inhabiting animals. Many of the Crus- 
tacea living in the dark caves have lost their eyes-by 
panmixia, Weissmann would say ; that is, in their peculiar 
environment their eyes are no longer of use, and they 
have therefore degenerated and disappeared, in the course 
of generations, by the lack of the direct preservative in- 
fluence of natural selection. So Weissmann thinks that 
the original immortality of living matter became lost to 
the non-reproductive cells in the many-celled animals 
because, being of no value to the species, indeed, on the 
contrary, threatening the species with an unnecessary 
burden, natural selection let it alone. 
Many eminent biologists have found a logical difficulty 
in understanding how from cells originally immortal 
cells that were mortal could have been derived by differ- 
entiation of any kind. They hold that natural selection 
can only operate upon a structure which exists, it cannot 
create a thing outright. If living matter was all origi- 
nally immortal how could natural selection, by negative or 
positive action, produce mortality, if in some degree this 
latter property was not already inherent in living matter. 
As one of the objectors (St. George Mivart) puts it, the 
difficulty is to understand the first step, the beginning of 
something from nothing. Objections of this kind are of 
course fallacious ; it is curious that they should have 
been seriously made by eminent men. The words mor- 
tality and immortality do not stand for definite things ; 
they are not substances or entities, or whatever term of 
this kind one may choose to use. On the contrary, they 
are in this case merely convenient phrases to express the 
kind of nutrition going on in living things, whether it 
is self-perpetuating or self-limiting. They are properties 
which are connected with the physical or chemical struct- 
ure of the living molecule, and this latter is a thing 
210 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 
Death, Origin of. 
Death, Origin of. 
which does exist and may be acted upon and modified 
by natural selection in many ways. 
In accepting or refusing Weissmann's theory of the 
origin of death, everything seems to depend upon the 
validity of his fundamental hypothesis with regard to 
the absence of natural death among the primitive forms 
of life. If we admit that there are simple organisms, 
such as the bacteria or amoeba, which do not propagate 
by conjugation or by any method of multiplication other 
than simple fission, it would seem logically impossible 
for such a species to be perpetuated unless its protoplasm 
is exempt from senility. If we do not accept this solu- 
tion, then we must suppose either that there is some 
kind of sexual rejuvenation which has not yet been dis- 
covered in these particular forms, or that there is some 
process of molecular rejuvenation occurring at periods 
in the life-history of such forms which brings the living 
substance back to its primitive constitution and nutritive 
vigor. Gotte has clearly recognized this necessity, and 
has proposed a theory which is logically acceptable. Ac- 
cording to Gotte, death is a necessity immanent in life. 
As regards the unicellular forms of life, he avoids the 
difficulty which has just been described by assuming 
that the process of encystment is the death of the old 
individual and the beginning of a new one. Encystment, 
of course, is known to occur among the unicellular forms. 
During the process the visible evidences of life, such as 
movement, come to an end, to be renewed again after a 
certain period, or under more favorable conditions. 
Gotte believes that during the encystment a change of 
molecular structure takes place. There is first a dis- 
sociation or dissolution, which is an actual death, inas- 
much as the properties of living matter are lost. This, 
however, is succeeded by a stage of reconstruction with 
the formation of new protoplasm possessed of the prim- 
itive powers of assimilation, and capable of developing 
and multiplying for a certain period. This is obviously 
an hypothesis which it is practically impossible to test by 
chemical investigations. To the physiologist it will 
probably not be acceptable on theoretical grounds be- 
cause of the difficulty of conceiving how matter once in 
the dead form can again pass into the living form, as 
the result of spontaneous molecular activities, and with- 
out the aid of an exciting or liberating force. Dead 
matter, as we know it, is converted into the living form 
only by the process of assimilation on the part of matter 
already living, whereas the hypothesis of Gotte calls 
upon us to believe that the transition may take place by 
virtue of the inter-molecular movements in the dead 
matter itself. Encystment, then, according to the theory 
of Gotte, represents at the same time the primitive form 
of natural death and the primitive method of reproduc- 
tion. As the metazoa have been derived from the uni- 
cellular forms, he further assumes that among the former 
both natural death and reproduction have been acquired 
by direct inheritance. As in the protozoa reproduction 
and death stand in a causal relationship, so in the simpler 
forms of metazoa, e.g., in the orthonectidae, this con- 
nection is still maintained, inasmuch as the liberation of 
the ova results in the death of the individual. Among 
the higher forms the relationship between reproduction 
and death is not so evident, though the theory demands 
always a causal connection between the two processes. 
It will be evident from this brief statement of Gbtte's 
views that he differs from Weissmann, not only in his 
belief of the necessity and universality of death, but also 
in respect of the discontinuity of life. Among the pro- 
tozoa, which propagate by encystment, his theory denies 
that the new individual is directly sprung from the living 
substance of the parent cell. On the other hand, the 
general belief has been that in some way the continu- 
ity of life is maintained. Darwin's theory of pange- 
nesis, which was formulated to explain the phenomena 
of heredity, implies a continuity of living matter be- 
tween parent and child. It will be remembered that 
in this theory the ova and spermatozoa are supposed to 
contain minute germs, gemmules, thrown off from the 
different cells of the body and collected in the germ-cells. 
Under the proper physiological stimulation, the gem- 
(SUPPLEMENT.) 
mules develop into organs like those from which they 
were derived. The gemmules must be considered as 
living matter ; hence the theory implies a direct carrying 
over of living substance from parent to child, a con- 
tinuity of living matter at least. In contrast with this 
the theory of Weissmann supposes a direct continuity of 
germ-plasm, the essential part of the germ-cells of the 
child being an actual portion of the germ-protoplasm of 
the reproductive cells of the parents. The immortality 
of the germ-plasm and the direct continuity of the germ- 
plasm, are, then, the fundamental parts of Weissmann's 
theory, and his hypothesis of the origin of death as re- 
gards the somatoplasm follows naturally if we accept 
these premises. It will be observed, however, that Dar- 
win's pangenesis theory may also be considered as im- 
plying the essential immortality of the material compos- 
ing the germ-cells, although neither Darwin himself nor 
those who have made use of his theory have ever made 
a specific statement of this kind. 
In the older treatises upon the nature of death a dis- 
tinction was often made between molecular death and 
somatic death. The former term was meant to include 
those changes of disassimilation or katabolism, to use a 
more modern word, which are supposed to be in play in 
every bit of living matter, and to lead to the formation of 
dead waste material, such as urea, carbon dioxide, and 
water. Somatic death was used, as it is at the present 
time, to describe the final cessation of all vital activities 
in the body at large. It was supposed that we had here 
the production of dead from living matter by two entirely 
different methods. The term molecular death is ob- 
viously an unhappy one, and has fallen into disuse, 
although it is possible that it is an accurate statement 
of what takes place. The essential nature of the physio- 
logical oxidations which lead to the formation of the 
products of disassimilation is at present a subject of dis- 
cussion, and will probably remain so for a long time. 
Treating the subject in the most general way, it seems 
evident that in disassimilation one of two things may 
take place. If, for the sake of simplicity, we confine 
our attention to a single cell, then it is possible, on the 
one hand, that the formation of the wastes of nutrition 
is brought about by the actual death and disintegration 
of portions of the cytoplasm, their places being supplied 
by new living material formed in other parts of the cyto- 
plasm or in the nucleoplasm. Or, on the other hand, it 
is equally possible that in normal disassimilation no 
single living molecule undergoes total destruction. The 
process of dissociation may be such that only a portion 
of the molecule is split off, and lost from the cell as dead 
material, while the remainder of the molecule recon- 
structs itself from the food material of the cell-juices into 
the originally complex molecule of living matter. This, 
in fact, is the hypothesis of physiological oxidation which 
has been proposed by Pfliiger with special reference to 
the metabolisms of muscle during functional activity. 
His theoretical view's have much to recommend them, 
and some account of them is usually given in the text- 
books of physiology. 
Refebences. 
Spencer : Principles of Biology. 
Weissmann : Essays upon Heredity, and Kindred Biological Problems, 
vol. i. English Translation, 2d edition, 1891. 
GOtte: Ueber den Ursprung des Todes. Hamburg und Leipzig, 1883. 
Pfliiger : Ueber die Kunst der Verlangerung des Menschlfchen Lebens. 
Bonn, 189C. Contains also references to cases of unusual longevity, 
taken from Flourens, De la Longevity humaine ; Spottiswood, History 
of the Church of Scotland ; Ollendorff. Lebensdauer in Realencyclo- 
padie der gesammten Heilknnde, vol. viii., etc, 
Pfliiger: Archiv. f. d. gesammte Physiologie, vol. x. 
Harvey : Philosophical Transactions, vol. iii. Contains an account of the 
autopsy of Thomas Parr. 
Minot : Journal of Physiology, xii., 97. Senescence and Rejuvenation, 
Maupas : Archives de Zoologie experimental? et generate. 2me Serie, t. 
vi., p. 165. 1888. 
Loew and Bokorney : Die Chemische Kraftquelle im lebenden Proto- 
plasma. Munich, 1882. Containing a theory of the structure of living 
proteid. 
Latham : British Medical Journal, 1886, i. ; 629. Containing a theory 
of the structure of living proteid. 
Todd : Cyclopaedia of Anatomy and Physiology. Articles : Death, by J. 
A. Symonds; Age, by J. A. Symonds; Life, by W. B. Carpenter. 
These articles give full references to the older literature. 
IT. H. Howell. 
211 Dermatol. 
Digestion. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
DERMATOL, the trade name for the subgallate of bis- 
muth, BiCTlIiOi, containing fifty-five per cent, of the 
oxide of bismuth. It is a fine, yellow powder, devoid of 
odor, quite insoluble in water or any of the ordinary sol- 
vents, free from irritating action, and non-poisonous. 
It has been introduced to replace iodoform, on ac- 
count of its freedom from many of the disagreeable 
qualities of that drug. 
It is not a bactericide, but prevents their growth or 
formation, and in this way compares favorably with iodo- 
form and aristol. Its beneficial action is due to its neu- 
tralizing the ptomaines produced. It is not only insoluble 
but also repels water, thus rendering the part unfavorable 
to the growth of bacteria. 
It is not so suited to the treatment of sloughing or sep- 
tic wounds as iodoform, nor is it sufficiently stimulat- 
ing in chronic indolent ulcers. It is most serviceable to 
promote cicatrization in healing surfaces, and in affections 
of the skin ; in burns, scalds, chancres, eczema, partic- 
ularly when characterized by much discharge, it has 
been used with marked success. In these cases the parts 
become dry on the second or third day of its use, and the 
relief is very marked. If the part is previously washed 
with an antiseptic lotion its action is greatly assisted. It 
may be applied by dusting on the part, or in the form of 
an ointment of one part in ten. It may with advantage 
replace oxide of zinc, starch, etc., as a dusting powder in 
scalded and denuded surfaces. 
In doses of thirty to ninety grains it has been given 
internally, as a substitute for the subnitrate, for diarrhoea 
in children, in phthisis, typhoid, etc., with good results. 
It may be given in wafers or as an emulsion. 
Beaumont Small. 
DIARRHCEA. If we are to credit the results of recent 
investigations, the symptomsand pathological conditions 
of diarrhoea, to a larger degree than we have supposed 
heretofore, are due to the products of bacterial action in 
the alimentary canal. It has been shown, almost con- 
clusively, that ptomaines develop in the intestines during 
the decomposition of food in diarrhoea, as well as some- 
times in the opposite condition of constipation, and the 
results of treatment show that in diarrhoeal states those 
medicaments are most useful which exercise a repressive, 
if not a destructive action upon bacterial growth. 
Numerous cases of obstinate constipation with anaemia 
and slight toxic symptoms have been promptly relieved 
by a free evacuation of the alimentary canal, and by the 
exhibition of antiseptic remedies like preparations of 
mercury, bismuth, and naphthol, strongly suggesting that 
some leucomaine poison must have been produced in the 
intestine, or cast into it, which, being absorbed, caused 
the mischief, and of which the constipation prevented 
the regular discharge. Cases of diarrhoea are not only 
benefited by germicide medicines taken by the mouth, 
but also by similar remedies introduced in the form of 
large enemas. 
In the treatment of diarrhoea the necessity of insuring 
perfect digestion of such food as is taken, and of keeping 
the intestinal canal free from abnormal decompositions, 
has been of late very much emphasized, and what we 
ought always to have understood is being recognized 
more than ever, that every particle of food taken that is 
not digested is a menace to the intestinal mucous mem- 
brane by the irritation its decomposition may light up. 
It should be a positive condition in the treatment of all 
cases, especially of the more chronic forms, of diarrhoea, 
to obviate that sort of indigestion or disorder ; and it is 
coming also to be recognized that such cases cannot be 
treated by an occasional dose of medicine, regardless of 
conditions and circumstances, but that the patient must 
be put upon a strict regimen, and that he cannot vary 
from it in any particular, or lose his courage or watchful- 
ness of himself for a day, without danger of a relapse. 
In the chronic cases the digestion may be conserved 
by various gastric and other tonics in small doses, and by 
peptogenic preparations, and by a most careful selection 
and preparation of food. 
The normal condition of freedom from vicious decom- 
(SUPPLEMENT.) 
positions in the intestinal canal may be conserved by 
moderate doses of salicylate of bismuth (2 to 5 grs.), sub- 
nitrate of bismuth (5 to 10 grs.), hydronaphthol or beta- 
naphthol, which may be taken in doses of 5 to 20 grains, 
or even more, without harm, calomel to gr.), bin- 
iodide of mercury to gr.), or bichloride of mercury 
gr.), and by salol (1 to 3 grs.), but the possible un- 
pleasant effect of the last upon the kidneys when given 
in large amount should lead to caution in its use. Arsen- 
ite of copper has been highly praised of late for diarrhoea, 
mostly for the acute forms, in very minute doses to 
Toirgr.), frequently repeated. It is a drug of superior 
value, both in the acute and chronic forms, and may be 
taken in somewhat larger doses than those mentioned 
above. There would seem to be no objection to using it 
in small doses regularly for a long time in those cases of 
debility which show a tendency to diarrhoea from even the 
smallest variation from the usual dietary or hygienic con- 
ditions ; for then its wholesome effect on the intestinal 
canal would be a sustained one, and the general tonic 
effect of the arsenic wrould be experienced. 
It has been discovered recently that a form of amoeba 
(amoeba coli) swarms in the intestinal canal at times and 
causes dysentery of such a character that it is liable to be 
mistaken for one of the forms of diarrhoea described in the 
original article on this subject in Vol. II. The dejections 
are liable to much variety in their character, and the di- 
arrhoea to alternate with constipation. The sanguineous 
and mucoid qualities of the discharges are less marked 
than in ordinary dysentery, although blood and thick 
mucus may freely appear at times. The disease lasts 
long and is very intractable to treatment, and the mor- 
tality is high. It is remarkably prone to produce com- 
plications, especially perforation, peritonitis, abscess of 
the liver, and, consecutive to it, of the lung. Fever is not 
a marked symptom in the disease when uncomplicated. 
Ulceration of the intestinal wall occurs in all bad cases, 
-deep excavations and underminings, but with little true 
suppuration. The amoebae can easily be found in the dis- 
charges, and, of course, are the sole diagnostic sign. 
Their discovery in small numbers in the stools in any 
case would not absolutely prove that they were the cause 
of a diarrhoea, since they are sometimes discovered in the 
dejections of health. As a matter of fact, in these cases, 
the amoebae swarm in the stools, as well as in the prod- 
ucts of the abscesses of the liver and of the lung. 
Injections of substances destructive to the parasites 
seem the most useful treatment. Their complete de- 
struction in the walls of the intestines is evidently dilli- 
cult, owing to the unavoidable obstacles to carrying 
effective quantities of the medicament to every nidus of 
their multiplication in the irregularities of the intestinal 
lining, as well as in the ulcers and excavations. 
The treatment of many of the more chronic forms of 
diarrhoea by enteroclysis, or injections of sterilized water 
containing various medicaments, is very properly coming 
more into vogue. A salt solution, of 6 or 7 parts of 
chloride of sodium to the 1,000 of water, is best for irriga- 
tion, and weak solutions of tannic acid (1 to 3 drachms 
to the quart) or boric acid, for destruction or repression 
of micro-organisms, work best. For any ordinary case 
of diarrhoea it is unsafe to use corrosive sublimate or car- 
bolic acid solutions ; they are too poisonous, whereas the 
tannic and boric acids, in proper quantities, are quite 
harmless, as is also hydronaphthol, which may be used 
in a saturated solution. Occasionally a slight admixture 
of some opiate is required, but ought never to be used 
unless demanded by pain or irritation of some sort. 
This method of medication is not by any means as dif- 
ficult to use as it would seem, since almost an unlimited 
amount of water can easily be introduced into the bowel, 
provided the patient is horizontal, and the movement of 
the water into the body is extremely slow, and the stream 
perfectly continuous from a fountain syringe, the reser- 
voir of which is elevated but a few inches. No pulsat- 
ing stream will do ; the water must be, when it reaches 
the intestine, as warm as the body, and may be two de- 
grees above the normal heat; it must be at least four de- 
grees above normal body heat as it leaves the bag. If 
212 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Dermatol. 
Digestion. 
too much is introduced for the large intestine to contain, 
it readily passes the ileocaecal valve into the small intes- 
tine, and, if further relief is required, into the stomach and 
out through the mouth. With the precautions named, all 
the tenesmus disappears, and even little children receive 
the treatment without complaint. But slowness of intro- 
duction of the water is a precaution never to he forgotten. 
The method has several distinct advantages : it washes 
the intestines free of mucus and decomposing and de- 
composed substances of numerous kinds ; it washes away 
vast myriads of microbes, which may be wholly or in 
part responsible for keeping up the diarrhoea, if not of 
causing it originally ; and it kills or lessens the growth 
and virulence of swarms of them that remain. In dys- 
entery, especially, a treatment of this sort is in the high- 
est degree useful when practised once or twice each day, 
particularly when the tannic acid is used ; only, to be 
most effective, it should be often repeated, or, better still, 
employed as an irrigation with a long double tube, hav- 
ing a large and free outflow. This procedure should be 
carried out once or twice each day. 
The treatment, moreover, is a rational application of 
the principles so effective on other parts of the body, 
namely, a thorough cleansing of inflamed surfaces, the 
removal from them of substances, however produced, 
which are capable of causing irritation, and the soothing 
of them by appropriate medicines. 
There is perhaps no form of diarrhoea where the carry- 
ing out of these principles is more demanded than in the 
summer diarrhoeas of children, often improperly called 
cholera infantum, and in these this treatment deserves a 
freer trial. But in this class of patients it is specially 
important that the treatment be carried out with care, 
caution, and faithfulness. It unavoidably requires the 
hand of the physician or of a most carefully instructed 
nurse. 
The frequency of the injections should depend on the 
effect. The effect of each one should be to quiet the ir- 
ritation for a number of hours, and during this time the 
bowel should remain unmolested, the treatment being re- 
peated on a recurrence of the symptoms. 
No attempt should ever be made to pass a tube through 
the sigmoid flexure. The effort is rarely successful, and 
the danger from the use of a hard tube is great. 
Norman Bridge. 
DIEPPE. A fashionable watering-place, and one of 
the favorite sea-side resorts of the Parisian " monde." 
It is prettily situated on the coast of Normandy, at the 
mouth of the river d'Orques, and between high calcareous 
cliffs. The bathing season lasts from June to Septem- 
ber. To quote from Baughan (" The Northern Watering- 
Places of France "): " The life of the place seems con- 
centrated on the beach, and at the Etablissement des 
Bains de Mer. The beach is quite a mile long, and 
extends from the timber-yards near the jetty to the foot 
of the high cliff on which stands the Chateau, a pictu- 
resque old building with a square tower, now used as a 
barrack. The beach at Dieppe was once but a stretch of 
meadow-land, but now it is a fine promenade, laid out as 
an English garden, and bordered by stately hotels. Trees 
would be an improvement, but of these there are none, 
which is a pity, for the heat at noontide along the un- 
shaded promenade is something not to be endured. 
There is a wide and beautiful expanse of sea at Dieppe, 
and though the beach at high tide is of bowlders, when 
the sea goes out there are sands, but the bathing at high 
tide is, of course, on the bowlders, and this is one of the 
greatest disadvantages of Dieppe. 
" The Casino ami the Etablissement des Bains de Mer 
are the property of the town, and they are charmingly 
managed. They are to the southwest of the beach- 
just beneath the cliff on which stands the Chateau. The 
Etablissement is built in imitation of the Crystal palace, 
London, and contains a theatre and ball-room, several 
charming salons, a billiard-room, and a reading-room. 
It is surrounded by a well-laid-out garden, where there 
is a place set apart for children's sports, a gymnasium, 
and several pavilions where different games are played." 
(SUPPLEMENT.) 
Accommodation.-The principal hotels are the Royal, 
1'Hotel de Bristol, le Grand Hotel des Bains, 1'Hotel de 
la Plage, and le Grand Hotel de Dieppe. All these 
hotels are situated along the beach, and are expensive. 
L'Hotel du Nord, Quai Henri IV.; 1'Hotel de la Paix, 
Grande Rue ; and 1'Hotel du Geant, Rue de Chene-Perce, 
are more moderate. 
Numerous interesting excursions can be made into the 
surrounding country. Of late years many English and 
American visitors are seen at Dieppe. 
Edmund G. Wendt. 
DIGESTION. The changes and additions now con- 
tributed to the articles furnished by the writer to the 
subject of " Digestion," the " Digestive Secretions," etc., 
are rendered necessary, in part, by the increase in our 
knowledge from new observations and experiments, but 
still more owing to an alteration in the point of view that 
must, sooner or later, work great, if not radical, changes 
in the whole of physiology. 
It is now being perceived that it is impossible to ex- 
plain vital processes entirely by the laws of physics and 
chemistry. The attempt to do so has led physiologists 
aside from the true path, and we are now obliged to con- 
fess failure and seek other ways. 
There is also a hopeful broadening taking place ; and 
it is not so common as it was to assume that, what holds 
for one animal applies to others, even though alike in 
many respects. Greater caution and breadth, and a truer 
insight, with less hasty generalization, will probably 
mark the physiology of the future. 
This has been very clearly illustrated by the views re- 
cently published on the subject of digestion, as the 
writer will endeavor to show. 
It would seem that we have been too ready to accept 
simple explanations, and to consider life processes as 
much less complicated than more recent investigations 
show them to be. 
Proteid Digestion.-It is still held that in peptic 
digestion, peptorte, or more properly peptones, are the 
final products of the action of gastric juice on proteids ; 
and that the process of digestion is one of hydration ; 
but between albumin on the one hand and peptones on 
the other, there are now recognized several bodies of 
distinct properties. 
The following tabular statement embodies the most 
recent views, and indicates the antecedents of the final 
peptones: 
Albumin. 
Hemi-albumin. 
Anti-albumin. 
Hemi-albumose. 
Hemi-peptone. 
Anti-albumose. 
Anti-peptone. 
Hemi-peptone may, by the pancreatic secretion, be split 
up into leucine, tyrosin, etc., but this is not true of anti- 
peptone. 
Albumoses may be classified chemically, according to 
the action on them of different reagents, thus : 
1. Proto-albumose.-Soluble in cold and hot water, and 
in dilute saline solutions ; precipitated by saturation with 
magnesium sulphate or sodium chloride. 
2. Hetero-albumose.-Insoluble in water ; soluble in 
cold solutions of sodium chloride of a strength of from 
one-half to fifteen per cent. ; precipitated by heating to 
65° C., the coagulum being soluble in dilute acids and al - 
kalies. It is precipitated by alcohol, but, unlike other 
albumoses, is thus altered to an insoluble body, dysalbu- 
mose. Like the preceding, it is precipitated by satura- 
tion with neutral salts. 
3. Deutero-albumose.-Soluble in cold and hot water; 
not precipitated by saturation with sodium chloride or 
magnesium sulphate, but thrown down by saturation 
with ammonium sulphate. 
It is in its reactions allied to the peptones, for it is not 
precipitated by copper sulphate, and only gives the 
nitric acid reaction in the presence of excess of salts. 
213 Digestion. 
Digestion. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Variety of proteid. 
Hot and cold 
Hot and cold 
Satu ration 
Satu ration 
Nitric acid. 
C o p p er sul- 
Copper sul- 
C o p per sul- 
water. 
saline solu- 
tion, e.g., 1(1 
per cent. Na 
Cl. 
with Na Cl 
or Mg SO4. 
with Am„ 
SO4. 
phate. 
phate and 
ammonia. 
phate and 
caustic soda 
or potash. 
Albumins. 
Soluble in 
cold, coagu- 
lated in hot, 
water. 
Soluble i n 
cold, coagu- 
lated in hot, 
solutions. 
Not precipi- 
tated. 
Precipitated. 
Precipitated 
in cold, not 
soluble on 
heating or 
only slight- 
ly- 
The same as 
albumins. 
Precipitated. 
Blue solution. 
Violet solu- 
tion. 
Globulins. 
Not soluble in 
either. 
The same as 
albumins. 
Precipitated. 
Precipitated. 
The same as 
albumins. 
The same as 
albumins. 
The same as 
albumins. 
Proto-albumose. 
Soluble i n 
both. 
Soluble in 
both. 
Precipitated. 
Precipitated. 
Precipitated 
in cold; pre- 
cipitate dis- 
solves with 
heat and re- 
appears on 
cooling. 
Precipitated. 
Violet solu- 
tion. 
Rose-red so- 
lution. 
Hetero-albumose. 
Insoluble, i.e., 
like globu- 
lins, precipi- 
table by di- 
alysis from 
saline solu- 
tions. 
Soluble i n 
both; partly 
precipitat- 
ed, but not 
coagula ted 
on heating 
to 65° 0. 
Precipitated. 
Precipitated. 
Precipitated 
in cold; pre- 
cipitate dis- 
solved with 
heat and re- 
appears on 
cooling. 
Precipitated. 
Violet solu- 
tion. 
Rose-red so- 
lution. 
Dentero-albumose. 
Soluble. 
Soluble. 
Not precipi- 
tated. 
Precipitated. 
This reaction 
only occurs 
in presence 
of excess of 
salt. 
Not precipi- 
tated. 
Violet solu- 
tion. 
Rose-red so- 
lution. 
Pe tone. 
Soluble. 
Soluble. 
Not precipi- 
tated. 
Not precipi- 
tated. 
Not precipi- 
tated. 
Not precipi- 
tated. 
Violet solu- 
tion. 
Rose-red so- 
lution. 
The above table, from Halliburtin's "Chemical Physi- 
ology and Pathology," puts the most recent information 
in a compact form. 
According to Neumeister, the relations of the various 
proteid bodies formed in the digestive process may be 
thus expressed : 
fatty acids and glycerine, from which result a certain 
proportion of soaps, yet there is reason to believe that 
the greater part of the fat finds its way into the blood as 
a very fine emulsion, or even as "molecular fat." 
The fact that, even in the absence of bile or pancreatic 
juice, some fat digestion may, if not at first, eventually 
take place in an animal, shows that we have been regard- 
ing digestion too much in a purely chemical light. 
Bile.-The tendency, in view of recent researches, is 
rather to confirm the opinions of those that held that the 
bile itself takes no essential part in digestion, though 
helpful to the pancreatic juice ; at the same time it must 
be said that a conservative-attitude is the most justifiable 
one at present. 
Faces.-Though actual experiment has not recently 
brought to light much that is new in regard to the com- 
position of faeces, it is still clear to the writer's mind that 
the facts of clinical medicine indicate that many harmful 
products are in all probability discharged from the body 
by means of the intestines. In other words, we must re- 
gard the intestine as a great excreting as well as secreting 
surface, and must believe that the faeces contain not only 
some of the altered digestive secretions and the indigesti- 
ble remnants of the food, but possibly numerous products 
of tissue-waste, either as they were formed in the cells of 
the various tissues, or as they were modified by the 
glandular and possibly other cells of the gut. 
A subject of which some notice may be taken is self- 
digestion of the stomach, etc. This is all the more nec- 
essary as the views that formerly prevailed indicate how 
much was overlooked. In this connection the writer 
begs leave to introduce an extract from his " Animal 
Physiology" (I). Appleton & Co., New York, 1889). 
" Self-Digestion of the Digestive Organs.-It has been 
found, both in man and other mammals, that when 
death follows in a healthy subject while gastric digestion 
is in active progress and the body is kept warm, a part 
of the stomach itself, and often adjacent organs, are 
digested, and the question is constantly being raised, 
Why does not the stomach digest itself during life? To 
this it has been answered that the gastric juice is con- 
stantly being neutralized by the alkaline blood ; and, 
again, that the very vitality of a tissue gives it the neces- 
sary resisting powers, a view contradicted by an experi- 
ment which is conclusive. If the legs of a living frog be 
allowed to hang against the inner walls of the stomach 
of a mammal, when gastric digestion is going on, they 
will be digested. 
"The first view (the alkalinity of the blood) would 
Albumin. 
Hemi-albumin. 
Anti-albumin. 
Proto-albumose. 
Hemi-deutero-albumose. 
Hetero-albumose. 
Ampho-deutero-albumose. 
Anti-albuminate. 
Anti-albumid. 
Hemi-peptone. 
Anti-deutero- albumose. 
From the above table it appears that albumin is made 
up of hemi-albumin and anti-albumin, and the subse- 
quent changes of each are indicated down to the final 
products in peptones, and all are to be regarded as stages 
in a hydration process. 
Primary albumoses are those formed directly from al- 
bumin, i.e., proto-albumose and hetero-albumose. Al- 
though this table shows that digestion is now regarded 
as a much more complex process than formerly, it seems 
to the writer that what we have ascertained is rather an 
indication of possibilities than actualities, and that our 
views may be expected to undergo great changes, if they 
are not shown to be wholly inadequate. It is also likely 
that the process of digestion of proteids may vary much 
for individuals, or even in the same individual at differ- 
ent times, not to mention differences for unlike groups of 
animals. But certain it is, that a modest and expectant 
attitude, in view of the radical modifications that have 
recently taken place in our ideas with regard to this sub- 
ject, is the only correct one. 
Besides, it is more and more apparent that conclusions 
founded on artificial or laboratory digestion are to be 
drawn with the greatest care. 
Digestion of Fat.-Owing to the more rational view 
now taken with regard to digestion generally, and with 
regard to the true nature of absorption, the digestion of 
fat is more readily comprehensible, though no very new 
light has been thrown on the action of those digestive 
juices that are concerned in altering the ingested fat. 
Though the pancreatic juice, especially when mixed 
with bile, has the power of splitting up neutral fats into 
Ampho-peptone. 
Anti-peptone. 
214 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Digestion. 
Digestion. 
(SUPPLEMENT.) 
not suffice to explain why the pancreas, the secretion of 
which acts best in an alkaline medium, should not be 
digested. 
" It seems to us there is a good deal of misconception 
about the facts of the case. Observation on St. Martin 
shows that the. secretion of gastric juice runs parallel 
with the need of it, as dependent on the introduction of 
food, its quantity, quality, etc. Now, there can be little 
doubt that, if the stomach were abundantly bathed, when 
empty, with a large quantity of its own acid secretion, it 
would suffer to some extent at least. But this is never 
the case; the juice is carried off and mixed with the 
food. This food is in constant motion, and doubtless the 
inner portions of the cells-which may be regarded as the 
discharging region, the outer, next the blood-capillaries, 
being the chief manufacturing region of the digestive 
ferment-are frequently renewed. 
" Such considerations, though they seem to have been 
somewhat left out of the case, do not go to the bottom of 
the matter. Amoeba and kindred organisms do not digest 
themselves. Some believe that the little pulsatile vac- 
uoles of the infusorians are a sort of temporary digestive 
cavities. 
"But, to one who sees in the light of evolution, it 
must be clear that a structure could not have been 
evolved that would be self-destructive. 
" The difficulty here is that which lies at the very basis 
of all life. We might ask, Why do living things live, 
since they are constantly threatened with destruction 
from within as from without? Why do not the liver, 
kidney, and other glands that secrete noxious substances, 
poison themselves ? We cannot in detail explain these 
things ; but we wish to make it clear that the difficulty 
as regards the stomach is not peculiar to that gland, and 
that even from the ordinary point of view it has been 
exaggerated." 
The Movements of the Alimentary Tract and 
the Nervous Mechanisms Concerned.-So far as 
the movements of the tract are concerned, we find a lo- 
calization of function with an interdependence corre- 
sponding to anatomical differentiations. The movements 
of the oesophagus and stomach, for example, are more in- 
dependent than those of the rest of the digestive canal. 
Peristalsis naturally takes place in the region lying be- 
tween the stomach and the caecum, while the large gut, 
and especially the sigmoid flexure of the colon and the 
rectum, have a subordinate degree of independence in 
this respect. 
The nervous supply is more or less distinct in those 
regions of greatest localization of movement. Neverthe- 
less we recognize both in health and in disease, even in 
such parts as the small intestine, that there is a tendency 
for the peristalsis to be confined to one region, tempo- 
rarily in health, but for a protracted period of time in 
disease, as in colic. 
There is little new to add to what appeared in the origi- 
nal article on the movements of the oesophagus or the 
nerves concerned, and we have still a great deal to learn 
about the innervation of the stomach. 
Gaskell, acting on the suggestion furnished by the 
double nerve-supply of the heart, has projected a scheme 
for the sympathetic system which, as applied to the ali- 
mentary canal, has already yielded some definite results, 
and it seems probable that it will be shown that there is 
to this long muscular tube, as to the less obviously simi- 
larly formed organ the heart (tubular in embryonic life 
and also derived from the mesoblast), a double nervous 
supply of motor or augmenter and inhibitory fibres. 
The more we learn of the vagus, the more wonderful 
a nervous path does it appear to be. It contains both 
afferent and efferent fibres for the alimentary canal, 
fibres which seem to be continued through nerves bear- 
ing other names, as the splanchnic, to a very wide dis- 
tribution. 
Fig. 151 gives in a highly diagrammatic form the most 
recently known facts regarding the innervation of the 
alimentary tract. Physiologists are not yet thoroughly 
agreed as to the true nature of the intestinal movements. 
The fact that they will take place in an isolated loop of 
intestine, that they are augmented by conditions produc- 
ing an increase in waste products, notably carbon dioxide, 
as in asphyxia, suggest that they may be independent of 
the central nervous system, yet usually more or less un- 
der its control. 
The functions of the ganglia in the intestinal walls 
are no more known than are those in the heart. Never- 
theless, the writer is inclined to believe that it will 
intimately be considered that nearly all functions are 
in a sense reflex, i.e., dependent on stimuli reaching a 
centre and determining the nature of the outgoing im- 
pulses. But in this there are all degrees. The cardiac 
and intestinal movements are so readily induced in any 
case that their essentially reflex character may not be so 
obvious ; and it is not surprising that some have been 
Fig. 151.-The whole ie purely diagrammatic, which renders the com- 
prehension of the general plan simpler. L. V., left vagus, passing to 
the anterior aspect of the stomach ; R. K, right vagus, communi- 
cating with left vagus in oesophageal plexus, <e. pl., and supplying 
the posterior part of stomach, then continued (R' V) to solar plexus, 
represented by a single ganglion, and connected with the inferior me- 
senteric ganglion (plexus), m. gl.; branches from solar plexus to stom- 
ach and small intestine, and from mesenteric ganglion to large intestine, 
represented by &; Spl. maj., large splanchnic nerve from thoracic 
ganglia, and r. c., rami communicantes from sixth to tenth dorsal ; 
Spl. min., small splanchnic nerve arising in like manner from tenth 
and eleventh dorsal nerves (these beth join the solar plexus and 
thence make their way to the digestive tract) ; n, nerves from the 
ganglia, etc., belonging to tenth, twelfth, and thirteenth dorsal and 
first and second lumbar nerves, reaching the inferior mesenteric 
ganglia (plexus) and thence proceeding by the hypogastric nerves, 
n. hyp., and hypogastric plexus, pl. hyp., to the circular muscles of 
the rectum ; n', nerves from the second and third dorsal nerves (S2, 
SS, nervi erigentes). reaching the longitudinal muscles of the rectum 
by the hypogastric plexus. (Modified from Foster.) 
inclined to hold to an independence of rhythm that is 
not natural but peculiar to the laboratory. At the same 
time they are not reflex in the same sense or degree as 
the movements of striped muscle may be. Experiments 
seem to show that in the vagus are found augmenter 
(motor) fibres for the intestine, and in the splanchnic 
both major and minor inhibitory fibres, since stimula- 
tion of tiie former causes movements of the gut, and of 
the latter, arrest of the same. 
It is certain that the splanchnic nerves are the paths 
of vaso-constrictor (augmenter) impulses to the blood- 
vessels of the gut, and probable that dilator (inhibitory) 
fibres are found in the vagus, which would correspond 
somewhat to the cardiac innervation. 
As regards the rectum, we are in possession of more 
definite knowledge. So far as the dog is concerned, and 
it is not likely that there is any essential difference for 
man, the longitudinal fibres of the rectum are under the 
control of fibres which are found in the anterior roots of 
the second and third sacral nerves (Fig. 151, 82, Sa) and 
pass along the nervi erigentes to the hypogastric plexus 
(pl. hyp.), and so reach the lower gut. Stimulation of 
215 Digestion. 
Digestion. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
these nerves leads to contraction that pulls down the rec- 
tum, owing to the action of the longitudinal muscular 
fibres. 
The supply to the circular fibres is derived from 
nerves which leave the spinal cord by the lower dorsal 
and upper lumbar (Fig. 151) nerves, and pass to the 
rectum by the inferior mesenteric ganglia, the hypogas- 
tric nerves, and hypogastric plexus (m. gl., n. hyp., pl. 
hyp.). The fibres lose their medullary sheath before 
reaching the gut. Stimulation of this set leads to con- 
traction of the circular fibres only, and results in the 
contents of the gut being squeezed out. 
As is well known, disease of the central nervous sys- 
tem is apt to be followed by obstinate constipation, so 
that it seems clear that the sigmoid flexure of the colon 
and the rectum, at all events, are governed by a reflex 
mechanism. It is likely that a similar mechanism will 
eventually be shown to exist for the small intestine, and 
possibly the stomach. 
The Removal of Altered Products from the 
Alimentary Canal, or Absorption.-The final prod- 
ucts of digestion, as this term is commonly understood, 
are peptones, sugar, and emulsified fats, principally. Till 
recently it has been customary to teach that peptone was 
absorbed by the capillaries, and passed as such into the 
blood-stream ; that sugar disappeared in the same man- 
ner ; and that the work of the villi-at all events of their 
columnar cells and structures other than the blood-ves- 
sels-was largely confined to the removal of fat. 
There was always a great difficulty in showing the 
presence of peptone in the blood-stream at all, even when 
digestion was in full progress ; while more recent re- 
searches have made it clear that the injection of peptone, 
the product of artificial digestion, results in undoubted 
poisoning. 
According to some investigators, peptone and albu- 
moses are absent from blood and lymph during even the 
most active digestion. 
This brings us to consider the real nature of so-called 
absorption. It has all along, till very recently, been as- 
sumed that " animal membranes," in which the intestine 
was included, acted very much as a piece of parchment, 
and that osmosis was the great force that determined ab- 
sorption. 
Certain experiments showing changes in peptone when 
placed in contact with the walls of an isolated loop of in- 
testine, or even pieces of the mucous membrane, tended 
to shake the older views. 
Recently, however, the whole subject of absorption 
has undergone a revision. 
Not to mention the fact that certain salts and other 
bodies disappear from the intestine at a rate altogether 
different from what would be expected from their os- 
motic equivalent, peptone itself is found to leave the liv- 
ing gut much faster than through any diffusive septum. 
For an account of experiments bearing on this subject 
which is easily accessible, the reader is referred to the out- 
line of Dr. Weymouth Reed's researches, published in 
the British Medical Journal for February 13 and May 
28, 1892. (See also Journal of Physiology, vol. xi., p. 
312.) Dr. Reed in the first series of experiments used 
frog's skin, and showed that the rate of transfer of fluid 
through the living skin was not in accordance with the 
laws of osmosis. 
Later, he showed that the mucous membrane of the 
intestine of a rabbit killed during full digestion, when 
exsected, does act differently from a diffusive septum ; 
i.e., even the removal of a saline fluid does not follow 
ordinary physical laws, or, in other words, it is a vital 
process. 
The absorption of the fat and the functions of the 
villi are questions still under discussion. The "striated 
border" of the columnar cells has always been regarded 
as playing some important role in absorption, though 
exactly what, was not and is not yet known. Hei- 
denhain, in some elaborate researches on the whole 
subject of the structure and functions of the intestinal 
mucous membrane (Pfluger's Archit), Bd. xliii., Suppl. 
Heft) concludes that this striated border is made up 
(SUPPLEMENT.) 
of rods set vertically to the plane of the mucous mem- 
brane, and a homogeneous substance between them, and 
that either the one or the other may be withdrawn within 
the cell. Nevertheless the meaning of the striated bor- 
der functionally has not been made clearer. There is 
still difference of opinion as to the part leucocytes play 
in the absorption of fats. 
The writer believes that he was the first to teach dis-, 
sent from the ordinary views on the subject of digestion 
and absorption, and to give expression to this in print. 
(See "Animal Physiology,'' chapter on the " Removal of 
Digested Products from the Alimentary Canal," etc.; 
" The Blood and Blood-vessels in Health and Disease," 
New York Medical Journal, September 13, 1890.) 
Briefly, the views the author has held for some six 
years are these : The laws of physics and chemistry as 
ordinarily understood will not explain vital phenomena. 
In seeking for explanations of physiological processes we 
must bear in mind the course of evolution in animalsand 
the embryological development of the organism. Accord- 
ingly, it is not possible to conceive of osmosis, etc., as an 
explanation of any vital phenomenon. The only solution 
that is in accordance with facts, is that the capillaries are 
not merely channels for blood, but are real constructive, 
ingestive, and secreting mechanisms (glands), and are such 
in the alimentary tract as well as elsewhere. In explain- 
ing digestion in mammals we must not forget the nature 
of the process in lower forms, even in amoeba itself. In 
tra-cellular digestion, well illustrated in the invertebrates 
(amoeba, hydra, etc.), probably exists in some degree 
in all animals. Taking this view, the digestion of fats 
and the absorption of fats become more readily compre- 
hensible. If the capillaries are glands, if their cells be 
considered as not devoid of living properties, we can 
understand that they may convert peptones into some- 
thing else, and so of all the cells that make up the ali- 
mentary tract. It is likely that we have hitherto not 
only been artificial in our views of the nature of diges- 
tion and absorption, but have in our conceptions restricted 
the work far too much both as regards the cells actually 
involved and the nature of the processes they perform. 
They do secrete fluids that are digestive, but they or 
other cells may also cause changes of products within 
themselves as in the invertebrate series of animals. It is 
infinitely better to be satisfied with views that are some- 
what vague and general than with others more definite, 
but narrow and out of harmony with the great funda- 
mental conceptions of modern biology. Time and pa- 
tient research will remedy the former, because we are in 
this case on the right track, but having started wrong, 
we may continue so, as indeed we have for long enough, 
and with great detriment to practical medicine as well as 
to physiological science. 
Since these views were taught by the writer a great 
change has come over physiology in this very quarter, 
though it has not extended equally to other depart- 
ments. The leading English writers on physiology are 
embodying such views in the latest editions of their 
works. 
As the writer years ago suggested, it would probably be 
well if we were to discard the term " absorption," at all 
events as applied to the digestive tract. 
" Digestion waits on appetite," i.e., the work of the 
alimentary canal is largely dependent on the condition of 
the tissues generally, a truth that it was quite impossi- 
ble to harmonize in any broad way with the older views 
of digestion and absorption, but plain enough in the light 
of what physiologists are now beginning to perceive. 
After all, in so complicated a process as digestion, " ex- 
periments '' can only go a certain distance. They are a 
guide, and tend to confirm rather than to " demonstrate," 
a term that has been somewhat misleading in physiology. 
Summary.-Digestion in mammals is made up of a 
series of processes, part of which result in fluids being 
poured out which produce chemical changes in food- 
stuffs which are more complicated than was once 
supposed, as has been proved in the case of pro- 
teids ; followed by other changes, which are intra-cellular 
and largely unknown in their exact nature, but generally 
216 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Digestion. 
Digestion. 
comprehensible in the light of evolution and embryology, 
and by bearing in mind that the processes and tissues of 
the body are related, and in higher animals are under 
the dominion of the nervous system. Digestion and ab- 
sorption cannot be separated by any sharp line of demar- 
cation. 
That starches are converted into sugar, proteids into 
peptone, fat emulsified and saponified, are truths so far 
as they go, but probably take us but a little way into the 
real nature of digestion. 
An abundant blood-supply is a usual accompaniment 
of the act of secretion, but is not absolutely essential 
to it. 
The whole process of digestion is under the control of 
the nervous system in the higher animals, including man, 
in the action of which we must largely recognize reflex 
processes. 
The whole process of the final elaboration of food (ab- 
sorption) is better understood by remembering the nature 
of intra-cellular digestion in unicellular and the simpler 
multicellular animals, and the true nature of capillaries 
and the cells of which they are composed, and by avoiding 
conceptions that tend to narrow the work of nature down 
to the limits of the laboratory. T. Wesley Mills. 
DIGESTION, DISORDERS OF. Within the past few 
years some advance has been made in the study of dis- 
orders of digestion due to faulty action of the stomach, 
through the use of the stomach-tube. The methods to 
be referred to are not to be advised in all, and probably 
not in the majority of, cases of dyspepsia, because, 1, 
they are often unnecessary ; 2, they are disagreeable to 
the patient ; 3, they are (very rarely) dangerous from 
the possibility of (a) injury to the stomach in case of 
an unsuspected ulceration ; (6) inhalation pneumonia 
from a sudden retching with the oesophageal tube in situ, 
causing food to be drawn into the trachea ; and (c) death 
from the actual nervous shock of this seemingly trivial 
operation. 
Moreover, these methods of examination involve much 
time and labor for the physician, so that they have 
not come into general employment, and are at present 
probably practised chiefly in hospitals where plenty of 
trained assistants are available. But all these reasons are 
insufficient to warrant the omission of such examina- 
tions in obscure cases which have resisted other clini- 
cal study. It is only as conjoined wfith the clinical 
evidence that these chemico-physiological researches are 
to be taken as evidence, for, as has often been said, " the 
stomach is not a test-tube." 
Unfortunately, as in so many other fields of medicine, 
the therapeutic results of these newer methods of research 
have as yet been incommensurate with their scientific 
interest. 
The mechanical means for becoming acquainted with 
the contents of the stomach is a soft, flexible-rubber 
tube or catheter, twenty-five to thirty inches in length, 
having bevelled eyelets. It is introduced into the phar- 
ynx, either simply warmed or lubricated with warm 
milk, and " fed " to the patient as the latter goes through 
the motion of deglutition. Care must be taken that it 
be introduced so that its end reaches below the level of 
the fluid to be withdrawn, and that it be not pushed in 
so far as to curl up and bring its extremity again above 
the surface of the liquid. 
The tube introduced, the stomach-contents are removed 
either by expression, aided perhaps by cough, or by 
aspiration. The fluid, which should be a half-ounce or 
more in quantity, is filtered, and reserved for further 
chemical examination. With this object in view the 
time of obtaining the specimen is important. Some au- 
thorities, notably Ewald, favor a small " test breakfast," 
consisting of a two-ounce roll and ten ounces of water or 
green tea, the tube to be passed one hour after the meal; 
others, following Leube, believe that a more generous 
meal is necessary to call out the full digestive capacity, 
and advise a meal of twelve ounces of soup, two ounces 
of scraped beef, and about as much bread, the specimen 
to be withdrawn in four hours. 
The fluid thus obtained may be subjected to the fol- 
lowing tests : 
1. For Digestive Power.-By putting the stomach fluid 
in a test-tube at the temperature of 99° F., adding a quan- 
tity of shredded egg-albumin, and noting the period of 
completed digestion ; this test may be controlled by others 
in which the fluid is acidulated with HCl, and by other 
tests with presumably normal gastric juice, the quantities 
of albumin used being constant. This is a test of the 
pepsine strength of the fluid, but it is practically found 
that the pepsine and other ferments have a pretty con- 
stant relation to the HC1 strength, so that especial atten- 
tion is directed to the latter constituent, which is more 
capable of exact determination. 
2. For General Acidity.-To be tested by litmus or 
Congo red paper. This does not distinguish between the 
different kinds of acids, whether HC1 or lactic, but if the 
Congo paper, for instance, is turned a deep blue, it may 
be interpreted to mean that there is enough HC1 for the 
purposes of digestion. 
3. For Free HCl.-Of many tests which have been 
suggested, I mention but one, the phloro-glucin-vanillin 
test. A solution consisting of two gms. phloro-glucin, 
one gin. vanillin, and thirty gms. absolute alcohol is pre- 
pared. A few drops of this are warmed in a white por- 
celain dish, with a cubic centimetre of the gastric fluid, 
when, if free HCl is present, a red color appears with the 
deposit of deep red crystals. This test is exceedingly deli- 
cate, and does not apply to any of the organic acids. 
4. Quantitative Test for HCl.-The per cent, of this 
acid normally existing in the gastric juice has been vari- 
ously stated, but may be assumed as about 0.2 per cent., 
with moderate limits of variation in either direction. 
Special importance attaches to its marked diminution or 
absence. At the period of full digestion HCl should be 
the only free acid in the stomach. 
A roughly quantitative estimate of HCl may be made by 
diluting the gastric juice to a definitely measured amount, 
till it produces merely a yellowish sediment instead of 
one of a bright rose color. The weakest solution capable 
of producing a distinct tinge is 1 in 20,000. If, then, a 
given specimen has been diluted ten times to give this 
color, it originally contained .0005 o'f HCl. 
For the accurate estimation of free HCl in the absence 
of other acids, a standard solution called the deci-normal 
solution of sodium hydrate is employed. Each cubic 
centimetre of this will neutralize .00364 gm. of absolute 
HCl. Into 10 c.c. of gastric fluid are dropped from 
a bottle enough of the alkaline solution to exactly neu- 
tralize it (the neutralization being determined either («) 
by litmus paper, or better (b) by an alcoholic solution of 
phenolphthallein, which latter substance has the prop- 
erty of developing in alkaline solution a brilliant carmine 
color, which is absent in acid or neutral solutions). The 
point of exact neutralization being noted, the quantity 
of alkaline solution is observed; e.g., if 7 c.c. were re- 
quired, there was in the 10 c.c. of stomach fluid .0255 
gm. of HCl, or in 1 c.c., .00255, or about a quarter of 
one per cent.-rather a large quantity. Unfortunately 
this process is applicable only in the absence of the 
organic acids. If they are present their removal re- 
quires distillation of the stomach contents and the re- 
moval of the organic acids by ether. 
. 5. For Lactic Acid.-The presence, however, of lactic 
acid may be demonstrated by mixing with a weak aque- 
ous solution of chloride of iron a two per cent, carbolic 
acid solution. If gastric juice containing nitric acid be 
added to this a yellow color is produced. This test 
responds to a strength of lactic acid equal to and 
is so delicate that the coincident presence of HCl does 
not usually interfere with it. 
What is the significance of these conditions of acidity 
in the gastric juice ? Here we have to acknowledge 
considerable uncertainty. Absence of free HCl does not 
prove that none has been secreted ; for it is possible for 
it to have entered into combination with certain bases, 
and thus to have only seemed to be wanting. A few 
years ago it was claimed as a diagnostic point of great im- 
portance that cancer of the stomach was the cause, and 
217 Digestion. 
Dinan. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
the only cause, of absence of HC1 in the contents. But 
later observations go to show that this absence indi- 
cates a large extent rather than any special nature of 
structural lesion. While it is generally reduced in quan- 
tity, if not wanting, in cases of cancer, it may also disap- 
pear for months in gastric catarrh, and even in so-called 
nervous dyspepsia. 
Riegel has claimed that in gastric ulcer the proportion 
of HC1 is always abnormally high. Ewald has shown 
that it is generally in excess and always present. A 
conservative view would be that in a case clinically in 
doubt between ulcer and cancer, the presence of free HC1 
in large, or even in moderate amount, would be evidence 
of considerable weight in favor of ulcer. 
Hyperacidity is a term applied to an increase in the 
proportion of HC1 at the height of digestion ; hypersecre- 
tion, to an increase in the amount of gastric juice, either 
continuous or occasional, and irrespective of the ingestion 
of food. The former may exist without the latter ; but 
the latter generally presupposes the former. Hypera- 
cidity, of course, contraindicates the exhibition of HC1, 
and calls for alkalies. Hypersecretion is to be suspected 
when, after thorough washing of the stomach, and some 
hours' fasting, a considerable quantity of gastric fluid 
can be expressed. This fluid is said to be generally acid, 
and capable of digesting albumin in the test-tube. Its 
presence is accompanied clinically by symptoms of py- 
rosis, eructations, and pain, and it occurs in some cases 
of so-called " nervous dyspepsia." It may be a cause of 
gastric dilatation. Lavage is the appropriate treatment 
both before and after the production of the ectasia. 
The duration of digestion can be investigated only 
through the use of the stomach-tube. Seven hours 
should be enough to accomplish the complete digestion 
of any meal, and after that interval the stomach should 
be empty. The tube will show whether it is so. Undue 
quickness of digestion, while it can be detected through 
the same means, is of much less clinical significance. 
Other evidence of value obtainable through the use of 
the stomach-tube relates to the size and position of the 
stomach. If the stomach be washed out, and so far as 
possible emptied, it can be inflated and its boundaries 
thus be made evident to percussion by attaching an or- 
dinary rubber bulb syringe and injecting air till the 
organ is moderately distended. The advantage of this 
method over that of the separate introduction of powders 
which shall effervesce when conjoined is sufficiently 
obvious ; the former method being less painful and being- 
under the perfect control of the physician through the 
tube, which can be unstopped at any time. After the 
area of tympanites has been marked out, a small quantity 
of water can be introduced which will of course seek the 
lower border of the stomach and displace the air, thus 
substituting flatness for tympanites. Normally, but sub- 
ject to considerable physiological variation, the cardiac 
orifice lies opposite the inner border of the seventh left rib ; 
the pylorus a little below the margin of the liver, within 
a line connecting the right nipple with the umbilicus, the 
greater curvature reaching nearly to the umbilicus. But 
in cases of dilatation the greater curvature may extend 
to the sigmoid flexure. The significance of gastric dila- 
tation is obstructed peristalsis. This is due to causes a 
froute, chief of which is pyloric stenosis (usually malig- 
nant, less often from cicatrized ulcers), or else to causes 
a tergo, of which the commonest is lack of muscular 
tone. 
The kinesis, or motor power of the stomach, is closely 
related in an inverse ratio to its dilatation. A test which 
has been used for measuring this power is the following : 
Salol is administered by the mouth. So long as it remains 
in acid gastric juice it is unaffected, but as soon as it passes 
out into the alkaline juices of the duodenum it forms sal- 
icylic acid, which is promptly eliminated by the kidneys. 
The test, applied to specimens of urine passed every fif- 
teen minutes, is a drop of the tincture of chloride of iron 
added to the urine, which, when salicylic acid is present, 
strikes a deep red-brown color. Normally it is said 
that this occurs in thirty to forty-five minutes after the 
ingestion of the salol. But it is probable that this test, to 
(SUPPLEMENT.) 
show the actual motor power of the stomach, should be 
made to include the time necessary to secure the expul- 
sion from the stomach of all the salol swallowed, and as 
the time needed for recovering this total amount of sali- 
cylic acid includes the time for emptying the stomach 
plus that of renal elimination, the test is left open to some 
doubt. 
The absorptive power of the stomach may be very well 
shown by the iodine test. Five grains of iodide of potas- 
sium are administered in a gelatine capsule, which must 
be thoroughly wiped after it has been tilled, so that none 
of the drug shall escape into the mouth. Beginning 
just before the capsule is swallowed, and at intervals 
of three or five minutes, the patient spits upon a piece 
of filter paper, which has been dipped into a solution 
of starch. These pieces of paper, numbered to distin- 
guish them, are tested with a drop of fuming nitric acid. 
This sets free the iodine (if any exist) in the saliva, 
and a blue color is formed with the starch. When the 
absorptive power of the stomach is good, iodine should 
appear in the saliva in fifteen minutes. 
Charles F. Wellington. 
DIGITALIS. Digitalis continues to maintain its posi- 
tion at the head of lieart tonics. In England and Amer- 
ica authorities are as one on this point. On the continent 
they are the same. Dujardin-Beaumetz assigns it the 
first rank and calls it " the type of heart tonics ; " Pro- 
fessor Nothnagel places it above all other heart tonics, 
and Herr Ftirbringer says, " the sovereign diuretic in 
cardiac disease has been, and still is, digitalis." Con- 
tinued use has confirmed the confidence placed in it, and 
the innumerable rivals that appear serve only to bring its 
superior qualities into bolder relief. Not much has been 
added to the uses of this remedy, but we know more def- 
initely its proper sphere, and apply it with more preci- 
sion to the conditions in which it will prove of value. 
In organic disease of the heart the guide for its use 
is the state of the compensatory action of that organ. It 
is not given as a remedy for the defective valves, nor with 
the expectation of benefiting any diseased condition of 
the organ ; it is simply a stimulant and tonic to the mus- 
cular tissue. So long as the heart is able to overcome 
the impediment to the circulation and maintain a free 
flow of blood, nothing is to be gained by the use of the 
drug, but, with the earliest symptoms of failing power 
its administration must be commenced. The system re 
sponds quickly to the first indication of this loss of 
compensation, the heart beats more feebly and quicker, 
the pulse becomes irregular, a slight degree of dyspnoea 
is noticed, and oedema of the feet and ankles begins. In 
such conditions the beneficial action of digitalis is most 
marked. The heart beats more slowly and forcibly and 
propels the blood onward, the arteries become filled, the 
engorged veins relieved, and the equilibrium of the cir- 
culation is re-established. This slower action of the heart 
allows of a prolonged period of diastole, during which it 
is at rest and recuperating ; the succeeding contraction 
is rapid and strong, due to the renewed strength and stim- 
ulating action of the remedy. 
No form of organic disease contraindicates the use of 
digitalis when the compensatory action is failing. Its 
typical action is produced in mitral disease, in which it 
acts rapidly and for a prolonged period. In mitral ste- 
nosis it has been thought to produce a peculiarly impor- 
tant effect, as the prolonged dilatation of the ventricle 
permits a greater flow of blood from the auricle through 
the narrowed channel. In aortic disease it may also be 
given with confidence. The old idea that the prolonged 
diastole would allow the ventricle to become overfilled 
appears to be but little regarded now, as its beneficial 
effect outweighs any such danger. The following con- 
clusions1 indicate its purpose not only in aortic, but in 
all forms of valvular disease : (1) In all cases of valvular 
disease the chief desideratum in regard to the heart itself 
is the condition of the cardiac walls in respect to dila- 
tation and hypertrophy ; (2) that the presence, in cardiac 
disease of symptoms indicating a disturbance of the 
circulation always means failure of compensation ; (3) 
218 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Digestion. 
Diiian. 
that the condition of over-hypertrophy or over-com- 
pensation does not exist ; (4) that the dangers in aortic 
disease arise from the same cause as the dangers in mi- 
tral disease, that is, a failure of the ventricular muscle 
to perform the ever-increasing work put upon it; (5) 
that if digitalis is safe and beneficial in mitral disease it 
is equally so in aortic disease. 
The one condition in which digitalis is contraindicated 
is fatty degeneration of the heart. In advanced stages of 
this disease, where the walls are thin and the cavities are 
much dilated, it must be used with extreme caution, as 
its action may be too violent for the feeble organ, and 
paralysis or rupture follow. In the lesser degrees of de- 
generation, where the evidences of such a condition are 
indistinct, a want of action on the part of the remedy is a 
sign that must not be disregarded. Dujardin-Beaumetz 
furnishes the following rule : " When in a patient, digi- 
talis, administered methodically, managed with care, 
produces no amelioration on the part of the heart and 
pulse ; when, above all, the quantity of urine is not aug- 
mented, be persuaded that there is a fatty degeneration of 
the heart and immediately cease the employment of the 
remedy." 
A cumulative action, in the sense of an accumulation 
of the drug in the system followed by an outburst of 
increased action, is no longer feared. No such condition 
occurs. Toxic symptoms arise only from an overdose 
or from its prolonged administration, and the condition 
of poisoning is preceded by its regular train of symp- 
toms. The first effect of digitalis 2 is to stimulate the 
vagus and the vaso-motor centres, which improves the 
action of the heart and increases the blood-pressure ; this 
is followed by a relaxation of the vaso-motor apparatus, 
which is first evident in the renal vessels. Up to this 
point the drug produces its therapeutic action, the re- 
laxed vessels in the kidneys, with a high arterial tension 
and powerful heart, furnishing all the conditions requisite 
for a free secretion of fluid. When the drug is pushed 
beyond this it produces the toxic symptoms : the renal 
vessels are relaxed, the reduced blood-pressure extends 
to the general circulation, the heart becomes weaker, and 
the circulation fails. When a fatal termination ensues it 
follows a continuance of this condition and ends with a 
failure of the heart, which is arrested in diastole. To avoid 
any ill effects it is safer to discontinue the drug for a few 
days, as soon as its action has been established ; it may 
be administered again when required. Where the proper 
conditions for its use are observed there should be no 
danger of any toxic action ; it is only when it is employed 
indiscriminately that any such effect arises. A case is 
reported3 where no bad result followed its use for nearly 
three years, thirty-five drops being given three times a day. 
The infusion appears to remain the popular prepara- 
tion, particularly when its diuretic action is required. 
Among the French, a maceration in cold water is the 
favorite method of employing the drug, and is considered 
superior to the infusion. Five grains of powdered digi- 
talis are macerated in four ounces of cold water for from 
eight to twelve hours, and then filtered. The dose is one 
tablespoonful every two hours. The tincture is preferred 
by some as a diuretic ; it is probably the most useful 
preparation when a simple tonic action is required. Os- 
ler 4 considers that either preparation is efficient if the 
drug is of good quality and given in full doses-fifteen 
minims of the tincture or half an ounce of the infusion 
every three hours for two days, and then in reduced 
quantities. The subcutaneous employment of the infu- 
sion has been recommended. In this way it has been 
found that very small doses will act when larger doses 
have failed when given in the ordinary manner. The 
advantage over the administration by the stomach is that 
usually the gastro-intestinal mucous membrane is in a 
catarrhal and (edematous state and absorption is pre- 
vented. It is also thought that the action is retarded 
and altered by the passage through the liver. An infu- 
sion of three parts of the leaf in one hundred of water 
is prepared, and fifteen minims of this infusion have 
been injected twice or three times a day, it is said, with 
good results. 
(SUPPLEMENT.) 
The relative value of the aqueous and alcoholic prepa- 
tions assumes more importance when the solubility of 
the several constituents is considered. Of the four glu- 
cosides, digitoxin, digitalin, digitalein, and digitonin, 
the first three are freely soluble in alcohol ; digitoxin is 
practically insoluble in water, digitalin only sparingly, 
and digitalein freely soluble in water. Digitonin is 
freely soluble in water, but hardly at all soluble.in alco- 
hol. Thus all alcoholic preparations contain the first 
three principles, and all aqueous solutions the last two. 
Therapeutically5 the first three are very similar in ac- 
tion, producing the characteristic effects of digitalis ; 
digitoxin being the most active. The fourth principle, 
digitonin, when isolated, has been found to be a direct 
poison to the muscular structure of the heart ; it de- 
creases its contractile power and produces a dilatation of 
the arteries. This toxic action is in a measure counter- 
acted by the other principles when administered together. 
The whole question of the digitalins, however, remains 
very unsatisfactory ; no true alkaloid has yet been sepa- 
rated ; many varieties of digitalin are in the market, and 
the significance of the term varies according as it is 
given to a German or a French preparation. 
Digitoxin-the digitalin of Nativelle-crystallized digi- 
talin, the most active of all the principles, is the one 
generally employed to replace the preparation of the 
leaves, but it is uncertain and at times violent in its ac- 
tion and must be used with care. The dose is from T-fio 
to grain, repeated two or three times a day. Hu- 
chard8 uses a single large dose of grain daily, giving 
fifty drops of a 1 to 1,000 solution. Under this treatment 
he finds diuresis augmented, sometimes after a single 
dose, generally after a second or third. Foquet ' recom- 
mends gV grain, to be followed by a daily dose of -row 
grain. This has also been used hypodermically, but it 
proves painful and irritating. 
Digitalis has been8 recommended as a means of abort- 
ing pneumonia if given early and in large doses. The 
treatment has been followed by Professor Petresco, of 
Bucharest, in a large number Of cases. He uses an in- 
fusion of one to three drachms of the leaves in eight 
ounces of water, and gives a tablespoonful every hour. 
As much as 120 grains of the leaves have been given in 
twenty-four hours. He states that these large doses abort 
the pulmonary process, shorten the attack, and hasten 
convalescence. The temperature in some instances drops 
from 105° to 96° F., and the pulse from 120 to 35 per min- 
ute. He thinks that this treatment would act almost as 
a specific if it could be commenced with the attack. 
In no instance were there any bad results, and the more 
severe the attack the better the action of the large doses. 
The good effects are due to the increased force of the 
circulation in the pulmonary tissue and the prevention 
of stasis and congestion. This can only follow the 
administration of large doses as early and as energeti- 
cally administered as possible. 
Professor R. Lepine 9 has employed digitalin in pneu- 
monia also with success ; grain was given in the morn- 
ing and often or grain in the evening. He does 
not think that it has any specific action, but finds it of 
great value in supporting the action of a weak and 
feeble heart during the course of the disease. 
Beaumont Small. 
1 British Medical Journal, March 12, 1892. 
3 I. Mitchell Bruce : Materia Medica and Therapeutics. 
3 New York Medical Journal, October 29, 1892. 
4 Osler : Practice of Medicine. 
6 Merck's Bulletin, December, 1S92. 
6 La Semaine Medicale, July, 1890. 
7 The Therapeutic Gazette, April, 1892. 
8 New York Medical Journal, July 16, 1892. 
9 La Semaine Medicale, March, 1892. 
DINAN. A watering-place and health-resort in the De- 
partment of C6tes-du-Nord, France. 
Location.-Dinan is a picturesque old town, situated 
among some of the finest scenery in Brittany. It stands 
on a steep spur of land, overlooking the left bank of the 
river Rance. It is only about ten miles from Dinan to St. 
219 Dinan. 
Diphtheria. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Malo, and just as far to popular Dinard. The population 
of the place now exceeds 10,000. 
Analysis.-There is a cold chalybeate spring at Di- 
nan, having the ordinary composition of a mild ferru- 
ginous water. 
Indications.-Dinan is chiefly resorted to on account 
of its healthfulness and its proximity to the sea-coast. 
The waters are taken mainly by women and children 
with scrofula or chloro-anaemia. 
Accommodation.-There are several moderately good 
hotels. The principal ones are the Hotel de la Paste, Hotel 
de Bretagne, Hotel de Commerce. Edmund C. Wendt. 
DINARD. A sea-side and climatic resort of growing 
fame and pretentions, in the Department of lie and 
Vilaine, France. 
Dinard is beautifully situated on the broad estuary of 
the river Rance, directly opposite to St. Malo. Little 
steamboats ply half-hourly between these resorts. It is 
favorably known on account of its agreeable climate, the 
fine beach, and the opportunity offered for many pretty 
excursions. 
The old town of Dinard is nothing more than a fishing 
village, running along the sandy shore. The English 
are partly responsible for the existence of the new Di- 
nard which overlooks the old village. 
The accommodations are fairly good. The principal 
hotels are the Hotel de France, Franklin, Hotel de Paris, 
and the Grand Hotel de Dinard. There is a small Casino 
and an Etablissement des Bains. Although a typical 
French resort, English and Americans visit Dinard in 
increasing numbers. In recent years it has become more 
and more a resort for families, and both at Dinard itself 
and at the adjoining village of St. Enogat numerous fur- 
nished villas may be rented for the summer season, or 
for a shorter period. At the latter place the prices are 
somewhat more moderate than at Dinard. But in both 
these places, as in the great majority of French sea-side 
resorts, it is not quite safe to use the general water-sup- 
ply for drinking purposes. The water should be boiled 
and then allowed to cool, or the bottled mineral waters 
should be used instead. During the past two or three 
summers a thoroughly competent English practitioner 
has been established at Dinard. Edmund C. Wendt. 
DIPHTHERIA. Introductory'.-The first reference 
to this affection in New England, or, in fact, in America, 
is probably to be found in Sibley's "Harvard Gradu- 
ates," vol. i., p. 94, where a number of children are said 
to have died from " bladders in the wind-pipe " in 1659. 
At various periods after this references to the disease are 
to be found, with some imperfect descriptions, as occur- 
ring in various parts of New England. 
The modern history of diphtheria begins with the pub- 
lication of Bretonneau's works, his first paper appearing 
in 1821. He asserted the identity of angina maligna 
(diphtheria) with membranous laryngitis (croup). He 
spoke of the continuity of the false membrane of the 
nose, pharynx, and respiratory tract, of its identity with 
some morbid processes of the skin, and asserted that 
diphtheria was a specific disease and not to be con- 
founded with catarrhal or scarlatinal inflammation. He 
claimed also that it was a purely local disease, an opinion 
which he afterward modified. His completed mono- 
graph appeared in 1826. 
From this time the literature of the disease becomes 
more and more voluminous year by year. Hardly a 
Yvriter upon medicine or an investigator of the etiology 
of disease but has had more or less matter for publica- 
tion. The points in dispute are, many of them, discussed 
to-day as vigorously as ever. The question of the iden- 
tity of the two processes, croup and diphtheria, from a 
pathological stand-point, may be considered to be settled 
in the affirmative so far as to justify the assertion that 
true croup, or membranous laryngitis, may be one form 
of diphtheria. 
The etiology of the disease, as to whether it is produced 
by bacteria, is no longer in doubt. This question has 
(SUPPLEMENT.) 
engaged the attention of many workers, and the solution 
seems to be reached at present. 
Since Bretonneau the principal contributions to the 
history of the disease have been made by Trousseau, 
Bourdeoise, Baumgarten, Rilliet and Barthez, and Vir- 
chow. In 1847, the latter first made the distinction be- 
tween the catarrhal, croupous, and necrobiotic varieties of 
laryngeal affections. 
Symptomatology. 
Symptoms in General.-The symptoms may vary 
from those of the slightest sore throat to those of Ilie 
most serious and malignant disease. For convenience 
these may be separated into several forms, according to 
the severity of the symptoms. 
1. The typical form. 
2. The catarrhal, or mild form. 
3. The malignant form. 
4. (Which is rare) the chronic form. 
1. The Typical Form.-A typical case of diphtheria pre- 
sents about the following phenomena : After a general 
feeling of malaise, or loss of tone, lasting from two to 
five days, the attack commences with a definite constitu- 
tional disturbance. The first stage presents a rapid rise 
of temperature, often reaching 103° or even 105° F., a 
feeling of chilliness, anorexia, nausea, and occasionally 
vomiting and diarrhoea. The throat early becomes dry 
and hot, with pain upon swallowing, and the neck is 
swollen, stiff, and tender. The tonsils, pillars of the fau- 
ces, uvula, and back of the pharynx, are red, swollen, 
turgid. The appearance of the false membrane does not 
occur until the arrival of the second stage. In this a 
viscid, yellowish secretion will be seen, gradually form- 
ing in the depressions of one or both tonsils. Later, cer- 
tain points of the superficial mucous membrane become 
infiltrated with a yellowish material, these points being 
somewhat elevated above the general surface. These 
points, at first more or less translucent, become opaque 
and grayish-white. They extend and coalesce and thus 
a considerable surface of the fauces and pharynx may 
become covered with a pseudo-membrane, which is con- 
stantly being reinforced by additions to its under sur- 
face. Portions of the membrane may be drawn off, and 
occasionally a perfect cast of the place from which it is 
removed may be obtained. The neck is swollen from 
the enlargement of the parotid and submaxillary glands, 
which are frequently hard and very tender. Fever is 
generally lessened with the appearance of the exudation ; 
exceptionally, however, it may remain as high as, or 
even rise higher than, it was at first. Swallowing is per- 
formed with difficulty, and the breath is fetid from 1 lie 
decomposition of the morbid secretion. The pulse is 
weak and compressible, and is either very rapid or very 
slow. The first sound of the heart is weakened, albu- 
minuria is a frequent symptom in the earlier stages of an 
attack, and the urine is apt to become scanty and high- 
colored. Hyaline casts are not uncommon, but the oc- 
currence of granular or epithelial casts is not constant. 
The morbid process may spread downward and invade 
the larynx and trachea, this usually occurring in from 
three to four days after the invasion, and making itself 
manifest by unmistakable signs. These are: hoarse, 
muffled voice, stridulous breathing, constant dry cough 
at first, later dyspnoea, increasing cyanosis, swelling of 
the face, and drowsiness passing into coma. The nasal 
cavities may be involved primarily, or by the extension 
of the disease from the fauces. This is indicated by the 
discharge from the nose of a fetid, dark-colored watery 
fluid, with the formation of false membrane in the nasal 
cavity. There is often, also, repeated, and sometimes 
fatal, nasal hemorrhage, and occasionally there occurs a 
blocking of the lachrymal ducts, or the disease may ex- 
tend by this channel to the eye. 
Trousseau goes so far as to say that he has never seen 
a case of diphtheria recover in which hemorrhage from 
the nose occurred. The morbid process may also pass 
through the Eustachian tube to the tympanic cavity, and 
eventually cause a perforation of the membrana tympani, 
with subsequent purulent discharge from the ear. If the 
220 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Diiian. 
Diphtheria. 
larynx be not attacked, the third stage is reached and the 
disease slowly disappears or death occurs very rapidly. 
If the result is to be favorable, a marked improvement 
takes place in all the symptoms by the end of the first or 
the beginning of the second week. The temperature be- 
comes normal, the pulse regains its strength and regu- 
larity, and anorexia disappears, the congestion of the 
fauces diminishes, the exudation ceases tp extend, and 
portions of it become detached. The patient feels very 
well, but the danger is not passed, for a relapse may 
occur which may -be more severe than the initial attack. 
Another danger to be feared at this time is syncope 
from failure of the action of the heart. If the termina- 
tion of the attack is unfavorable, death may occur from 
a secondary blood-poisoning with typhoid symptoms or 
coma, or, more frequently, from cardiac embolism or 
syncop*. 
2. The Mikl Form.-In a case of this character the 
symptoms are often so slight that the diagnosis must 
lie excessively doubtful, the symptoms being those of 
an ordinary catarrhal sore throat. The constitutional 
disturbance is very slight ; the elevation in temperature 
being but one or two degrees, and the pulse being but 
little affected. 
There may be slight pains or dryness in the throat, 
and so*ne difficulty in swallowing. The submaxillary 
glands may be swollen and tender ; the tonsils, soft pal- 
ate, and pharynx red and swollen ; and in a day or two 
minute yellowish spots, the size of a pin-head, may 
make their appearance. These are easily removable. 
The symptoms improve on the third or fourth day, and 
often the presence of persistent and general weakness is 
the only definite sign that the case has been one of diph- 
theria. This form is often, however, introductory to an 
acute attack, which breaks out in a few days in full force, 
and the definite diagnosis can only be made by means of 
the bacteriological examination. 
3. The Malignant Form.-In a case of this kind there are 
at once rigors, headache, vomiting, and, not infrequently, 
epistaxis. The throat symptoms are not always very 
severe, but decomposition of the secretion and the result- 
ing fetor are very marked. The temperature is not nec- 
essarily high ; the pulse is small, rapid, and wavy. The 
patient becomes drowsy ; the skin is cold and clammy ; 
the face pale, the tongue dry, brown and tremulous ; 
the mucous surfaces bleed easily, and petechiae under the 
skin are often present. All the symptoms of a typical 
case develop rapidly one after the other, and the patient 
dies comatose or in syncope. 
4. Chronic Diphtheria is rare. Mackenzie ("Diph- 
theria," p. 31) quotes a case in which the membrane per- 
sisted in reforming for a period of three months. Other 
cases have also been reported in which this repeated for- 
mation of membrane was a characteristic feature. 
Symptoms in Detail.-Prodromes.-In a majority of 
cases there is a prodromic stage lasting for a day or two. 
The patient feels indisposed to exertion ; is slightly fe- 
verish, and is apt to have some difficulty in deglutition. 
There may be headache with occasional vomiting. 
Pharynx and Soft Palate.-The pharynx and soft 
palate are the principal seats of the local diphtheritic dis- 
turbance ; larger or smaller deposits being found there, 
loosely attached or deeply embedded according to the 
location. Sometimes there is but one spot, but usually 
there are several, and in a short time (twelve to twenty- 
four hours) they coalesce to form a membrane. On the 
uvula, soft palate, and posterior wall of the pharynx the 
membrane is superficial and may sometimes be easily re- 
moved. It is more firmly attached upon the tonsils, and 
sometimes extends into the deeper tissues. There is, oc- 
casionally, no actual membranous formation, and in such 
cases the tissues are swollen, the raucous membrane is 
more or less reddened, and the infiltration into the tissues 
gives a somewhat grayish-white discoloration. When 
the uvula is involved the swelling is usually more con- 
spicuous than when the rest of the fauces alone is af- 
fected. 
Jacobi speaks of three distinct processes in the throat: 
1, A membrane lying on the mucous membrane, and 
(SUPPLEMENT.) 
which can be separated without much, if any, injury to 
the subjacent epithelium ; 2, a membrane implicating 
the upper layer of the mucous membrane ; 3, a whitish 
or grayish infiltration of the surface and deeper tissues 
which may occasion necrotic changes. When the symp- 
toms are of long duration, and deep infiltration occurs, 
hemorrhages from the affected parts are not uncommon. 
They may be slight, but occasionally large vessels are 
opened and death may result. Gangrene sometimes oc- 
curs after extensive infiltration has taken place, and a 
decided loss of substance is revealed after the falling off 
of the membrane, which loss of substance more usually 
takes place upon the tonsils. 
The Nasal Cavities.-The morbid process often passes 
into the nasal cavities from the posterior aspect of the 
soft palate or pharynx, especially when the uvula is af- 
fected. The disease may also occur primarily in the 
nose, and this happens more often after an acute catarrh. 
The secretion is very profuse, slightly flocculent, and 
frequently very offensive. The first certain indication 
of nasal diphtheria is the occurrence of tumefaction of 
the cervical glands. Before this it is often impossible to 
diagnosticate the disease in this situation. This adenitis 
is often found very persistent, a permanent induration 
sometimes remaining. Chronic nasal catarrh, with elon- 
gated uvula and enlarged tonsils, are frequent results of 
the disease. 
The Eye.-The eye is frequently affected by extension 
of the process from the nose through the nasal duct, al- 
though it may also be a seat of primary infection. Diph- 
theritic conjunctivitis is an exceedingly grave affection, as 
regards the safety of the eye ; the cornea often being de- 
stroyed by pressure, from diphtheritic keratitis, in twenty- 
four hours. Von Graefe first studied diphtheria of the 
eye in 1854. It is not a frequent affection. Sometimes 
a single eyelid is the seat of the disease. The process 
may first appear on the conjunctiva bulbi, and pass from 
this to the conjunctiva palpebrarum. The cornea be- 
comes hazy very early, and ulceration occurs, as a result 
of which perforation is to be feared, with possible pro- 
lapse of the iris and consequent destruction of the eye, 
or, at least, loss of sight. 
The Ear.-The ear may become affected by way of the 
Eustachian tube, and an acute otitis media may develop, 
with perforation of the membrana tympani, and even 
necrosis of the mastoid bone. An otitis interna is also 
sometimes observed. 
The Epiglottis.-It is not rare to find patches of mem- 
brane in the depression at either side of the face of the 
epiglottis, which is then swollen, with hard and reddened 
edges ; the great part of the diphtheritic process occur- 
ring upon its upper surface. Dyspnoea and hoarseness 
are only occasional, and only when there is accompany- 
ing oedema at the entrance to the larynx. This oedema 
produces a functional paralysis of the vocal cord, with 
marked dyspnoea upon inspiration. 
Larynx.-When membrane forms in the larynx in- 
spiration and expiration are both interfered with. Fever 
and pain are not necessarily prominent, but, as the pro- 
cess goes on, the respiration becomes more difficult, com- 
plete aphonia comes on, and the hoarse, croupy cough 
becomes more and more suppressed. If the affection 
progresses, all the symptoms of suffocation and poisoning 
by carbonic acid gas may be observed. The supra-cla- 
vicular and intercostal regions are retracted with each in- 
spiration, sometimes also the ensiform cartilage. Usually 
a number of days elapse between the first laryngeal 
symptoms and death. At times, however, a fatal result 
occurs in a few hours. 
Trachea.-Jacobi and a few others claim that the 
trachea and bronchi may be the original seat of the dis- 
ease, and that the diphtheritic process may spread up- 
ward to the larynx and into the fauces. This is denied, 
however, by Henoch, Oertel, and Steiner. Cases of gen- 
uine adhesions between the arytenoid cartilages, with a 
resulting paralysis of the internal thyro-arytenoid mus- 
cles, have been occasionally reported. 
The Lungs.-Lobular pneumonia is the occasional result 
of the inhalation of pieces of false membrane into the 
221 Diphtheria. 
Diphtheria. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
((SUPPLEMENT.) 
smallest bronchi. Fibrinous pneumonia is also known 
to occur. Broncho-pneumonia frequently develops after 
the trachea becomes affected. In all these forms the 
diagnosis is extremely difficult if the larynx be affected, 
because of the noisy respiration which interferes with 
the recognition of the signs upon auscultation. If the 
trachea is open, this difficulty is done away with. 
The Mouth.-Primary infection of the mouth is not 
common. Diphtheria often occurs in this situation, how- 
ever, in association with the same affection in the nose 
and the fauces. The morbid changes occur on the cheek, 
tongue, angles of the mouth, gums, and lips, appearing 
here as in other places by preference where there has 
been a solution of continuity in the mucous membrane. 
Diphtheria of the mouth is an indication of a probable 
long duration of the disease, with the danger of septic 
poisoning following. 
(Esophagus and Cardiac Orifice of the Stomach.- 
The occurrence of genuine diphtheria of these parts is 
asserted by some authorities, while others say that the 
formation of membrane ceases at the upper portion of 
the oesophagus. Intestinal diphtheria occurs, but is rare 
in the human subject, although not uncommon in cows 
and certain other of the lower animals. Wounds of all 
kinds are easily and rapidly infected and may quickly 
become covered with the false membrane. Death oc- 
curs by general infection from such a source, and may 
come as well from diphtheritic infection of abrasions of 
the skin as from that of wounds resulting from amputa- 
tion or other surgical interference. 
The Skin.-At the beginning of an attack, sometimes 
not for two or three days, a more or less general ery- 
thema may appear upon the skin. Its principal seat is 
over the shoulders, chest, or back, and it is very similar 
to, and often indistinguishable from, the eruption of scar- 
latina. Erysipelas also often occurs, and is a complica- 
tion much to be dreaded. 
Genito- Urinary Organs.-The diphtheritic process may 
occur in these organs secondarily, but not often. Some- 
times it is primary in this locality. The disease has oc- 
curred in the vulva, the vagina, and the bladder, and in 
circumcision wounds. 
The Kidneys.-These are the most actively involved of 
any of the internal organs during the progress of diph- 
theria. Wade, in 1858, first spoke of albuminuria in this 
disease, and was followed some months later by See (in 
the Union Medicale for 1858, p. 407). The presence of 
albumin is not of such great significance as was at first 
supposed. It occurs in large quantities in mild cases, 
and in small amounts or not at all in severe attacks. It 
may appear either before or after tracheotomy. It is 
often unaccompanied by any other sign of renal disease, 
but may be accompanied by various kinds of casts and 
epithelial cells. 
The Heart and Blood.-There may be weakness of the 
cardiac muscles, sluggish circulation, dyspnoea, and 
muffled heart-sounds, cool and pale skin, feeble and fre- 
quent, sometimes slow, pulse. Occasionally there is 
actual endocarditis affecting the valves, more especially 
the mitral. This is characterized by high fever, precor- 
dial pain, syncope, and a systolic murmur. 
The Nervous System.-This is often affected, and fre- 
quently very seriously. The influence exerted was sup- 
posed for a long time to be localized in certain nerves, or 
groups of nerves, and that the first points attacked were 
always the arches of the soft palate. This is not true, 
however, nor is the assertion that severe paralyses follow 
severe local manifestations, for the opposite is very often 
the case, viz., that a very mild attack of diphtheria may 
■be followed by a very severe form of paralysis. Many 
theories of the method of production of this paresis are 
put forward, such as, that they are produced by fatty or 
granular degeneration of the muscular fibres, or by ca- 
pillary hemorrhages, or by amyloid degeneration, or by 
cedematous infiltration of the part and consequent press- 
ure. All of these, however, are more speculative than 
based upon actual facts observed. 
The most frequent paralysis is that of the soft palate, 
which appears, as a rule in the second week, although 
often earlier and sometimes later. Paralysis of the con- 
strictor muscles of the pharynx also may occur, and 
these two conditions produce imperfect speech and dif- 
ficult deglutition, with frequent regurgitation of fluid 
through the nose. In such cases sometimes life can only 
be sustained by the use of the oesophageal tube. Paraly- 
sis of the power of accommodation conies next in fre- 
quency. Then follow paralyses of the low'er and upper 
extremities, these rarely occurring suddenly, and usually 
involving only one set of muscles at the same time. 
Complete fatty degeneration, although rare, may occur. 
The muscles of the neck are sometimes affected, produc- 
ing inability to hold the head erect. The fingers alone 
may be paralyzed. The bladder and sphincters may be 
affected, but this is not a common occurrence. Some- 
times the muscles of respiration are attacked, such cases 
being very apt to terminate fatally. We have thus far 
spoken only of motor paralysis, but affections of the sen- 
sory apparatus may also occur. Anaesthesia of the en- 
tire upper part of the body has been observed. Some- 
times the two are combined and locomotor ataxia is the 
result. Diphtheritic paralyses are irregular in regard to 
the place of appearance, their severity, their duration, 
and their responsiveness to treatment. They may last 
from six weeks to six months, may recover with treat- 
ment and without it, and may prove refractory to any- 
thing that can be done to remove them. 
Pathological Anatomy. 
The most important part of the diphtheritic process is 
the false membrane. It is the most prominent character- 
istic, as well as the one most frequently met with. It is 
tough, dry, yellowish, or grayish-white, firm and elastic. 
It swells upon the addition of acetic acid and becomes 
more or less transparent. It is soluble in caustic alkali, 
insoluble in water, and yields neither gelatine nor albu- 
min. It varies in appearance from a thin transparent 
pellicle to a skin of considerable thickness. On separa- 
tion, if the attack has been a mild one, the subjacent 
mucous membrane is found to be smooth and paler than 
normal; if the attack has been severe, more or less ulcer- 
ation is left behind. The membrane consists, first, in 
great part of fibrin, the result of epithelial changes, or a 
direct product from the exuded blood-serum. It con- 
tains, also, epithelium, more or less degenerated blood, 
mucus, and bacteria. 
Its method of formation is somewhat as follows : The 
pavement epithelium becomes cloudy, swollen, and den- 
tated, and dissolves into a net-work. It becomes, later, 
the recipient of newly formed cells. There is a consid- 
erable infiltration of the mucous membrane with pus 
cells and granules. The cellular tissue is studded with 
granules also, its decomposition resulting in a fine gran- 
ular deposit and necrosis-a process considered by Vir- 
chow to be an important element in severe forms of diph- 
theria. 
The clinical differences between the membrane of 
croup and that of diphtheria are not borne out by the 
microscopical examination, which shows no essential dis- 
coverable difference. 
The, Heart.-This organ is often found to be perfectly 
healthy. It may present numerous petechiae and there 
is often fatty degeneration of the muscular tissue, and 
parenchymatous inflammation or hemorrhages may oc- 
cur. Endocarditis is found affecting the mitral more 
often than the tricuspid or pulmonary valves. Perfora- 
tion of the septum of the right auricle and of the aorta 
has been seen. 
Lungs.-These organs present various inflammatory 
or congested appearances ; oedema, broncho-pneumonia, 
atelectasis, emphysema, ecchymoses, and infarction are 
all found at various times. The lungs may also be en- 
tirely unaffected. 
The spleen is often increased in size and congested, 
and it may be friable, with more or less extensive infarc- 
tions. 
The kidneys may be normal, simply congested, or the 
seat of parenchymatous or interstitial nephritis. 
222 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Diphtheria. 
Diphtheria. 
In the muscles are sometimes found ecchymoses, myo- 
sitis, gray degeneration, or atrophy. 
The lymphatic glands are also swollen and inflamed. 
They may be hard or yielding to pressure. Abscesses 
are not common. The tissue about the glands is often 
involved in the inflammatory process also. 
Intestinal Canal.-Unless the actual seat of the disease 
this tract presents no peculiar appearance. Virchow 
considers that diphtheria of the intestinal canal is charac- 
terized by fibrinous deposits on the surface and in the 
tissues of the intestine, with a subsequent granular de- 
generation of the tissues, and Radjewsky claims that his 
experiments prove that bacteria are important factors in 
the production of the diphtheritic membrane after pre- 
vious inflammation has taken place in the intestine. 
The Brain.-If death has occurred from asphyxia, the 
brain presents a venous engorgement of the membranes 
and cerebral structure, with minute extravasations of 
blood. Pus and lymph have also been found on the 
arytenoid in cases in which mental disturbances have 
been very marked. In many cases, however, there are 
no perceptible alterations in the cranial cavity. 
Etiology. 
Diphtheria is pre-eminently a disease of early life, 
the proportionate number of cases diminishing very 
rapidly as the age increases. Of five hundred deaths in 
Vienna from this disease in 1868, but one case had 
reached the age of sixty. Sex seems to exert no spe- 
cial influence. It occurs mostly in children ; the pre- 
disposition of this age is explained by the softer con- 
dition of the mucous membrane of the mouth and 
pharynx, and by the narrowness of the pharynx, the 
protuberant condition of the tonsils, the large number 
and size of the lymphatics, and the greater communica- 
bility between them and the system at large, all of which 
aids in the development of the disease. On the other 
hand, the free acid secretions of the mouth after the 
third month tend to hinder its occurrence after this 
period. There seem to be families in which there is an 
apparent predisposition to this disease. 
Climatic and Atmospheric Conditions.-The disease is 
most common in temperate climates, but it occurs almost 
everywhere. It is probable that moisture favors the de- 
velopment of the poison, and also that it can lie dormant 
for a long time, and until some special agency calls it 
into activity. 
The disease prevails more extensively during the 
winter months, apparently at the time when catarrhal 
conditions are most common, and the mucous membrane 
is in a receptive condition. Social position offers no 
safeguard during an epidemic, although sporadic cases 
seem to especially attack those living under bad hygienic 
surroundings. Exhalations from sewers and filthy per- 
sonal habits are also said to produce the disease, but the 
weight of evidence is against their possessing anything 
more than a favoring action. 
Manner of Infection.-Whether diphtheria be a local 
disease with constitutional sequelae, or whether it be a 
general disease making its most marked appearance at 
certain points, is a question which has been much dis- 
cussed. If, however, as is practically certain, it is ex- 
cited by the activity of a micro-organism, the question is 
settled that the local manifestations are usually the signs 
of the place of entrance, and the constitutional disturb- 
ances the evidence of the general distribution of the 
poison. 
The infectiousness of diphtheria is undoubted. The in- 
fectious material may be communicated directly by the 
patient, and it seems to cling to solid bodies, and may be 
transported in this way to a distance, but how far is, as 
yet, undetermined. 
The methods of transportation which have been 
thought to offer the most usual channel for the spread of 
the disease are milk of diseased cows and infected animals. 
Many researches make it certain that the disease occurs 
among domesticated animals, although the more recent 
investigations seem to indicate that it is really a disease 
(SUPPLEMENT.) 
resembling human diphtheria as regards its clinical 
symptoms, but differing from it in the fact that it is pro- 
duced by a micro-organism which differs somewhat 
from the true diphtheria bacillus. The question being 
determined in the affirmative may furnish a probable ex- 
planation of the origin of many cases in human beings in 
which the source of infection has been obscure. 
The Nature of the Diphtheritic Poison.-Investigation 
of this point has occupied the attention of observers for 
years past. As long ago as in 1840 Henle expressed his 
belief in a contagium vivum, and Buhl first found micro- 
organisms in the diphtheritic membrane, but he expressed 
no opinion as to their special import. 
The work of Loeffler, first published in 1884, described 
a specific micro-organism which he had found in the 
tissues of individuals suffering from diphtheria. This 
discovery has been confirmed by so many observations 
and by so many different observers since that time, that 
the question of the specific infectious agent in diphtheria 
must be considered as definitely settled at the present 
time. This question is one of such great importance, 
and the disease is one in which positive therapeutic re- 
sults seem to be so clearly promised, that it has been 
thought best to give a full description of the organisms 
found in the diphtheria of men and of the lower animals. 
The Bacteria Occurring in Diphtheria.-For the 
following summary of the present state of opinion in 
regard to the bacteria of diphtheria, we are very largely 
indebted to the admirable resume of the work done, and 
the views entertained, by various authors, to be found in 
Sternberg's "Manual of Bacteriology" (published by 
William Wood & Co., New York, 1892). 
The condition of the question in regard to a specific 
organism occurring in diphtheria is such that to-day we 
have a very precise knowledge of the specific infecting 
agent, together with evidence that it produces during its 
growth a very potent toxic substance, the absorption of 
which from the seat of local infection accounts, in a sat- 
isfactory manner, for the general symptoms of the dis- 
ease, which are due to a toxaemia and not to an invasion 
of the blood and tissues by the pathogenic micro-organ- 
isms producing it, although the latter statement seems 
likely to be more or less modified by future investiga- 
tion, as is indicated by the work of Frosch, quoted in this 
article. Many examinations have failed to demonstrate 
the presence of bacteria in the blood of patients suffering 
from diphtheria, but a variety of micro-organisms have 
been obtained in cultures from diphtheritic pseudo-mem- 
branes, and among them are the well-known pus organ- 
isms, especially the streptococcus pyogenes, that is ap- 
parently very commonly present and is perhaps the active 
agent in the production of certain forms of pseudo-diph- 
theria. But the malignant specific diphtheria has been 
shown to be due to a bacillus first recognized by Klebs in 
1883, and cultivated and described by Loeffler in 1884. 
In his first article, the latter author did not claim to have 
fully demonstrated the etiological relationship of this 
organism, but his own later work and that of many 
others show constant success in finding the same bacillus 
in other cases of diphtheria, and the same successful re- 
sult from inoculation experiments with pure cultures of 
the organism in certain of the lower animals. 
There has also been found, by Loeffler and others, an 
organism that does not possess pathogenic properties, but 
which resembles very closely the diphtheritic bacillus. 
And to this organism has been given the name of the 
pseudo-diphtheritic bacillus. It is still uncertain whether 
this bacillus is to be considered a distinct species or a 
non-pathogenic variety of the true diphtheria bacillus, as 
is maintained by the French authors Roux and Yersin. 
The evidence upon which the bacillus of diphtheria is 
now generally conceded to be the specific infectious agent 
in true diphtheria rests upon the following principal 
points : 
1. It is found in all undoubted cases of diphtheria, and 
in support of this there are the results of experimentsand 
researches made by a very large number of experimental- 
ists who, in nearly every case, have demonstrated with- 
out difficulty the presence of this bacillus. The one 
223 Diphtheria. 
Diphtheria. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
eminent observer who failed to find the organism, in a 
series of twenty-four cases studied by him, was Prudden, 
of New York. But later, in a subsequent series of twelve 
cases, Prudden obtained Loeffler's bacillus in cultures 
from eleven, and he says, " We are now, it would seem, 
justified (as it did not appear to the writer that we were 
two years ago), owing to the large number of important 
researches which have been made in the interim, to 
maintain that the name diphtheria, or, at least, primary 
diphtheria, should be applied, and explicitly applied, to 
that acute infectious disease usually associated with a 
pseudo-membranous inflammation of the mucous mem- 
brane, which is primarily caused by the bacillus called 
bacillus diphtherise of Loeffler.'' 
In this country Welsh and Abbott have also demon- 
strated the presence of the Loeffler bacillus in a series of 
cases occurring in Baltimore, and have proved its spe- 
cific pathogenic power by inoculation in animals. 
Loeffler attempted to show how long after convales- 
cence the diphtheria bacillus may be present in the 
throat of an infected person, and, in a typical case, a bac- 
teriological examination was made daily, from the com- 
mencement until fourteen days after its termination. 
The fever disappeared on the fifth day and the exudation 
had all disappeared on the sixteenth day. Up to this 
time the bacillus was daily obtained in cultures, and 
subsequently nearly every day up to the twenty-fifth, 
that is, for three weeks after the febrile symptoms had 
disappeared. 
Roux and Yersin have also obtained the bacillus in cult- 
ures from mucus scraped from the throat of convales- 
cents several days after the disappearance of all evidence 
of the disease. 
2. The Klebs-Loeffler bacillus is found only in diph- 
theria. In his earlier researches Loeffler obtained the 
bacillus in a single instance from the mouth of a healthy 
child, and this fact led him to hesitate in announcing it 
as his conviction that it was the true cause of diphtheria. 
But in extended researches made subsequently, he has 
not again succeeded in finding it except in association 
with diphtheria, and he admits now that he may have 
been mistaken as to the identity of the bacillus found. 
This seems not improbable, in view of the fact that very 
similar bacilli have been found by various bacteriolo- 
gists. Von Hoffman obtained a similar, but non-patho- 
genic bacillus from the mucus of chronic nasal catarrh, 
and from a healthy mucous membrane; Babes, from 
cases of trachoma ; Neisser, from ulcers ; Zarinko, from 
the surface of various mucous membranes ; but all of 
these were shown to possess certain differences in their 
biological character by which they could be differenti- 
ated from the true diphtheria bacillus. 
Welsh and Abbott in their comparative studies did 
not find the Loeffler bacillus, "or any bacillus that an 
experienced bacteriologist would be likely to confound 
with it." They examined mucus from the throat of 
healthy children ; from those suffering from simple in- 
flammation of the tonsils and pharynx ; and from four 
cases of so-called follicular tonsillitis. As a result of 
their investigations they agree with Loeffler and with 
Roux and Yersin as to the great practical value, for di- 
agnostic purposes, of a bacteriological examination, by 
cover-glass specimens and by cultures, of cases in which 
there is any doubt of the true character of the disease. 
They say further, " the only species of bacteria which 
we have found constantly in the cases of diphtheria 
have been the Loeffler bacillus. Two other species have 
been present in many cases, namely, the well-known 
streptococcus, which grows in much smaller colonies 
and less rapidly than the Loeffler bacillus, and a short, 
oval, often slightly pointed bacillus, growing in long 
chains running parallel to each other. There are 
often marked irregularities in shape, and especially in 
size, of this bacillus, even in individuals of the same 
chain. The colonies of this bacillus are grayish-white, 
moist, larger than those of the streptococcus but smaller 
than those of the Loeffler bacillus." 
3. As shown by Loeffler's earlier researches, pure cult- 
ures of this bacillus induce characteristic diphtheritic in- 
flammation when inoculated into the mucous membrane 
of certain of the lower animals. Roux and Yersin have 
also shown that local paralysis is as likely to occur in in- 
oculated animals as it is in a case of diphtheria in man. 
In speaking of their inoculations into the trachea in 
rabbits these investigators say the affection which is thus 
induced in the rabbit resembles croup in man. The dif- 
ficulty which the animal experiences in breathing ; the 
noise made by the air in passing through the obstructed 
trachea ; the aspect of the trachea, which is congested and 
covered with false membrane, and the cedematous swell- 
ing of the tissues and glands of the neck make the re- 
semblance absolutely remarkable. 
Welsh and Abbott give the following account of the 
results of inoculation into the trachea in kittens. A half- 
grown kitten is inoculated in the trachea with one plati- 
num loop from a pure culture of the Loeffler bacillus on 
glycerine-agar eleven days old. For this inoculation a 
small median incision was made over the trachea, and in 
the latter a hole just large enough to admit the platinum 
loop was made. The culture was rubbed over the mu- 
cosa of the trachea for an extent of about three centime- 
tres in length, and in this process sufficient force was used 
to abrade the mucous membrane. On the day following 
the inoculation no special alteration in the animal was 
observed, but on the morning of the second day it was 
found to be in a very weak condition. In the course of 
this day it became so very weak as to lie completely mo- 
tionless, apparently unconscious, with very feeble, shal- 
low respiration. Several times it was thought to be 
dead, but on careful examination it was found still to be 
breathing feebly. It was discovered dead on the morn- 
ing of the third day. At the autopsy the wound was 
found gaping and covered with a grayish, adherent, ne- 
crotic, distinctly diphtheritic layer. For a considerable 
distance around the wound the subcutaneous tissues were 
very cedematous, the oedema extending from the lower 
jaw down over the sternum and to the side of the neck, 
and along the anterior extremities. The lymphatic 
glands at the end of the jaw were markedly swollen and 
red. The mucous membrane of the trachea, beginning 
at the larynx and extending down for six centimetres, 
was covered with a tolerably firm, grayish-white, loosely 
attached pseudo-membrane, in all respects identical with 
the croupous membrane observed in the same situation in 
cases of human diphtheria. 
The account which we have just given, together' with 
many others that might be quoted, seems to show that 
the organism spoken of and studied by so many observ- 
ers, is unquestionably the cause of the specific disease, 
diphtheria. As has already been inferred, it is also un- 
questionably true that there may be other processes clini- 
cally resembling diphtheria which involve the throat and 
other mucous surfaces, and which owe their origin to 
other bacteria. ■ 
Description of the Bacillus of Diphtheria.- 
It was first observed in 1883 by Klebs in diphtheritic 
false membrane. It was first isolated in pure culture 
and its pathogenic power demonstrated by Loeffler in 
1884. It was found in diphtheritic pseudo-membranes, 
and especially in the deeper portions, intermingled with 
numerous other bacteria, while the superficial layers of 
the membrane commonly contained a few cells or bacilli, 
or were invaded by other species, especially by the strep- 
tococcus pyogenes. The bacilli may not be found in the 
affected mucous membrane, or in sections from the in- 
ternal organs in fatal cases of this disease, although re- 
cent bacteriological examinations by various authors 
have shown their pretty constant occurrence in these sit- 
uations (see Frosch, infra). 
Morphology.-The organism is a rod, straight or 
slightly curved, with rounded ends, having a diameter 
of from one-half to eight-tenths of a micromillimetre, 
and from two to three micromillimetres in length. Ir- 
regular forms are very common, and, indeed, are charac- 
teristic of this bacillus. In the same culture, and espe- 
cially in an unfavorable culture-medium, very great dif- 
ferences in form and dimensions may be observed, one 
or both ends appearing swollen or the central portion be- 
224 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Diphtheria. 
Diphtheria. 
ing notably thicker than the extremities, or the rod may 
be made up of irregular, spherical, or oval cells. Multi- 
plication occurs by transverse subdivision only, and the 
bacilli do not appear in long chains at any time. In un- 
stained preparations certain portions of the rod, and 
especially the extremities, are observed to be more highly 
refractive than the remaining portion, and in stained 
having a slightly alkaline reaction, in nutrient agar, in 
glycerine agar, or in alkaline bouillon. But the most 
favorable medium appears to be that first recommended 
by Loeffler, which consists of a mixture of three parts of 
blood-serum with one part of bouillon, the latter contain- 
ing one per cent, of peptone, one per cent, of grape- 
sugar, and one-half of one per cent, of sodium chloride. 
Fig. 152.-Diphtheria Bacillus, from a Diphtheritic Membrane in the 
Trachea. Cover-glass preparation, stained with alkaline methylene 
blue. (X 1,000.) (Fraenkel.) 
Fig. 154.-Diphtheria Bacillus. Culture on solidified blood-serum. Cov- 
er-glass preparation, stained with alkaline methylene blue. (X 1,000.) 
(Fraenkel.) 
preparations these portions are seen to be more deeply 
colored. The bacillus may be stained by the use of 
Loeffler's alkaline solution of methylene blue, but is not 
so readily stained with some of the other aniline colors 
commonly employed. It is stained also by Gramm's 
method. 
For the demonstration of the bacillus in sections of 
diphtheritic membrane, nothing can surpass in brilliancy 
and sharp differentiation, sections stained doubly by the 
modified Weigert fibrin stain and picro-carmine (accord- 
ing to Welsh and Abbott). 
Biological Character.-The diphtheria bacillus is aero- 
This mixture is sterilized and solidified at the tempera- 
tures usual with blood-serum, and upon it the develop- 
ment is so rapid in the incubating oven that at the end 
of twenty-four hours the large, round, elevated colonies 
of a grayish-white color and moist appearance may be 
easily recognized, while other associated bacteria have, 
as a rule, not yet developed colonies large enough to in- 
terfere with the recognition of those of the diphtheria 
bacillus. Upon nutrient agar plates the deep-lying col- 
onies, when magnified about eighty diameters, appear as 
round or oval, coarsely granular disks, with rather ill- 
defined margins, or, when several colonies are in juxta- 
Fig. 153.-Diphtheria Bacillus. Colony on agar plate, twenty-four hours 
old. Impression preparation, stained with alkaline methylene blue. 
(X 1,000.) (Fraenkel.) 
Fig. 155.-Diphtheria Bacillus. Colony on agar plate, twenty-four hours 
old. Unstained. (X 100.) (Fraenkel.) 
bic, non-motile, and non-liquefying. It does not form 
spores. It grows most freely in the presence of oxygen, 
but is also a facultative anaerobic organism. Develop- 
ment occurs in various culture-media at a temperature of 
from 20° to 42° C., the most favorable temperature being 
about 35° C. It grows very readily in nutrient gelatine, 
position, as figures of irregular form. The superficial col- 
onies are grayish-yellow in color, have an irregular, not 
well-defined outline, and a rough, almost reticulated sur- 
face. The growth upon glycerine agar is very similar. 
The first inoculation in a plain nutrient agar tube often 
gives a comparatively feeble growth, which becomes 
225 Diphtheria. 
Diphtheria. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
more abundant in subsequent inoculations in the same 
medium. In needle cultures in glycerine, or plain agar, 
growth occurs to the bottom of the line of inoculation, 
and also upon the surface, but is not at all characteristic. 
The same may be said in reference to cultures in nutri- 
ent gelatine. Plate cultures in this medium containing 
fifteen per cent, of gelatine at 24° C., give rather small 
colonies, which are white by reflected light, and under 
the microscope are seen as yellowish-brown opaque disks, 
having a more or less irregular outline and a granular 
structure. In alkaline bouillon the growth is sometimes 
in the form of small whitish masses along the side and 
bottom of the tubes, but at other times a diffusely cloud- 
ed growth occurs in this medium. After standing for 
some time in the incubating oven, a thin white pellicle 
may form upon the surface of the bouillon. The re- 
action of the bouillon becomes at first acid, but later it is 
alkaline. 
With reference to the growth on potato, authors have 
differed, probably because the growth is slightly visible. 
Welsh and Abbott say : " Our experience has been that 
the bacillus of diphtheria grows on ordinary sterilized 
potato without any preliminary treatment, but that the 
growth is usually entirely invisible, or is indicated by a 
dry thin glaze after several days. Doubtless the invisible 
character of the growth has led most observers into the 
error of supposing that no growth existed, whereas a mi- 
croscopical examination reveals a tolerably abundant 
growth, which on the first potato is often feebler than on 
succeeding ones. Irregular forms are particularly nu- 
merous in potato cultures, and in general the rods are 
thicker than on other media. In twenty-four hours, at 
a temperature of 35° C., microscopical examination 
showed distinct growth. We have cultivated the bacil- 
lus for many generations on potato." 
Milk is a favorable medium for the growth of this 
bacillus, and as it grows at a comparatively low tempera- 
ture in it-20° C.-it is evident that this fluid may be- 
come a medium for conveying the bacillus from an in- 
fected source to the throat of a previously healthy per- 
son. 
Cultures of the diphtheria bacillus may retain their 
vitality for several months, and when dried upon silk 
thread for several weeks, colonies may still develop in a 
suitable medium. Its drying has been found not to de- 
stroy its vitality for a period as long as from three to 
four weeks, when the desiccation process took place in a 
room, or for a period of from five to ten weeks (in one 
instance fourteen weeks), when the desiccation took place 
in an exsiccator. In dried diphtheritic membranes, pre- 
served in small fragments, the bacillus retained its vi- 
tality for a period of nine weeks, and in larger frag- 
ments for one of from twelve to fourteen weeks. The 
thermal death-point, as determined by Welsh and Ab- 
bott, is 58° C., the time of exposure being ten minutes. 
Loeffler had previously found that it did not survive 
exposure for half an hour to a temperature of 60° C. 
Pathogenesis.-In view of the evidence that has here- 
tofore been recorded, it may be considered as demon- 
strated that this bacillus gives rise to the morbid phe- 
nomena which characterize the fatal disease in man 
known as diphtheria. 
The effects of inoculation in rabbits and cats have 
already been referred to, these giving rise to a charac- 
teristic diphtheritic inflammation with general toxaemia 
and death from the absorption of soluble toxic products 
formed at the seat of local infection. 
This inference as to the cause of death seems justified 
by what we know in regard to the life history of the 
bacillus, and is supported by additional experimental 
evidence given below. 
Subcutaneous inoculations in guinea-pigs of a small 
quantity of a pure culture of the bacillus (from one tenth 
to one half a cubic centimetre of a bouillon culture) 
caused death in from one to five days. The usual changes 
observed are an extensive local oedema, with more or 
less hypertemia and ecchymosis at the seat of inoculation. 
Frequently there are swollen' and reddened lymphatic 
glands ; increased serous fluid in the peritoneum, pleura, 
and pericardium ; enlarged and hemorrhagic supra-renal 
capsules; occasionally slightly swollen spleen; some- 
times fatty degeneration in the liver, kidney, and myo- 
cardium. 
"We have always found the Loeffler bacilli at the 
seat of inoculation, most abundant in a grayish-white 
fibrino-purulent exudate present at the point of inocula- 
tion, and becoming fewer at a distance from this, so 
that the more remote part of the cedematous fluid does 
not contain any bacilli" (from Welsh and Abbott). The 
authors quoted also agree with Loeffler and others in 
stating that the bacillus is only found at the point of in- 
oculation. In all cases their cultures from the blood and 
from the various organs gave a negative result, but this 
is purely negative evidence, and cannot stand as against 
the positive results of Martin, Behring, and Frosch. 
Rabbits are not so susceptible, and may recover after 
the subcutaneous inoculation of very small doses, but 
they usually die in from four to twenty days when from 
two to four cubic centimetres of a bouillon culture have 
been introduced beneath the skin. In these animals also 
there is an extensive oedema, enlargement of the neigh- 
boring lymphatic glands, and a fatty degeneration of the 
liver. Roux and Yersin have shown that in these animals, 
when death does not ensue too quickly, paralysis of the 
posterior extremities frequently occurs, thus completing 
the experimental proof of the specific pathogenic power 
of pure cultures of this bacillus. 
Similar symptoms are produced in pigeons by the sub- 
cutaneous inoculation of one-half a cubic centimetre or 
more, but they commonly recover when the quantity is 
reduced to two-tenths of a centimetre (according to Roux 
and Yersin). 
The rat and the mouse have a remarkable immunity 
from the effect of this poison, and, according to the 
authors just spoken of, a dose of two centimetres, which 
would kill in fifty hours a rabbit weighing three kilo- 
grammes, is without effect upon a mouse that only weighs 
ten grammes. Old cultures are somewhat less virulent 
than fresh ones, but when replanted in a fresh culture- 
medium they manifest their original virulence. Thus a 
culture upon blood-serum, five months old, was found 
by Roux and Yersin to kill a guinea-pig in five days, but 
when replanted, it killed a second animal of the same 
species in twenty-four hours. 
Evidently a micro-organism which destroys the life of 
a susceptible animal when injected beneath its skin in 
small quantities, and which, nevertheless, is usually only 
found in the vicinity of the point of inoculation, must 
owe its pathogenic power to the formation of a potent 
toxic substance, which being absorbed gives rise to toxae- 
mia and death. 
This inference in the case of the diphtheria bacillus is 
fully sustained by the results of recent experimental in- 
vestigations. Roux and Yersin first demonstrated the 
pathogenic power of cultures which had been filtered 
through porous porcelain. Old cultures were found by 
these experimentalists to contain more of the toxic sub- 
stance than recent ones, and to cause the death of a guinea- 
pig, in the dose of two centimetres, in less than thirty- 
four hours. The filtered culture produced in these 
animals the same effects as those containing bacilli, 
viz., local oedema, hemorrhagic congestion of the organ, 
and effusion into the pleural cavities. Somewhat larger 
doses were fatal to rabbits, and a few drops injected 
subcutaneously sufficed to kill a small bird within a few 
hours. 
In their second paper, published in 1889, a year after 
the first, the same authors state that so long as the re- 
action of a culture in bouillon is acid, its toxic power is 
comparatively slight, but that in old cultures the reaction 
is alkaline, and in these the toxic potency is greatly aug- 
mented. With such a culture, filtered after having been 
kept thirty days, a dose of one-eighth of a centimetre in- 
jected subcutaneously sufficed to kill a guinea-pig, and 
in larger amounts it proved to be fatal to dogs when in- 
jected directly into the circulation through a vein. 
The same authors, in describing the nature of the poi- 
son in their filtered cultures, say that it is related to the 
226 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Dipiitlieria. 
Diphtheria. 
diastases, and state that its toxic potency is very much 
reduced by exposure to a comparatively low temperature 
(58° C., for two hours), and completely destroyed by the 
boiling temperature (100° C., for twenty minutes). It 
was found to be insoluble in alcohol, and the precipitate 
obtained by adding alcohol to an old culture proved to 
contain the toxic substance. Loeffler also has obtained, 
by adding five volumes of alcohol to one of a pure culture, 
a white precipitate, soluble in water, which killed rabbits 
in a dose of one-tenth to two-tenths of a gramme when 
injected beneath the skin of these animals. It gave rise 
to a local mdema and necrosis of the skin in the vicinity 
of the point of inoculation, and to hyperaemia of the in- 
ternal organs. This deadly toxine appears to be an al- 
buminous substance, but its exact chemical composition 
has not yet been determined. 
Brieger and Fraenkel have succeeded in rendering 
guinea-pigs immune against virulent cultures of the diph- 
theria bacillus by injecting bouillon cultures three weeks 
old, which had been sterilized by exposure for an hour to 
a temperature of from 60° to 70° C., into the subcutane- 
ous tissues ; to the amount of from ten to twenty centi- 
metres. 
At first the susceptibility of the animal is rather in- 
creased than diminished, but at the end of two weeks 
immunity is said to be complete. Fraenkel is of the 
opinion that immunity results from the introduction of a 
substance which is not identical with the toxic product 
to which the cultures owe their pathogenic power. This 
latter is destroyed by a temperature of from 55° to 60° C., 
while the substance which gives immunity is still present 
in the culture after an exposure to a temperature of from 
60° to 70° C., as is shown by the protective results of in- 
oculation made with such cultures. 
The recent researches of Behring show that the blood of 
immune animals contains some substance that neutralizes 
the toxic product contained in virulent cultures of the 
diphtheria bacillus. This effect is said to be produced 
when blood from such an animal is added to a filtered 
culture without the body as well as when the culture is 
injected into the living animal. This remarkable fact, if 
fully confirmed by further investigation, opens up a new 
field of experimental research, and may lead to important 
results in the therapeutics of diphtheria and other infec- 
tious diseases. 
According to Roux and Yersin, attenuated varieties of 
the diphtheria bacillus may be obtained by cultivating it 
at a temperature of from 39.5° to 40° C., in a current of 
air. And these authors suggest that a similar attenua- 
tion of pathogenic power may occur in the fauces of 
convalescents from the disease, and that possibly a sim- 
ilar non-pathogenic bacillus, which has been described by 
various investigators, has originated in this way from 
the true diphtheria bacillus. 
These authors further state, in favor of this view, that 
from diphtheritic false membranes preserved by them in a 
desiccated condition for five months, they obtained nu- 
merous colonies of the bacillus in question, but that the 
cultures were destitute of pathogenic virulence. They 
say it is then possible, by commencing with a virulent 
bacillus of diphtheria to obtain artificially a bacillus 
without virulence, quite similar to the attenuated bacilli 
which may be obtained from a benign diphtheritic an- 
gina, or even from the mouth of certain persons in good 
health. This microbe, obtained artificially, resembles 
completely the pseudo-diphtheritic bacillus. Like it, it 
grows more abundantly at a low temperature ; it renders 
bouillon more rapidly alkaline ; it grows with difficulty 
in the absence of oxygen. 
Generalized Occurrence of the Bacillus of Diph theria.- 
Frosch (Zeits. f Hygiene, vol. xiii., part 12, p. 49) 
gives the result of a series of his investigations upon 
this subject, prefacing them by the remark that 
the idea seems to have taken a pretty firm hold among 
observers that the diphtheria bacillus occurs only in 
those organs where there is a possibility for the forma- 
tion of membrane, this observation having been made 
by Babes, Kolisko, and Paltaus and Spronck. 
Frosch extended his study over fifteen cases of diph- 
(SUPPLEMENT.) 
theria, of which but ten turned out to betrue diphtheria, 
according to the bacteriological examination. Of the re- 
maining five, one was excluded after a critical examina- 
tion had been made; the second was also excluded 
because it was impossible to find the bacillus of diph- 
theria ; two of the remaining three proved to be cases of 
pneumonia produced by a bacillus ; and finally the fifth 
case was found to be one of tonsillitis, characterized by 
the presence of a new organism that will be described 
later by him. In the remaining ten cases the diphtheria 
bacillus was found in the blood and in the internal organs 
in every instance. 
After describing the method which he followed in 
making these observations, Frosch says that in these cases 
the diphtheria bacilli were found in the brain, the lungs, 
the liver, the spleen, the kidneys, in the cervical and 
bronchial lymphatic glands, as well as in the heart, blood, 
pericardial and pleural fluid, in greater or less numbers. 
Their occurrence in all of these organs was not uniform, 
but in all of the cases the bacilli were found in a number 
of the organs, and, therefore, the observations go to prove 
that diphtheria may be a generalized disease with only a 
local manifestation, and that the local manifestation in 
the throat need not of necessity always be due to the 
diphtheria bacillus : and finally, that the only way def- 
initely to prove whether the case is one of true diphtheria 
or no, is the discovery of the bacillus of diphtheria by 
means of bacteriological examination. 
Description of the Pseudo-Diphtheritic Bacil- 
lus.-The organism which we are now about to consider 
is one of great interest, whether it be considered distinct 
from, or a modified form of, the true bacillus of diph- 
theria. Loeffler, Von Hoffman, and others have report- 
ed finding bacilli which closely resemble the bacillus 
diphtheria?, but which differ from it chiefly in being non- 
pathogenic. 
The following account we take from the latest paper 
upon the subject by Roux and Yersin (their third paper, 
1890): Out of 45 children in a Paris hospital, suffering 
from various non-diphtheritic affections, they found this 
variety of bacillus in the mucus from the pharynx and 
tonsils in 15 instances. Out of 59 healthy children in a 
village school on the seaboard, they found this organism 
26 times. Of 6 children with a simple angina, but 2 
furnished cultures of this bacillus. Finally, out of 7 
cases of measles they found 5 in which they discovered 
this bacillus. The description which they give of it is 
as follows: 
The colonies of the pseudo-diphtheritic bacillus culti- 
vated on blood-serum are identical with those of the true 
diphtheria bacillus. At a temperature of from 33° to 
35° C. multiplication begins and continues at an ordi- 
nary temperature, although slowly. Under the micro- 
scope the appearance of the bacillus which forms these 
colonies is the same as that of the bacillus diphtheriae. 
It stains readily with Loeffler's solution of methylene 
blue, and intensely by Gramm's method. Sometimes it 
colors uniformly, at other times it appears granular. It 
grows in alkaline bouillon, leaving a deposit upon the 
walls of the vessel containing the culture, and in this 
medium it often presents the "inflated" forms-pear- 
shaped or club-shaped. It is destroyed in a liquid me- 
dium by a temperature of 58° C. maintained for ten 
minutes. All of these characters are common to the 
pseudo-diphtheritic bacillus and the true bacillus diph- 
theriae. As points of difference between them we may 
note that the pseudo-diphtheritic bacillus is often shorter 
in the colonies grown upon blood-serum ; that its cult- 
ures in bouillon are more abundant ; that they continue 
to grow at a temperature of from 20° to 22° C., at which 
the true bacillus grows very slowly ; finally, that when 
comparisons of cultures in bouillon are made, it is ob- 
served that they both become acid and then alkaline, but 
that the change occurs much sooner in the case of the 
pseudo-diphtheritic bacillus. Like the true diphtheritic 
bacillus, the pseudo-diphtheritic grows in a vacuum, but 
less abundantly than the other. 
Inoculation of animals with cultures of this bacillus 
has never caused their death, but it is to be noted that 
227 Diphtheria. 
Diphtheria. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
in some experiments a decided oedema has been produced 
in guinea-pigs at the point of inoculation, while in others 
there has been no local lesion. The most marked oedema 
resulted from cultures obtained from cases of measles. 
Do the facts that have been reported explain the ques- 
tion which occupies us ? Can it be concluded that there 
is a relation between the two bacilli ? On the one side, 
the presence of the pseudo-diphtheritic bacillus in the 
mouths of healthy persons, and of those who have angina 
manifestly not diphtheritic, seems to be opposed to the 
idea of a relationship between them. On the other hand, 
when it is considered that the non-virulent bacillus 
is very rare in cases of diphtheria ; that it is more 
abundant in " benign " diphtheria ; that it becomes more 
common in severe cases as they progress toward recov- 
ery ; and finally, that they are more numerous in persons 
who have recently had diphtheria than in healthy per- 
sons, it is difficult to accept the idea that the two microbes 
are entirely distinct. The morphological differences 
which have been referred to are so slight that they prove 
nothing. The two micro-organisms can only be distin- 
guished by their action upon animals, but the difference 
of virulence does not at all correspond with the difference 
of origin. 
As regards the forms and the aspect of cultures the true 
and the false diphtheria bacilli differ less than virulent 
anthrax differs from a very attenuated anthrax bacillus 
originating from the same source. Besides, the sharp 
distinction which is made between the virulent and non- 
virulent bacilli is arbitrary. It depends upon the sus- 
ceptibility of guinea-pigs. If we inoculate animals still 
more susceptible, there are pseudo-diphtheritic bacilli 
which must be classed as virulent. If, on the contrary, 
we substitute rabbits for guinea-pigs in our experiments, 
there are diphtheritic bacilli which must be called pseudo- 
diphtheritic. In our experiments we do not simply en- 
counter bacilli which are very virulent, and bacilli which 
are non-virulent: between these two extremes there are 
bacilli of every degree of virulence. 
Abbott has recently (1891) published the result of his 
researches with reference to the presence of the pseudo- 
diphtheritic bacillus in benign throat affections. He 
made a bacteriological study of 53 patients, 9 of whom 
were suffering from acute pharyngitis, 14 from acute fol- 
licular tonsillitis, 8 from ordinary post-nasal catarrh, 2 
from simple enlarged tonsils, 15 from chronic pharyn- 
gitis, 1 from subacute laryngitis, 1 from chronic laryn- 
gitis, 1 from rhinitis, and 2 from an affection of the 
tonsils and pharynx. In 49 cases nothing of particular 
interest was observed. A variety of micro-organisms 
were isolated, and of these the pyogenic micrococci were 
the most common. In four cases micro-organisms were 
found which resembled the bacillus diphtheria; of Loef- 
fler in their morphology and growth in the culture-me- 
dia, but which proved not to be pathogenic. Abbott 
says the single point of distinction that can be made out 
between the organism obtained in three of his cases and 
the true bacillus of diphtheria is in the absence of path- 
ogenic properties from the former ; whereas, in addition 
to this point of distinction, the organism from a fourth 
case gives, as he states, a decided and distinct growth 
upon the surface of sterilized potato. 
Experiments have been made which tend to show that 
diphtheria, as it is observed in the lower animals, is not 
the same thing as the diphtheria which affects man. It 
has been found that there are distinct varieties of bacteria 
in these different forms of diphtheria. Descriptions of 
these will now be given. 
The Bacillus Diphtheria Columbarum.-This was 
described in 1884 by Loeffler, who obtained it from diph- 
theritic pseudo-membranes in the mouths of pigeons dead 
of a form of diphtheria which prevailed in some parts of 
Germany among these birds, and among chickens. Red- 
dened patches first appear upon the mucous membrane 
of the mouth and fauces, and these are covered later with 
a rather thick yellowish layer of fibrinous exudate. In 
pigeons, the back part of the tongue, the fauces, and the 
corners of the mouth are especially affected ; in chickens, 
the tongue, the gums, the nares, the larynx, and the con- 
junctival mucous membrane. 
The disease is especially fatal among chickens-the 
young, and those of choice varieties being most suscepti- 
ble. It is attended at the outset by fever, and usually 
proves fatal within two or three weeks, but may last for 
several months. 
Morphology.-They are short bacilli, with rounded 
ends, usually associated in irregular masses, and resem- 
bling the bacilli of rabbit septicaemia, but a little longer 
and not quite so broad. In sections from the liver they 
are seen in irregular groups in the interior of the vessels. 
It is an aerobic, non-motile, non - liquefying bacillus. 
It grows in nutrient gelatine in the form of spherical 
white colonies along the line of puncture, and upon the 
surface it has a whitish layer. Under the microscope 
the colonies in gelatine plates have a yellowish-brown 
color and a slightly granular surface. Upon blood- 
serum the growth consists of a semi-transparent grayish- 
white layer ; upon potato a thin layer is formed having 
a grayish tint. 
Pathogenesis.-Pigeons inoculated with a pure culture 
in the mucous membrane of the mouth are affected ex- 
actly as are those which acquire the disease naturally. 
Subcutaneous inoculation in pigeons gives rise to an in- 
flammation resulting in local necrotic changes. 
Pathogenesis for Rabbits and for Mice.-Subcutaneous 
injections in mice give rise to a fatal result in about five 
days. The bacillus is found in the blood and in the va- 
rious organs, in the interior of the vessels, and sometimes 
in the interior of the leucocytes, and they are especially 
numerous in the liver. The lungs are dotted with red 
spots ; the spleen is greatly enlarged, and the liver has a 
marbled appearance from the presence of numerous ir 
regular white masses scattered through the pale red 
parenchyma of the organ. These white masses are seen 
in sections to consist of necrotic liver tissue, in the centre 
of which the bacilli are found in great numbers, in the 
interior of the vessels. This appearance is so character- 
istic that Loeffler considers inoculation in mice to be the 
most reliable method of establishing the identity of the 
bacillus. It is not pathogenic for chickens, guinea-pigs, 
rats, or dogs. There seems to be some doubt whether the 
form of diphtheria which prevails among pigeons, and 
which Loeffler has shown to be due to the bacillus above 
described, is identical with the diphtheria of chickens. 
Diphtheria in man has been supposed by some authors to 
be identical with that which prevails among fowls, and, 
possibly, this may be the case, under certain circum- 
stances. But the evidence seems to be convincing that 
there is an infectious diphtheria of fowls which is pecu- 
liar to them, and which, under ordinary circumstances, 
is not communicated to man. 
The Bacillus Diphtheria Vitulorum.-This was 
described by Loeffler in 1884, and was obtained by him 
from the pseudo-membranous exudation in the mouths of 
calves suffering from an infectious form of diphtheria. 
The disease is characterized by the appearance of yel- 
low patches upon the mucous membranes of the cheeks, 
the tongue, and sometimes the larynx and nares of in- 
fected animals. There is a yellowish discharge from the 
nose, an abundant flow of saliva, occasional attacks of 
coughing and diarrhoea. Death may occur at the end of 
four or five days, but usually the animal survives for 
several weeks. Diphtheritic patches, similar to those in 
the mouth, are also found in the large intestine, and 
there are scattered abscesses in the lungs. Loeffler, in a 
series of seven cases examined, obtained from the deep 
portion of the pseudo-membranous deposit ,a long bacil- 
lus which appeared to be the cause of the disease. 
Morphology.-They are bacilli five to six times as long 
as they are broad, usually united in long filaments. The 
diameter of the rod is about half that of the bacillus of 
malignant oedema. 
Biological Characters. - Attempts to cultivate this 
bacillus in nutrient gelatine, blood-serum from sheep, 
and various other media, were unsuccessful. But when 
fragments of tissue containing the bacillus were placed 
in blood-serum from the calf, a white border consisting 
228 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT. 
Diphtheria. 
Diphtheria. 
of the long bacilli was developed. These could not, 
however, be made to grow when transferred to fresh 
blood-serum. 
Pathogenesis.-Mice inoculated subcutaneously with 
the fresh diphtheritic exudation died in from seven to 
thirty days. The autopsy disclosed an extensive infiltra- 
tion of the entire walls of the abdomen, which often 
penetrated the peritoneal cavity and enveloped the liver, 
the kidneys, and the intestines in a yellowish exudate. 
The bacillus was found in this exudate, and by inoculat- 
ing a little of it into another animal of the same species 
a similar result was obtained. It is not pathogenic for 
rabbits or guinea-pigs. 
The Bacillus of Intestinal Diphtheria in Rab- 
bits.-This was described by Ribbert, in 1887, and was 
obtained by him from the organs of rabbits which had 
an affection characterized by a diphtheritic inflammation 
of the mucous membrane of the intestines. The autopsy 
revealed, also, swelling of the mesenteric gland, and 
minute necrotic foci in the liver and spleen. 
Morphology.-Bacilli with slightly rounded ends, from 
three to four micromillimetres long and from one to one 
and four-tenths micromillimetre in diameter. Often 
united in pairs or in filaments containing several ele- 
ments. Stain with the usual aniline colors, but not so 
readily in sections as do some other bacteria. 
Ribbert recommends staining with aniline-water, fuch- 
sine solution, washing in water, then placing the section 
in methylene blue solution and decolorizing in alcohol. 
The bacilli cannot be stained by Gramm's method. 
Biological Character.-It is an aerobic, non-liquefying 
bacillus. The question of its motility is not yet settled. 
Upon gelatine plates semi-transparent, grayish colonies 
are formed, which later turn a brownish color. The sur- 
face of these is finely granular and of a pearly lustre. In 
needle cultures in nutrient gelatine the growth along the 
line of puncture is very scanty. On potato a flat, whitish 
layer is formed which extends slowly over the surface. 
It grows best at a temperature of from 30° to 35° C. 
Pathogenesis.-Pure cultures injected into the peritoneal 
cavity, or subcutaneously, in rabbits cause the death of 
these animals in from three to fourteen days, according 
to the quantity used. At the autopsy necrotic foci are 
found in the liver and spleen and the mesenteric glands 
are enlarged, but the intestines present a healthy appear- 
ance ; but when cultures are introduced into the alimen- 
tary canal the characteristic diphtheritic inflammation 
of the mucous membrane of the intestines is produced. 
This result was obtained both by direct injection into 
the interior of the intestines and by injecting cultures into 
the mouth. 
Diagnosis. 
The characteristic sign of diphtheria is the presence of 
a circumscribed membrane with more or less congestion 
of the surrounding parts. The fever is not always a 
prominent symptom, and but little importance can be 
attached to it. High fever at the beginning of the dis- 
ease should make the diagnosis doubtful for the time. 
Swelling of the glands of the neck, especially about the 
angle of the jaw, is an important aid in the diagnosis. 
The absence of this sign is, however, of no weight as 
negative evidence. It is of especial value when the pro- 
cess is seated in the nose, and its exact location cannot be 
readily ascertained. 
Diphtheria of the vagina and conjunctiva and of 
wounds can only be confounded with a simple purulent 
coating where ocular examination alone is at command : 
confusion between the two processes can very seldom oc- 
cur. The eruption, when it is present, occurs about the 
chest, neck, and abdomen, and is to be distinguished from 
that of scarlatina, according to Jacobi, in that this latter 
first appears about the hips and extremities. Not in- 
frequently, however, the differential diagnosis is ex- 
tremely difficult, and can be made only after sufficient 
time for observation of the efflorescence has elapsed. 
Albuminuria, if present in the first few days of attack, 
is an indication of diphtheria ; if it appears later, of 
scarlatina. The diagnosis of diphtheritic paralysis pre- 
sents no difficulties if the case has been watched from the 
beginning and the diagnosis of the primary disease has 
been satisfactorily made. 
The settlement of the question as to whether a paresis 
is a sequel of diphtheria or not, is often impossible if the 
previous history be obscure. The special characteristics 
of the diphtheritic paralysis are, that it very frequently 
starts from the pharynx ; that its course is exceedingly 
irregular ; and that it is mostly peripheral in character, 
generally motor, and sometimes sensory. 
Differential Diagnosis.-Diphtheria may be confounded 
with scarlet fever, confluent herpes of the throat, acute 
tonsillitis, and acute laryngitis. 
In addition to the points already touched upon, the 
following aids to diagnosis may be mentioned : 
The disease may be differentiated from scarlet fever by 
a consideration of the following facts : In scarlet fever 
there is less constitutional disturbance ; the throat is less 
uniformly reddened ; the membrane, if any exists at all, 
is more easily detached ; and the larynx is almost never 
attacked ; but, on the other hand, haematuriais common, 
while it is rare in diphtheria. The rash is different in the 
two diseases. In diphtheria it is not commonly present; 
it appears at irregular periods, is partial, appears sud- 
denly in patches, and is of an uniform erythematous red- 
ness, without the punctated appearance peculiar to the 
scarlatinal eruption (Meigs and Pepper). 
It is very often impossible to differentiate acute tonsil- 
litis from diphtheria at first. If the case be one of ton- 
sillitis, however, the inflammation either subsides or 
suppuration occurs, which at once makes the diagnosis 
plain. In such cases aid must be sought from the bac- 
teriological examination. Confluent herpes has the pecu- 
liarity of a rapid rise in temperature, followed by an 
equally rapid fall. The pain in the throat is of a pecu- 
liar smarting character, and there is no tendency to 
spread. The presence of herpes of the lips is often of 
very great help in making out the diagnosis. Catarrhal 
laryngitis of a severe form is oftentimes impossible to 
differentiate from diphtheria, especially in the early 
stages. When the disease is fully developed it is easier 
to distinguish it correctly, for catarrhal laryngitis nearly 
always ends in recovery and without the severe sequelae 
of diphtheria. 
Decent investigations shore that it is not possible to make 
a certain diagnosis of diphtheria excepting by the bacterio- 
logical examination; the discovery of the true bacillus of 
diphtheria, in material taken from the suspected spots of 
inflammatory reaction, settles the question. 
That there are other throat affections very closely 
resembling, from a clinical point of view, true diph- 
theria, is unquestionable, and in this connection the work 
of Martin (to be found in the Annales de VInst. Pasteur, 
May, 1892, p. 335) is of very great interest. In this 
article the author reports that he has made both a clini- 
cal and a bacteriological examination of two hundred 
children who were sent into the diphtheria ward with a 
clinical diagnosis of diphtheria. The very full extracts 
that we shall give from this article are justified by the 
extreme importance of the subject. 
He says that when a child arrives at the hospital, it is 
likely to present one of these two different conditions, 
viz. : 1, There may be a white angina, with or without 
laryngeal trouble ; or, 2, there may be no visible false 
membrane, the child presenting only the symptoms of a 
laryngitis ; in other words, as the parents say, it has the 
croup. 
The rapid examinations to which these patients are 
submitted are necessarily inconclusive, but usually, as a 
result, they are sent into the diphtheria ward. 
In order to arrive at a certain diagnosis, bacteriology, 
according to this author, now furnishes two methods of 
procedure, first, the examination of the false membrane, 
and second, cultivation upon coagulated serum and ex- 
amination of the cultures after twenty-four hours. 
1. The Direct Examination of the False Membrane.- 
This examination was made after the method of Roux 
and Yersin (in the Annales de VInst. Pasteur, 1890), and 
in many cases it was possible to discover at once a bacil- 
229 Diphtheria. 
Diphtheria. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
lus of diphtheria, thus facilitating the making of a rapid 
diagnosis. This, however, was not always practicable, 
much care and great expertness being required for such 
work ; many preparations had to be examined, and it had 
to be definitely determined that the bacillus seen stained 
well according to Gramm's method. Very often it is 
exceedingly difficult to recognize the bacillus of diph- 
theria among a great number of other bacteria, and when 
it is not discovered it is not permissible to say that the 
case is not one of diphtheria. 
2. Cultivations from the Suspected Spots.-In certain 
cases of croup without false membranes the microscopic 
examination of the mucus of the posterior portions of 
the throat, spread out upon a cover-glass and colored 
with methylene blue, did not permit a definite diagnosis, 
and at the same time this same mucus sowed upon serum 
gave very numerous colonies of the bacilli of diphtheria. 
The best method is to always use coagulated serum, 
which is a medium that is very favorable for the devel- 
opment of the bacillus of diphtheria, and upon which it 
develops in a few hours, before any-or at any rate most 
-of the other bacteria of the mouth. 
The culture is to be taken directly from the throat with 
a platinum needle flattened into the shape of a spatula at 
the end ; the false membranes, when they exist, are to be 
touched, or simply the mucus in the apparently simple 
cases of laryngitis without false membrane; then the 
spatula is drawn over two or three tubes of serum with- 
out retouching the throat. The tubes are then to be 
placed for twenty-four hours in a thermostat at 37° C., 
and, if it be a case of true diphtheria, numerous colonies 
will soon appear, especially upon the flrst tubes that were 
inoculated ; even after the lapse of eighteen hours they 
can be recognized and examined, and it was never found 
necessary for the author to wait more than twenty-four 
hours. After a longer time than this the other bacteria 
commenced to develop and rendered the diagnosis more 
difficult. In cases of severe diphtheria the colonies of 
the bacillus of Loeffler are more numerous than in mild 
cases. In certain anginas that were not diphtheritic no 
colonies developed during the first twenty-four hours. 
The presence of a great number of colonies upon the 
tubes make probable the diagnosis of diphtheria, espe- 
cially if this occurs soon ; but there are certain anginas 
produced by a coccus that also gives numerous colonies 
after the lapse of twenty-four hours, upon inoculation 
upon blood-serum. In the latter case the microscopic 
examination will determine the truth and render all con- 
fusion impossible. 
Upon the serum the colonies of the diphtheria-bacillus 
are round and very regular, of a yellowish-white color, 
and more opaque in their centre by transmitted light ; as 
they grow older they increase in size, remain regular, and 
become sometimes of a pale yellow color. Certain cocci 
give, also, colonies resembling those of diphtheria, but 
their surface is more moist, while their centre is not thicker 
than the edges. 
The colonies of the streptococci are still very small at 
the end of twenty-four hours, and it is not possible to 
confound them with those of the bacillus of diphtheria, 
which are at least six or seven times as large. Colonies 
of the staphylococcus aureus have also been found, as 
well as other bacteria that liquefy the serum. These 
colonies develop especially after twenty-four hours, and 
do not trouble the observer. In the entire observation 
only those colonies need be considered that develop upon 
serum, and this is the only nutrient medium that it is at 
all necessary to employ. 
When the diphtheria colonies were in a great major- 
ity, the cases were regarded as pure diphtheria ; but if 
with the bacillus of diphtheria numerous colonies of 
different species were found, then the bacteria mixed in 
the secretions were considered. Those most often asso- 
ciated with the bacillus of diphtheria were micrococci and 
streptococci, their presence seeming to have an influence 
upon the progress of the disease, and furnishing, also, a 
basis for a prognosis. 
The author claims that the examination of the number 
and of the form of the colonies is only a preparatory 
(SUPPLEMENT. 
work, and must be followed by the microscopical exam- 
ination, which shows that the bacillus of diphtheria does, 
not always present itself under the same form. He dis- 
tinguishes three varieties : (1) Long bacilli, which are the 
typical organisms of diphtheria described by all the au- 
thors ; there are also (2) small bacilli that are placed side 
by side, and appear thicker than the ordinary bacilli, be- 
cause they are shorter ; and finally, between these two, 
there is (3) an intermediate form of bacillus of a medium, 
length, the individuals of which are also placed side by 
side. The colonies of these three forms are not distin- 
guishable upon serum, although the short bacilli often 
give whiter, more moist colonies, which continue to in- 
crease, even outside of the thermostat, and answer very 
closely the description given by Loeftier of the pseudo- 
diphtheritic bacillus. 
From the point of view of virulence there are differ- 
ences between these bacilli of different forms, but they 
are considered to be, all of them, bacilli of diphtheria. 
Martin found the short bacilli very mild in their action, 
the medium-sized bacilli a little more toxic, while the 
long bacilli are the most infectious. Among a number 
of cases of diphtheria which he had verified by bacterio- 
logical examination there were several fatal ones in which 
the short bacilli were found, but these were always asso- 
ciated with the streptococci; and often, in cases of mea- 
sles with sore throat, were found the short bacilli, which, 
although mild under ordinary conditions, seemed, in 
these particular cases, to take on more virulent proper- 
ties. 
The author, in discussing further the question of diph- 
theria, lays especial stress upon what appears to be an 
exceedingly important point, particularly in the light of 
the investigation of Frosch, already quoted in this arti- 
cle. He says, that at autopsies he often looked for the 
bacilli of diphtheria in the respiratory tract, especially in 
the pulmonary parenchyma, and that he very often suc- 
ceeded in finding them in these places. In all cases 
there was an inflammation of the lungs, which appeared 
under the form of a lobular broncho-pneumonia. Many 
times it was in the lungs that the greatest quantity of 
the bacilli was found, and in these observations there 
was no false membrane in the throat and very little in 
the trachea. It appeared to be the pulmonary paren- 
chyma that was the principal seat of the infection. It 
even appeared to him, in certain cases, that the lungs 
were primarily attacked, and that the trachea and the lar- 
ynx were only the secondary seats of the disease. 
By this study of two hundred cases of supposed diph- 
theria it has been established that there are in reality 
three great classes of disease : the non-diphtheritic an- 
ginas, of which there were forty-three cases ; the diph- 
theritic anginas of which there were sixty-nine cases; 
and croup, of which there were eighty-eight cases. In 
other words, forty-three cases had been sent to the diphtheria; 
ward that did not have diphtheria at all. Among these 
cases four were attacked with measles. This point 
alone emphasizes, more than anything well could, the ex- 
treme importance of a correct differential diagnosis, and 
that this diagnosis should be made before the patient is 
sent in to the diphtheria ward. In other words, every 
hospital should have a detention-room or observation 
ward, in which suspected cases of diphtheria should be 
detained long enough to determine whether or not they 
be cases of true diphtheria, and whether, as a conse- 
quence, they should or should not be sent to the diph- 
theria ward. There can be no doubt but that this is a 
matter of very great importance. 
More remarkable still is the observation that out of 
these forty-three cases thirty-six, in which it was not 
possible to determine the presence of the diphtheria ba- 
cillus, showed the occurrence of false membranes in 
some portions of the throat. There were, therefore, this 
number of clinical errors in diagnosis, and the sufferers 
were put in jeopardy of their lives by reason of the 
omission of this extremely important point in diagnosis. 
The non-diphtheritic cases are divided into angina pro- 
duced by micrococci-the most common of these occur- 
ring in the form of a diplococcus, which has already been, 
230 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT. 
Diphtheria. 
Diphtheria. 
described by Roux and Yersin, and which is found in 
immense numbers in the false membrane, where it ap- 
pears in places as a pure culture. This diplococcus is to 
be regarded as the cause of the process. If we sow the 
cocci taken from one of the false membranes which they 
have produced, upon serum, there will be developed, in 
less than twenty-four hours, non-liquefying colonies that 
are as numerous and as pure as the colonies of the true 
diphtheria-bacillus obtained from typical cases. Upon a 
superficial examination these colonies appear to resemble 
those of diphtheria, but they are more moist and more 
transparent. Loeffler's methylene blue easily stains the 
coccus, which also stains by the method of Gramm, and 
it can also be cultivated upon nutrient agar. The false 
membranes produced by the activity of this organism re- 
semble so closely true diphtheritic membranes that they 
are almost invariably regarded as such. Like the latter, 
they are reformed very quickly if they be torn away. 
The progress of the cases is characterized by the exhi- 
bition of extreme prostration, and a marked characteristic 
of these false membranes is their tendency to recurrence. 
The sore throats produced by this coccus do not as a 
rule terminate fatally ; they generally become better very 
rapidly and leave no evidences of systemic poisoning be- 
hind them. 
A second class of non-diphtheritic cases owe their ori- 
gin to the presence of streptococci. The streptococcus 
pyogenes is an organism which is very commonly found 
in the mouth, and which can produce alterations of the 
mucous membrane resulting in fibrinous exudation and 
the formation of pseudo-membranes. A number of ob- 
servers have seen this occur, notably Prudden, who 
worked upon cases of apparent diphtheria produced by 
this streptococcus, and confounded these cases with those 
of true diphtheria. Cases produced by this streptococ- 
cus are not virulent any more than are those of the pre- 
ceding coccus, at least to anything like the same degree 
as the cases resulting from the activity of the true diph- 
theria bacillus. 
The second class into which the 200 cases are divided 
is that of diphtheritic anginas without croup. Of these 
there were 62 cases of pure diphtheritic anginas, fol- 
lowing out the ordinary clinical history of cases of 
diphtheria. Of the remainder, some of the cases were 
diphtheritic anginas mixed with the streptococci, and 
diphtheritic anginas mixed with the micrococci. The 
general history of these tended to show that a mixed in- 
fection produces a milder form of diphtheria than when 
the diphtheria bacillus is present by itself. 
Another division of the cases was into croup-croup 
with false membranes-of which there were 54 cases, 
and of these there were 17 cases which were shown to 
be non-diphtheritic, and 13 cases of diphtheritic croup 
with mixed bacterial infection-some of them with the 
streptococcus and some with the coccus alone. And 
then there were cases of pure diphtheritic angina accom- 
panying croup. Finally, the last division of cases is that 
of croup without false membrane in the throat ; and of 
these there were 34, 21 of which were proved to be diph- 
theritic, while 12 were not. 
The author, in concluding his work, says that his first 
object in undertaking it had been to find out how far 
bacteriology could aid the clinician in the diagnosis of 
diphtheria ; and he makes the statement, which can 
scarcely be disputed, that the most accurate clinician is 
deceived once out of five times-whether it be in the 
direction of mistaking a non-diphtheritic angina for 
diphtheria, or in that of not recognizing a case of true 
diphtheria. Bacteriological researches have furnished 
many extremely interesting and important points bearing 
upon the clinical and bacteriological history of the pseudo- 
membranous anginas that are non-diphtheritic. Bacteria 
play an exceedingly important part in affections of the 
throat, and it is bacteriology alone that can clear up the 
question of the anginas, for their clinical characteristics 
are entirely insufficient to distinguish them. 
As a conclusion to this remarkable and important pa- 
per the author makes the following statements : 
Many anginas with false membranes, and, also, many 
cases of croup, are confounded with diphtheria. Bac- 
teriological examination furnishes the most certain and 
the most rapid means for making the exact diagnosis of 
diphtheria. There are pure diphtherias and diphtherias 
associated with other bacterial infections, and among 
the latter-the diphtherias with other bacteria-those in 
which the streptococci are found are the most severe, 
while those in which the micrococci are found are the 
most benign. The temperature curve furnishes an ex- 
cellent method for determining the prognosis, and upon 
this point the'author has laid very great stress, instanc- 
ing many cases (accompanied by reproductions of charts) 
in which a study of the temperature observations, made 
at the same hour morning and night, revealed the fact 
that there appeared to be a curve almost as characteristic 
for diphtheria as that which is usually supposed to be- 
long to typhoid fever. 
In a recent number of the Philadelphia Medical News 
(December 10, 1892) Wyatt Johnston, of Montreal, makes 
a suggestion for the ready diagnosis of diphtheria that 
seems to be entirely practicable. It consists in boiling 
an egg hard, which, of course, solidifies the albuminous 
contents, and, at the same time, sterilizes the shell. There 
is prepared at the same time an ordinary egg-cup, which 
may be sterilized by burning a little alcohol in its hol- 
low. A small portion of the shell of the egg is then 
chipped off at one end, and a minute portion of material 
from the throat of the suspected case is drawn over it 
with a platinum needle, three or four separate times, 
■without retouching the platinum needle to the throat, 
and the egg is then inverted in the egg-cup and the 
whole placed in a warm place over-night. By this 
means it is often possible to make a perfectly satisfac- 
tory diagnosis of diphtheria in a comparatively short 
time, and with the simplest form of apparatus. For if 
the diphtheria bacillus is present it will grow rapidly 
upon this solidified egg-albumen, and the characteristic 
colonies will be present upon the following morning, 
when the diagnosis may be further verified by micro- 
scopic examinations of the colonies that have made their 
appearance. Park, in a recent number of the Medical 
Record (February 11, 1893), expresses some doubt in re- 
gard to the trustworthiness of the method just described. 
Among those who have expressed themselves strongly 
in regard to the importance of resorting to bacteriologi- 
cal examinations in making a diagnosis of diphtheria 
may be mentioned Martin, from whose paper we have 
already given very full extracts ; Park {Medical Record, 
July 30 and August 5, 1892, and February 11, 1893); Ba- 
ginsky (Berliner klin. Wochenschr., February 29, 1892); 
and Koplik (Neic York Medical Journal, August 25, 1892). 
There is doubt whether in the course of time clinical 
features will be discovered by means of which true diph- 
theria can be distinguished from the forms of disease 
which resemble it. 
Prognosis. 
The prognosis in each individual case should be very 
guarded. To assume that recovery is probable, before 
the disease has run its course, is exceedingly unsafe, and 
even then relapses may occur and the result be once 
more placed in doubt. The general course of an epi- 
demic may have some influence upon prognosis, but 
that influence is exceedingly small, for it is the mild 
cases that are often the most deceptive. Speaking very 
generally, the prognosis is favorable where the local 
manifestation of the disease is of small extent and is 
situated on a part that has but little communication, by 
way of the lymphatics, with the rest of the system. An 
indication of sluggishness in the course of the disease, 
as in diphtheria of the womb or the angles of the mouth, 
is unfavorable, as is also the extension of the disease to 
the larynx. The septic or gangrenous forms of diphtheria 
are especially dangerous, but the elevation of the body 
temperature has not been thought to have any particular 
bearing on the final result. Martin, however (loc. cit.), 
lays great stress upon the temperature curve as a guide in 
prognosis. A rapid, small, and irregular pulse is a sign 
of failure of the heart, but is not a very bad sign so long 
231 Diphtheria. 
Diphtheria. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
as there is an approximately normal relation between it 
and the rate of respiration. Every complication adds to 
the gravity of the prognosis. During convalescence the 
extension of the paralysis to the muscles of respiration is 
a very alarming sign. The indications of immediate 
danger are croupy symptoms arising from the extension 
of the membrane into the larynx, a brown or black ap- 
pearance of the false membrane, a hemorrhage from the 
nose, throat, bronchi, or intestines, copious discharge 
from the nostrils, intense albuminuria, great swelling of 
the cervical glands, decided fall of temperature, and nau- 
sea or diarrhoea at an advanced period of the disease. 
Any one of these may occur without being necessarily 
fatal, but two or more mean extreme danger. 
Treatment. 
There is no specific for diphtheria. Treatment is to 
be based, first, upon general principles, and, second, 
upon local applications. Measures to sustain the general 
health are of the greatest importance, and should receive 
special attention. The room should have a temperature 
of from 62° to 65° F. ; it should also have, if possible, a 
sunny exposure, and there should be an open fire. The 
diet should be very nutritious, consisting of beef-tea, 
milk, and the like, given regularly in small quantities 
and at short intervals, especially during the night, for it 
is then that the vital powers are in their least resistant 
state. 
If signs of failure of the heart appear, the patient's head 
should be kept as low as possible. High fever should be 
treated with sponge-baths of tepid water ; quinine and 
salicylate of sodium are also recommended. Collapse 
should be met with the free exhibition of stimulants, and 
severe vomiting or diarrhoea should be checked at once. 
Quinine and the method of employing it should be left to 
the judgment of the physician. As complete isolation of 
the case as is possible should be practised ; the sick-room 
should be kept cool (the temperature spoken of above is 
the best), and plenty of fresh air should be admitted. 
The nurses should keep the mouth closed when over the 
patient, and any caressing or fondling should be abso- 
lutely prohibited. It is also a good plan to wear cotton 
in the nostrils as a filter. 
The general treatment should be begun early, as there 
is no typical course to the disease, and, therefore, delay is 
dangerous. There is small chance of giving too much 
stimulant, and a tonic never does harm, whereas its 
omission may be seriously felt. 
An exceedingly important measure is the disinfection 
of the room, and of all objects which may have come 
in contact, in any way, with the patient. In the case of 
a room this may (?) be effected by fumigation ; two 
pounds of rolled sulphur to every seventeen hundred 
and twenty-eight cubic feet of space being burned for 
this purpose. A copperas solution, one and a half 
pound to a gallon of water, may be used for everything 
that can be placed in it. Better than this is a solution 
of corrosive sublimate (one part to ten thousand of 
water) which should be freely used in all drains, privies, 
and so on, and for soaking all soiled linen or cloth- 
ing. 
The instructions given for disinfection by the National 
Board of Health, Bulletin No. 10, September 6, 1879, are 
simple and effective, provided the corrosive sublimate 
solution be substituted for the other agents mentioned. 
Best of all, however, is prolonged boiling of all infected 
material. 
The infectious agent is confined, as we know, to the 
affected area, and in diphtheria of the mouth and air-pas- 
sages, it will be found only in these situations or in 
material coming from them. The spread of infection 
should therefore be a comparatively easy matter. All 
saliva, mucus, blood, etc., coming from the patient, 
should be received upon towels or old rags that may be 
at once folded inward and subjected to boiling for at 
least half an hour. The same treatment should be given 
to the bed-clothing of the patients. Spoons and other 
articles coming in direct contact with the affected parts 
should be dropped at once into a vessel containing water, 
and then also boiled as in the case of the other articles. 
Nurses and other attendants may avoid infection, them- 
selves, or the danger of carrying it in their clothing, if 
they put on a loose gown, tight at the wrists and neck, 
at the entrance to the sick room, and remove this article 
of dress immediately upon leaving the room. The 
hands should at once be thoroughly cleansed by soap 
and water as hot as can be borne. 
The special precautions that are needed in the case of 
diphtheria of the air-passages, for the safety of the ob- 
server, are to avoid inhalation of the breath of the pa- 
tient, and this especially at the time of coughing. The 
infectious material of diphtheria is so well known now, its 
localization is so defined, and at the same time so limited, 
that there should be no especial danger in the future of 
its being transported. 
Special Treatment.-There is, at present, no specific for 
diphtheria. The first indications are to employ those 
remedies which have, or seem to have, an effect in soften- 
ing or destroying the false membrane. The principal 
among these are steam inhalations, which have been em- 
ployed in various ways, as from the nozzle of a kettle 
and by dropping hot bricks into water. The best method 
of employment is by means of the atomizer, used very 
frequently in conjunction with some therapeutic agent, 
such as carbolic acid, salicylic acid, salt, or chlorate of 
potassium. This latter remedy is one very widely em- 
ployed and of especial benefit-not, however, as a specific 
against the disease. Its beneficial effects arise from its 
alleviating the laryngitis and stomatitis accompanying 
the disease, and from its placing the surrounding parts 
in such a condition that the false membrane rarely 
spreads. It should be given freely, that is, in small 
doses and frequently. One of the best methods of ap- 
plication is by the steam atomizer ;-using the spray for 
five or ten minutes every hour has been followed by the 
most successful results. The strength of the solution to 
be used is that of saturation ; a sufficient dilution for 
safety being effected by the steam. For children the 
solution should be weakened so that a child of three 
years will not get more than twenty grains in the twenty- 
four hours. Serious results, such as acute nephritis, 
have been recorded from overdoses of this drug, but 
properly employed its great value is unquestionable. It 
does not have any marked effect in dissolving the diph- 
theritic membrane, as has been supposed. 
Steam is of value only in those cases in which the 
membrane is upon the surface. Water, to promote the 
secretions, is of value, either given alone or combined in 
hot drinks of various kinds. Cold water and cold ap- 
plications in the form of ice-bags are useful in many 
ways in easing the discomfort of the swollen and sore 
throat. Cracked ice, water ices, and ice-cream, give re- 
lief. Sponging with tepid water when the body tempera- 
ture is high, and the skin hot and parched in conse- 
quence, gives great comfort to the patient. If there are 
signs of a weakened circulation, however, this remedy 
is contraindicated. Lime-water, either alone or in com- 
bination with glycerine, applied locally to the throat by 
means of spraying, sponges, or gargles, has been very 
highly thought of as exerting some solvent effect upon 
the membrane. The action is so slow, however, that 
the good results obtained are probably due, as suggested 
when speaking of chlorate of potash, more to their 
cleansing effects than to any specific action ; and the 
same is probably true of acetic acid and other well- 
known remedies. 
Peroxide of hydrogen is one of the more recent and 
highly endorsed remedies in the treatment of diphtheria. 
I have obtained good results, apparently, from the use 
of the following formula : 
3. Acid, sulphuros. dil x.-xxx. 
Tinct. ferri chlor 3 v. 
Syrup, aurant. cort $ jss. 
Aq. dest § ijss. 
M. Sig. : Half a teaspoonful to a teaspoonful in a 
tablespoonful of water. 
232 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Diphtheria. 
Diphtheria. 
This may be repeated every two to four hours, and 
should be given through a glass tube. 
Inhalations of the oil of turpentine are recommended 
to be administered for ten or fifteen minutes every hour, 
il better method of employment is by boiling some water, 
containing half an ounce of the spirits of turpentine, in 
the room. This should be kept going continuously, 
Chloride of ammonium seems to be of use occasionally. 
Dose, internally, from one to two grains every two or 
three hours, for a child of two years ; or half a drachm 
to be burned over a flame in the room. 
Mercury has been extensively used, and is very strongly 
supported by Jacobi, of New York. 
Astringents, such as alum, tannin, nitrate of silver, 
have almost entirely passed out of use ; their employ- 
ment seeming to retard, rather than to favor, the sub- 
sidence of the exudative process. 
Chloride of iron, introduced by Gigot, in France, in 
1848, has been used very extensively and beneficially, if 
given freely and at frequent intervals. As much as from 
five to ten drops of the tincture every half hour may be 
given. 
Carbolic acid is helpful merely as a cleansing agent, 
and perhaps not even for that. Ozone has been recom- 
mended, with no very great results from its employment. 
Salicylic acid, quinine, potassa fusa, and other strong 
gaits, bromine, and so on, are among the remedies that 
have been proposed. Boric acid solution (one to thirty), 
used as a gargle, and benzoate of sodium (one to eighteen 
parts of water), are among the other remedies that have 
been proposed. Sulphur and cubebs (used in capsules) 
nearly complete the list of remedies. 
Gargles, sprays, and local applications of 'watery solu- 
tions of corrosive sublimate (varying from one in three 
thousand to even greater strengths) have also been em- 
ployed. 
Mechanical removal of the membranes must not be 
practised. When these can be detached without force 
they will come off of themselves, and this time should be 
patiently awaited. 
Swelling of the lymphatic glands in diphtheria must 
be treated as if an idiopathic affection, by applications of 
cold water or ice compresses, and, if absolutely neces- 
sary, by incision. 
Nasal diphtheria must be combated by the assiduous 
use of douches composed of some of the remedies spoken 
of above ; they should be used every hour. 
Laryngeal diphtheria is occasionally helped by the em- 
ployment of emetics. It is when the symptoms become 
urgent, in this form of disease, that tracheotomy is re- 
sorted to; the indications for the operation being the 
danger of suffocation from stenosis of the larynx. The 
mortality after the operation increases in proportion to 
the delay in its performance. 
As a substitute for tracheotomy in stenosis of the larynx 
in diphtheria, the famous procedure of intubation has 
been very widely employed. The success attending this 
substitute for the cutting operation has not been so.great 
as was hoped at first; doubts of its effectiveness in prac- 
tice have increased very much of late. Farther on in 
this volume, under its appropriate heading, will be 
found a fresh contribution to the subject of intubation, 
by the inventor of the procedure, Dr. Joseph O'Dwyer, 
of New York. The reader is referred to this for ad- 
ditional information on the subject. 
Diphtheritic paralysis may in many cases be treated 
simply by rest, good food, stimulants, tonics, such as 
iron and quinine, and sometimes by electricity. Strych- 
nia is recommended, but its usefulness is very doubtful. 
Diphtheritic conjunctivitis must be attacked at once, 
and vigorously, with ice applied locally, and boric acid in 
concentrated watery solution, every hour. The unin- 
fected eye must be carefully protected from inoculation, 
and this is best done by covering it with lint and col- 
lodion, or with lint, cotton, and adhesive plaster. 
General Investigations for Methods of Treat- 
ment by Bacteriological Research.-In order to 
understand clearly the attempts which have been made to 
obtain something in the way of a cure for diphtheria by 
(SUPPLEMENT.) 
bacteriological methods, a statement should be made of 
the general way in which immunity and cure, in infec- 
tious diseases, has been sought by different observers, 
along bacteriological lines. These methods are well 
summarized by Behring in the tables given by him in 
the first part of his work upon " Blood-serum Therapeu- 
tics," published in Leipzig, 1892. In this first part he 
gives three tables : 
Table I. A Method of Obtaining Immunity 
against Infectious Disease.-A. Immunity with the, 
help of disease-producing materials, similar to those against 
which immunity is sought. 
1. The Attenuation Method (Pasteur's method ; Vacci- 
nation). Of general applicability, (a) Immunity by the 
employment of attenuated cultures of living bacteria. 
(b) Immunity by attenuated poisons. In both of these 
cases one has the choice of producing the attenuated ma- 
terial by the following methods : (a) Attenuation by high 
temperature ; (b) attenuation by low temperature ; (c) 
attenuation by means of chemical agents ; (d) attenua- 
tion by atmospheric influences, especially insolation. 
2. The method by dilution. Of limited applicability. 
Consists in the employment of (a) cultures of full viru- 
lence, (b) culture-fluids of full toxicity. 
3. The combined method (Behring's method). Of gen- 
eral applicability. Consists in the obtaining of immunity 
by the help of the attenuation method first, and then fol- 
lowing it by the employment of cultures of full virulence 
and full toxicity in order to obtain a very high degree of 
immunity. 
B. Obtaining immunity by the help of disease-producing 
materials of a different kind from those against which im- 
munity is sought. 
1. The employment of living bacteria cultures, or of 
specific chemical materials which are contained in it. 
2. The employment of chemical preparations. 
3. The obtaining of immunity by the direct transfer- 
rence of the immunity-containing agent. This is Behr- 
ing's blood-serum therapeutics. 
Table II. The Method of Action of the Agent 
Producing Immunity.-1. By the destruction of the 
living cause of the disease. 
2. By hindering the growth of this living cause. 
3. By the destruction of its infectious properties, 
which result, according to Behring, is effected by taking 
away from the bacteria their power of producing their 
poisonous products. 
4. By the destruction in the infected organism of the 
poisonous material produced there. 
5. By such a change of the central organs, or of the 
living cells, that they obtain a higher degree of resisting 
power against the nerve toxines and cell toxines pro- 
duced by the bacteria. 
Table III. Conditions Necessary for the Pro- 
duction of Immunity.-A. A passive state of the organ- 
ism (the exhaustion theory, and the theory of non- 
favorable culture media). 
B. A functional condition of the organism, divided into : 
1, A function of the living condition of the organism 
(the contest theory); 2, a function of the dead condition 
of the organism. 
These three tables give a very accurate view of the 
various theories upon which experimental work has been 
based in order to secure immunity from, or cure of, 
infectious diseases. 
Of all these the one which has been especially applied 
to the study of diphtheria, is that of Behring, marked (c) 
in Table I., and is included in what Behring has called 
" blood-serum therapeutics." 
The history of the investigations which have been made 
in the domain of diphtheria is exceedingly interesting. 
The first paper that appeared on the subject was by 
Behring and Kitasato, in 1890 (in No. 49 of the Deut. Med. 
Wochenschriff) ; the second was by the same authors in 
the same year (No. 50 of the same journal); the third 
was by Boer (a monograph upon the methods of treating 
guinea-pigs infected with diphtheria with chemical 
preparations) ; and the fourth was by Behring and Wer- 
nicke, in 1892 [Zeitschrift f. Ilyg., 1892, vol. xi.), upon 
233 Diphtheria. 
Diphtheria. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
the immunity and cure of animals affected with diph- 
theria. The result of all this work is to furnish a prom- 
ise of something of great value in the future. Certainly 
great results have been obtained by similar work in the 
domain of tetanus in man, and the outlook for something 
really satisfactory in the domain of diphtheria is very 
promising. 
The theory acted upon in the production of immunity 
against diphtheria may be best explained as follows : It 
is a long time since the theory that immunity might be 
due to the presence of a deterrent substance in the blood 
entered the mind of scientific men,-this substance being 
something that would prevent the growth of the invad- 
ing bacteria or prevent the development of their toxic 
poison ; but it has been an exceedingly difficult matter to 
secure evidence upon the point. 
The first experimental researches were negative (those 
of Grawitz and Gamaleia), but in 1884 Grohmann showed 
that fresh serum exerted an attenuating influence upon 
the bacilli of symptomatic anthrax. Fodor found that 
fresh blood destroyed them, while Nuttall established 
the fact that organic fluids, blood-serum, aqueous humor, 
pericardial fluid, etc., really possessed the power of de- 
stroying bacteria, and that this germicidal action was 
taken away by raising these fluids to a temperature of 
about 60° C. Buchner showed that this power rested 
solely in the serum, and that the breaking up or mixing 
in of the blood-corpuscles masked or diminished its ac- 
tivity. He also showed that repeated freezing divided 
the serum into layers, of which the lowest was the most 
active in destroying bacteria, and that this power of the 
serum is destroyed if it be diluted with distilled water, 
or if it be dialyzed against it. After Buchner, the most 
important work has been done by Ogata and lasuhara, 
and Behring and Kitasato, in showing the great influence 
of the fluid portion of the animal tissues in the acquisi- 
tion of immunity. According to the work of these 
authors, immunity is due to the action of albuminoid 
substances, called by Hankin defensive proteids, which 
have the power of destroying pathogenic bacteria, of at- 
tenuating them, and of destroying their toxic products. 
It is necessary that one should have a clear idea in re- 
gard to these defensive proteids, if one is to understand 
what extreme importance is to be attached to their dis- 
covery, and to the prosecution of researches upon them. 
First, in regard to germicidal proteids. Certain ani- 
mals have in their blood, and the other fluids of the body, 
substances endowed with a very considerable germicidal 
power, and an example that has been better studied than 
some others is found in the blood of the white rat. 
These animals are refractory to inoculation with an- 
thrax, and the reason for this immunity to so virulent a 
disease has been found by Behring to exist in the fact 
that the animal's blood-serum destroys the bacteria. By 
comparative tests it was shown that two and one-half 
centimetres of rat serum possessed the same germicidal 
action as would the same quantity of corrosive sublimate 
in the strength of one to one thousand, or of carbolic 
acid (one to fifty). To appreciate this fact it is necessary 
to consider another quality of chemical germicides, viz., 
the toxic action of these materials upon the animal. 
Thus, for example, it appears that both the sublimate 
and the carbolic acid will kill the animal in a dose five 
to seven times smaller than is necessary to secure their 
germicidal action, and that they cannot therefore be 
thought of for internal antiseptics, while the germicidal 
proteids are present in quantity sufficient for the perfect 
accomplishment of such germicidal action in the serum 
of the perfectly healthy white rat. This is the most strik- 
ing and valuable property of these defensive proteids, viz., 
that they are the least toxic of all germicides known, 
and this leads up to the more important fact that it 
seems possible to employ them in active measures for the 
treatment and cure of infectious disease. 
Many points, of course, still remain to be cleared up, 
as, for instance, such an apparent contradiction as that 
the serum germicidal power does not, in all cases, corre- 
spond with the natural immunity of the animal furnish- 
ing the serum ; but thus far investigation has only 
served to show that these apparent discrepancies can be 
easily explained. 
The second class of these proteids is made up of the 
attenuating varieties, the existence of which was first 
suggested by the fact that the bacteria of symptomatic 
anthrax were attenuated in virulence when injected into 
animals refractory to the disease, and yet at the same 
time their vitality was not interfered with. It is to the 
work of Ogata and lasuhara that we owe the first expe- 
rimental determination that this attenuating property re- 
sided in the serum of the animals experimented upon, 
and not elsewhere. 
Such an attenuating action upon bacteria would ex- 
plain very naturally the immunity of the animal in 
whose blood it was found, and the authors, by further 
experiments, showed that this property continued to ex- 
ist in the serum after its removal from the body of the 
animal in which it was found, and could be made to 
serve as a retarding influence, and even as a curative 
agent, in animals inoculated with true anthrax. The ex- 
istence of these attenuating proteids has been confirmed 
by other observers in the case of anthrax and in other 
diseases, and the establishment of the fact would be 
exceedingly important if this were all ; but further re- 
search has shown the existence of a third class of these 
proteids. 
We know now that there are not only germicidal and 
attenuating, but also antitoxic proteids, and their discov- 
ery is the most important of all. The former classes act 
directly upon the bacteria themselves, either by actually 
destroying them, or by so limiting their development in 
the animal's body that their growth becomes a matter of 
slight moment as affecting the health of the individual 
attacked. 
The first announcement of results in this direction was 
made by Behring and Kitasato in 1890 (see the quotations 
above). They had found that the blood of rabbits pro- 
tected against tetanus had the power of destroying the 
toxic alkaloid of tetanus (tetanin) in the lifetime of the 
animal attacked. They also found that it was not only 
possible to protect animals against an inoculation of the 
tetanus bacilli, but also to cure it after this inoculation 
had taken place, and even after the appearance of the 
symptoms of the disease. 
The importance of such results, especially as they have 
been repeatedly verified by independent observers, can 
hardly be over-estimated. Almost in the same week 
with the announcement of the discovery made by Behr- 
ing and Kitasato with reference to tetanus came those of 
Fraenkel and Brieger in regard to diphtheria ; and it is 
with regard to these latter, of course, that we are especially 
interested. So far as tetanus is concerned, if later reports 
can be trusted, the method of cure has been successfully 
applied in a number of-cases which, as we have every rea- 
son to believe, would have terminated fatally, as such 
cases almost invariably do. Results similar to these have 
been obtained in animals in the case of some of the sup- 
purative bacteria, in anthrax and in erysipelas, and the 
variety and extent to which experiments must go in the 
elucidation of the points brought up by these new facts, 
are almost unlimited. 
As will be readily seen, we have at last caught sight of 
materials effective for the destruction of the bacteria, or 
their toxic products-materials that at the same time will 
leave the animal tissues unharmed after their applica- 
tion. Hitherto we have been able to employ for such a 
purpose only materials that were in themselves destruc- 
tive to the vital organism, and the remedy, when effec- 
tively employed, has been worse than the disease. 
The Toxalbumins of the Diphtheria Bacillus.- 
The toxalbumins of the diphtheria bacillus are at present 
attracting so much attention that the following account 
of the work of Wassermann and Proskauer (Dent. Med. 
Woch., April 23, 1891) in extracting them can scarcely 
fail to be of interest. 
Employing methods very similar to those of Brieger 
and Fraenkel (detailed in the Berliner klin. Woch., 1890, 
Nos. 11 and 12) they attempted to follow out the same 
line of investigation. For their observations they used 
234 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Diphtheria. 
Diphtheria. 
a culture of the bacillus of diphtheria in bouillon'which 
was about three weeks old and whose activity against 
animals was proved by experiments. This bouillon cult- 
ure was made in the usual meat-water-peptone bouillon, 
with one per cent, of peptone and one-half per cent, of 
common salt. Its virulence was tested upon animals. 
One-tenth of a cubic centimetre of it injected into the 
animal was found to kill guinea-pigs after from twenty- 
four to thirty-six hours. Of such a bouillon culture 
three litres were made bacteria-free by passing through 
Kitasato's filter. That the filtrate was free from bac- 
teria was proved by a double method of testing it: by 
cultivation upon nutrient agar, and further by leaving it 
in the brooding-oven for from twenty-four to forty-eight 
hours. After it was shown to be sterile by these tests, it 
was reduced to one-third of its'bulk in a vacuum exsicca- 
tor at a temperature of from 27° to 30° C., having been 
made strongly acid with acetic acid. Absolute alcohol 
was added in the proportion of eight to ten times its mass, 
and the resulting precipitate was filtered after standing 
for twenty-four hours. This precipitate was then dis- 
solved in water and further treated, and the operation 
was repeated as often as was found necessary to render the 
watery solution perfectly clear. Then it was three times 
dialyzed for twenty-four hours, and after dialyzing it 
was further treated with alcohol, and the precipitate col- 
lected and dried in vacuo at 37° C. 
The observation was made that after leaving the precipi- 
tate in solution for one or two days in alcohol it became 
manifestly smaller in bulk. If this were then filtered and 
the filtrate again treated with absolute alcohol, another 
precipitate was obtained, differing markedly from the first. 
It thus appeared clear that a part of the precipitate 
was more soluble in alcohol than the other, and as the 
alcohol was made more dilute it passed again into solu- 
tion. This observation coincided with that of Brieger 
and Fraenkel, who, in their solutions, were able to isolate 
two bodies possessed of different solubility in dilute and 
absolute alcohol. 
It was further observed that both bodies dialyzed very 
slowly ; that they both gave the albumin reaction, and 
that only one of them was possessed of pathogenic prop- 
erties. After a large mass of this bacteria-free material 
had been obtained, it was treated in vacuo at between 27° 
and 30° C., and was reduced to a tenth of its volume. 
Then at a low temperature it was dialyzed against dis- 
tilled water for twenty-four hours three times, in order 
to get rid of the peptone and globuline. The authors 
were able to observe in neither of these-the peptone or 
the globuline-any pathogenic or poisonous properties. 
The peptone was obtained in fair quantity, but the 
globuline in very small quantity. The fluid obtained in 
the dialyzer was filtered clear, and only when it was ob- 
tained clear were the next procedures carried on. Seven 
times its volume of from sixty to seventy per cent, alco- 
hol was added to the clear filtrate (freed of globuline and 
of the greater part of the peptone), the alcohol having 
previously been made acid with a drop or two of acetic 
acid. The precipitate thus obtained remained in alcohol 
for twenty-four hours, after having been allowed to settle 
for some time. It was then filtered and the dilute alco- 
hol-the filtrate-was again treated with alcohol, and as 
often as a new precipitate was obtained it was again col- 
lected on the filter. Both substances were treated with 
water and the solution thus obtained again precipitated 
and treated as before. In order to free it as far as pos- 
sible from peptone, it was treated with twice its bulk of 
a saturated solution of sulphate of ammonia, and the 
precipitate resulting from this, which contained the al- 
bumoses, was again brought into solution with distilled 
water, then passed through the dialyzer in flowing water 
until the reaction with sulphuric acid and ammonia dis- 
appeared, and finally was brought into solution with as 
small a quantity of absolute alcohol as was possible. 
This procedure-dissolving in water and precipitating 
with alcohol-was repeated until the solution became as 
perfectly clear as water. When this point was reached 
the precipitate was collected from the filter and dried in 
vacuo at 37° C. 
(SUPPLEMENT.) 
In this way were obtained from cultures of diphtheria 
two albuminoid substances which resembled very closely 
those of Brieger and Fraenkel. The body precipitated by 
dilute alcohol was a finely granular white powder, while 
that thrown down by absolute alcohol, after drying, ap- 
peared in the form of a yellowish brown, crystalline 
body. Both dissolved very easily in water, and these 
solutions gave simply albuminoid reactions. These 
bodies were broken up by concentrated mineral acids, 
by strong metallic salts, and by acetic acid, but this was 
not effected by nitric acid, by bisulphate of soda, or by 
warming the solution. They also gave the typical color 
reaction for albuminoid bodies. 
The elementary analysis of the white toxic body gave 
the following from its ash : Carbon, 44.82 per cent. ; 
hydrogen, 6.91 percent. ; nitrogen, 16.18 per cent. ; sul- 
phur, 1.69 per cent. ; oxygen, 30.40 percent. 
The same analysis obtained by Brieger and Fraenkel, 
fortheir material gave : Carbon, 45.35 per cent. ; hydro- 
gen, 7.13 per cent. ; nitrogen, 16.33 per cent. ; sulphur, 
1.39 per cent.; oxygen, 29.81 per cent. 
The difference between the two analyses can be easily 
accounted for by the difficulty of the task. It was found 
that only the pure white, easily precipitated material had 
any toxic effect upon animals, while the other, even in 
considerable mass, could be injected without any un- 
fortunate results following its use. 
Investigations of this kind, as well as those of Behring, 
give promise of future results that are almost boundless 
in their extent and importance. The pity of it all lies in 
the fact that we in this country must stand idly by, power- 
less to help in pushing on these investigations, because 
of the lack of support for them in the way of money 
and institutions endowed for such researches. 
Harold C. Ernst. 
DIPHTHERIA IN CHILDREN. Membranous forma- 
tion occurs very rarely in children under one year, but it 
has been seen even in the newly born. Most cases occur 
between the ages of three and fifteen. The clinical diag- 
nosis of diphtheria covers at least two diseases, caused, 
one by the Klebs-Loeffler bacillus, the other by a strepto- 
coccus, and according as the disease is the one or the 
other, the symptoms vary somewhat, and the prognosis 
differs widely. A mixed infection is, however, not in- 
frequent. A bacteriological examination is the only 
means of distinguishing positively between the two. 
True Diphtheria, Due to the Klebs-Loeffler 
Bacillus.-The patient presents local and constitutional 
symptoms, the former the result of the position and ex- 
tent of the membrane, the latter the result of the absorbed 
products of the bacilli. 
Local Symptoms.-The membrane may be visible, or, 
by reason of its location, invisible. When visible it may 
be a mere point on one tonsil, or it may cover both ton- 
sils, the soft palate, uvula, pillars of the fauces, and 
pharynx. It may extend up through the naso-pharynx 
and the nose, involve the conjunctivae, and even appear 
in the ears. It may also cover the inner surfaces of the 
cheeks and extend out upon the skin. On the other hand, 
it may be confined to an area out of sight, or it may ex- 
tend into the larynx, down the trachea and small bronchi, 
and rarely down the oesophagus. The membrane may 
be thin, transparent, and like a white veil, or thick and 
opaque ; and in the latter case it may be yellow, green, 
gray, or black. It may be firm and closely adherent when 
young, or loose, shreddy, and soft when old. It may 
disappear in less than two days, and may last three or 
four weeks. Usually, however, the membrane begins to 
separate on the fourth or fifth day, and in about ten days 
the throat clears and convalescence begins. When the 
disease affects the neighborhood of the larynx there may 
be dyspnoea, due to a functional paralysis of the vocal 
cords, or to actual obstruction by membrane. With the 
dyspnoea come an altered voice, perhaps aphonia, and a 
cough. If the obstruction is considerable, cyanosis and 
retraction of the intercostal, supra-sternal, and supra-cla- 
vicular spaces are evident. If the naso-pharynx or nose 
235 Diphtheria. 
Diuretics. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
is affected, there may be complete occlusion of either or 
both nostrils, epistaxis, and there is regularly an acrid, 
watery, or purulent discharge. 
Constitutional Symptoms.-The constitutional symp- 
toms may be almost entirely absent, and on the other 
hand, when the local signs are slight, prostration may yet 
be extreme. Initial chilliness, aching of body or limbs, 
anorexia, and some soreness of the throat, are customary. 
The temperature may be very slightly raised, normal, or 
subnormal. Albuminuria, which is present in about 
half the cases, may begin the first day, and there may 
rarely follow a severe nephritis with uraemia. Rapid, 
feeble pulse, emaciation, prostration, and intense pallor are 
characteristic of toxaemia from absorption of ptomaines, 
and this toxaemia in a mild form may persist for weeks 
after the disappearance of the membrane. It is then prob- 
ably due to continued slow absorption of ptomaines stored 
near the original site of infection. Paralysis, the result 
of a multiple neuritis, is frequent, and may come at 
any time from three days to six weeks after the begin- 
ning of the disease, but occurs oftenest in the second or 
third week of convalescence. The parts affected are pri- 
marily the soft palate and the muscles of accommodation, 
but all the muscles, even those of respiration and the 
sphincters, may be involved. The knee-jerk may be 
absent from the first day of the disease. There may be 
some slight cervical glandular enlargement, but in such a 
case there are usually streptococci present with the 
bacilli. With the mixed infection, too, there may be a 
broncho-pneumonia, which, like the persistent toxaemia, 
may kill the patient after the active disease is over. 
Various skin rashes may appear at the onset or later, and 
temporarily confuse the diagnosis. 
Prognosis.-True diphtheria is extremely fatal in chil- 
dren under two years ; children under one year almost 
never recover. Death is usually the result of one of the 
following causes : (1) Laryngeal stenosis ; (2) septic in- 
fection ; (3) broncho-pneumonia ; (4) diphtheritic paraly- 
sis ; (5) uraemia. Factors which increase the gravity of 
the prognosis, in any case, are marked prostration, great 
extent, thickness, and rapid spread of the membrane, 
long persistence of the membrane, its presence in the 
larynx, much albumin in the urine, the supervention of 
broncho-pneumonia, complications with other diseases, 
and persistent vomiting, especially if nourishment is 
taken poorly. On the other hand, a thin, slowly spread- 
ing membrane is favorable, as is one confined to a 
small area. Membrane which spreads to the naso- 
pharynx is unfavorable, but if it is confined to the nose, 
recovery is to be expected. From paralysis recovery is 
usual, after a period varying from one week to six 
months. 
PSEUDO-DIBIITIIERIA, THE RESULT OF INFECTION BY 
Streptococci.-As in the true diphtheria, the symp- 
toms are local, due to the membrane, and constitutional, 
due to the penetration into the tissues of the cocci and 
to the entrance into the circulation of their poisonous 
products. 
Local Symptoms.-The membrane cannot be positively 
distinguished in site or appearance from that of true 
diphtheria, and the symptoms due to its presence are the 
same. 
Constitutional Symptoms.-There is frequently consid- 
erable temperature-103' to 104° F.-without any corre- 
sponding prostration. Glandular swelling is usually 
quite marked. Frequently, too, a broncho-pneumonia 
develops, sometimes late, but usually in the first week ; 
if this does not happen, however, convalescence is ex- 
tremely rapid. 
Prognosis.-The prognosis is much better than in the 
true form, the mortality being about three per cent, in un- 
complicated cases of the pseudo-diphtheria, as compared 
with a mortality of about thirty per cent, in the real 
diphtheria. Factors which are unfavorable are : (1) 
Complication with other infectious disease ; (2) bron- 
cho-pneumonia ; and (3) laryngeal stenosis. In the last 
case, if intubation or tracheotomy be performed, the 
prognosis for recovery is good. 
Treatment.-Prophylactic treatment should be advised 
for children, especially those in institutions. Such con- 
sists in reduction of hypertrophied tonsils, care of the 
teeth, and the use of antiseptic gargles. All, old or 
young, exposed to cases showing membrane in the throat, 
should use frequently some antiseptic gargle. 
Isolation of the patient should be absolute in the true 
form, but need not be so rigid in the pseudo-diphtheria. 
In the latter, however, contact with children should be 
carefully avoided. It is as yet uncertain whether bacilli 
are, or are not, found in the throat after the membrane 
has disappeared. It is wise, therefore, to continue such 
isolation for a week after the membrane has gone, and 
to continue antiseptic gargles during that time. 
Local Treatment.-Any injury to the mucous mem- 
brane allows the membrane to spread ; therefore all 
rough applications and swabbing are to be avoided. 
Sprays are not notably efficient; but of the beneficial 
effect of steam in laryngeal cases, before and after opera- 
tion, there is no doubt. The steam from kettle, steam- 
pipe, or other source, should be delivered close to the 
face of the patient. 
Fumigation by calomel is certainly successful in coat- 
ing the larynx, trachea, and larger bronchi with the 
powder, and with this substance there is, in addition 
to the local effect, a constitutional action. The method 
is to construct a close tent of sheets over the bed, and 
then to volatilize within the tent, on a metal plate, over 
an alcohol or oil flame, twenty grains of calomel. The 
tent should be kept closed except for frequent inspection 
of the patient, till the odor of the calomel has nearly dis- 
appeared, i.e., usually about half an hour. This fumi- 
gation should be repeated at hourly intervals till the 
constitutional effect is reached, and this means hourly 
fumigations for at least twenty-four, and sometimes for 
forty-eight hours. 
Irrigation with an antiseptic solution is probably the 
most efficient local treatment. The solution can be di- 
rected by an ounce-syringe fitted with a short, soft rubber 
cap over the point, so as not to hurt the tissues touched, 
and the solution should be forced up one nostril and made 
to return by the mouth or other nostril. To do this it 
may be necessary to push the piston home with consider- 
able force, but the nozzle should not plug the nostril so 
tightly that, if the obstruction is considerable, fluid may 
not pass back out around the nozzle. Perhaps the best 
solution for this purpose is corrosive sublimate in strength 
from Tiuro to roiw Some will be swallowed accident- 
ally, but not enough to be injurious. The mouth is to 
be irrigated in every case, the nose when there is any 
discharge. The irrigation should be made every half- 
hour or hour. It is very regularly the rule that after the 
irrigations are begun the membrane stops spreading. 
Constitutional Treatment.-The three drugs most to be 
relied on are alcohol, mercury, and iron. 
Alcohol is best given in the form of brandy or whiskey, 
and the dose should be at one-hour or at most two-hour 
intervals. Its use should be begun early, and in grave 
cases pushed to the utmost short of narcotism. Nearly 
every case at all ill, will take three ounces in twenty-four 
hours, and a child, six years old, may need ten or twelve 
ounces in the same time. 
Mercury is given internally in the form of the bichlo- 
ride, one-sixtieth of a grain every hour for children 
under five years, and one-fortieth of a grain for those 
over five. 
Iron, as the tincture of the chloride, in glycerine, to 
prolong the local effect, should be given frequently in 
small doses, two to five minims every half-hour, for a 
child six years old. 
Food, in easily digestible form, should be given in as 
large quantities and as frequently as the patient will take 
and digest it. 
Treatment of Laryngeal Stenosis.-In the beginning, 
steam inhalations and emesis are advisable. If operation 
becomes necessary, it is to be remembered that mortality 
is less in early operations. If the consent of the parents 
is obtained for either intubation or tracheotomy, the 
choice depends mainly on : 1, The experience of the phy- 
sician ; 2, the age of the patient. A physician without 
236 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Diphtheria. 
Diuretics. 
considerable practice will usually do better with tracheo- 
tomy, and it is wise to be prepared always, at an intuba- 
tion, to do an immediate tracheotomy if the first opera- 
tion fails. Intubation is to be preferred if the patient is 
less than two years old. John II. Huddleston. 
DIURETICS. Two diuretics of striking power have 
lately come into use. One of them, calomel, was for- 
merly much used in combination with squill and digi- 
talis ; the other, sodio-theobromine salicylate, or diu- 
retin, was introduced in 1890. 
Calomel.-The diuretic power of calomel was dis- 
covered by Jendrassik 1 and announced by him in 1886. 
It had, however, been observed long before that calomel, 
in cases of dropsy, sometimes caused very profuse diu- 
resis ; but this was forgotten, and the writers on thera- 
peutics in the last two decades either entirely ignored the 
use of calomel as a diuretic, or recommended it only as 
an adjuvant to squill and digitalis. 
Jendrassik accidentally, in a case of dropsy, with 
syphilis, found that calomel acted as a powerful diuretic. 
He then tried it in other cases of dropsy. In cardiac 
dropsy its use was almost uniformly followed by profuse 
diuresis, but in renal dropsy, in ascites, and in pleuritic 
effusion, no very decided effect resulted, and in most 
cases none at all. Jendrassik's success led others to try 
calomel. On the whole, their reports show that in car- 
diac dropsy calomel produces marked diuresis, but acts 
feebly or fails to act in other forms, but especially in 
renal dropsy. 
All observers found that the polyuria does not begin 
on the first day of administration, but usually on the sec- 
ond, the third, the fourth, or the fifth day. The quan- 
tity of urine then augments very rapidly, is most profuse 
on the second day, and subsequently slowly diminishes. 
As a rule, the polyuria continues until the symptoms of 
dropsy have completely disappeared. In cases of exten- 
sive dropsy the maximum quantity of urine voided in 
one day was twenty pints. 
As the quantity of calomel necessary to produce such 
profuse diuresis is quite large, the ordinary effects of 
large doses supervene, unless prevented by prophylactic 
measures. Diarrhoea nearly always results. If not more 
than two or three stools occur daily, diuresis may still 
take place ; but if the stools are very numerous no in- 
crease of the quantity of urine will result, doubtless be- 
cause the calomel is expelled from the intestines before 
absorption can take place. To prevent such rapid dis- 
charge of the medicine, opium in small doses should be 
combined with it. 
' Some of the general symptoms of acute mercurialism 
usually become manifest-a disagreeable metallic taste, 
some soreness of the gums, increased secretion of saliva, 
•and offensiveness of the breath. Some patients, how- 
ever, have taken calomel in moderate doses for ten or 
twelve days without any of these effects. In most cases, 
if the calomel be long continued, the effects on the 
mouth become very severe, and some cases have been re- 
ported in which extensive ulceration and even gangrene 
resulted. Hence no more calomel should be employed 
than is necessary to cause decided diuresis. To prevent 
the effects upon the mouth, prophylactics should be used 
from the beginning of the treatment. Generally chlorate 
of potassium is preferred, the mouth being rinsed every 
two or three hours with a three or four per cent, solution 
of the salt. Jendrassik supposes that an acid reaction in 
the mouth, especially in the vicinity of decaying teeth, 
greatly favors stomatitis, and he has used with success a 
three or four per cent, solution of carbonate of sodium. 
Tincture of myrrh, tincture of krameria, and permanga- 
nate of potassium have also been used as preventives. 
If, notwithstanding the employment of these means, 
stomatitis should take place, the use of calomel must be 
discontinued. But it is not likely to occur, or only very 
mildly, if the calomel be given in the cautious manner 
lately recommended by Jendrassik.2 
Calomel as a diuretic is indicated in cardiac dropsy 
when other appropriate means, such as digitalis, stro- 
phanthus, caffeine, diuretin, etc., fail to give relief. 
The presence of albumin in the urine does not interfere 
with the action of calomel, and generally the urine, if it 
contain albumin, will become normal after the subsidence 
of the dropsy. It should be recollected that the mere re- 
moval of the dropsy does not restore compensation in 
cases of cardiac insufficiency, and that, after the diuretic 
has proved successful, it will be necessary to administer 
remedies to improve the heart's action. Should these 
not succeed and the dropsy return, calomel should again 
be used, and, if necessary, it may be employed as often 
as the dropsy becomes extensive. Its employment at in- 
tervals of some weeks becomes necessary in some cases of 
heart disease in which the rupture of compensation can- 
not be rectified. If the calomel be carefully used no 
harm will result, and the patient may be made comfort- 
able and life be prolonged for some years. Jendrassik 
states that he treated a patient whose life had been pro- 
longed for five years ; each year it was necessary to give 
calomel from fifteen to twenty times to remove the drop- 
sical symptoms. In the intervening periods the patient 
was able to lead a tolerably active life. Another patient 
that >had marked insufficiency of the heart had been 
treated seven times since 1886. On each occasion he 
came to the hospital wTith grave symptoms-enormous 
anasarca and ascites, with severe dyspnoea and sleepless- 
ness. His urine always contained albumin. Once the 
ascites was so extreme that, to save life, it was necessary 
to tap the abdomen. In this case the calomel always 
acted well and enabled the patient to return to active life. 
Jordan has recorded a case in which twenty-three suc- 
cessful trials with calomel were made, and during the 
treatment the patient took, without perceptible injury, 
107.5 grammes (nearly 3| ounces) of calomel. 
The dose of calomel in most of the reported clinical 
experiments was three grains, given from three to five 
times daily for several days, usually together with one- 
sixth grain of opium to prevent catharsis. Lately Jen- 
drassik. has stated, after further experience, that one and 
a half grain is the best single dose, and that this should 
be given eight or ten times within a day. After the 
administration for one day the polyuria, he says, is just 
as profuse on the third or fourth, day as if the medicine 
had been given on the intermediate days, and that it is 
certainly erroneous to persist in the administration of 
calomel after the urine has begun to increase in quan- 
tity. 
Jendrassik holds that the diuretic effect is caused by 
increased resorption of the dropsical fluid by the blood. 
In the cases in which calomel acted very decidedly no 
changes in the circulation took place that would account 
for the polyuria ; hence it does not act like digitalis and 
some other medicines that increase blood-pressure. In 
experiments Jendrassik found that a very dilute solution 
of chloride of sodium diffused into a solution of albumi- 
nate of oxide of mercury, placed in a suitable dialyser, 
in much greater quantity in a given time than into a 
simple solution of albumin of the same strength. As 
calomel after absorption doubtless circulates in the blood 
as an albuminate, Jendrassik supposes that it causes the 
dropsical fluid to pass by endosmosis into the inspissated 
blood in greatly increased quantity, thus rendering the 
blood more watery. The excess of water in the blood, as 
soon as it reaches the kidneys, is rapidly excreted. 
Experiments made by Benczur and Csatary3 support 
this view. They determined the quantity of haemoglo- 
bin in the blood of patients for several days before and 
during the administration of diuretics. From the quan- 
tity of haemoglobin found they calculated the degree of 
concentration of the blood. In a case of dropsy they 
gave forty drops of tincture of strophanthus for three 
days. The quantity of urine voided in the three days 
was, respectively, 900, 1,900, and 3,200 c.c. On these 
days 100 c.c. of blood contained 7.851, 8.659, and 8.730 
grammes of haemoglobin. This shows, say Benczur 
and Csatary, that the diuresis produced by strophanthus 
is associated with a simultaneous inspissation - of the 
blood. In a case of severe cardiac dropsy they gave 0.2 
of calomel six times daily for two days. The quantity 
of urine in these two days, and in the following four 
237 Diuretics. 
Dyspepsia, Nervous. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
days, was as follows : 950, 1,000, 3,900, 4,500, 2,400, and 
1,000 c.c. The quantity of haemoglobin contained in 
100 c.c. of blood in the same days was as follows : 7.19, 
5.32, 7.93. 7.85, 9.31, and 8.32. These figures seem to 
show that when calomel produces free diuresis the blood 
at first becomes hydraemic, and that inspissation takes 
place only during the progress of the polyuria. Hence 
Benczur and Csatary contend that calomel increases re- 
sorption, thus rendering the blood very watery, and that 
the kidneys simply remove the excess of water in the 
blood. 
Stintzing and some others hold that calomel acts di- 
rectly upon the kidneys, because they observed an increase 
of the urine of some patients not affected with dropsy. 
Some clinicians concluded that it acts upon the epithelium 
of the kidneys because it manifests no diuretic action in 
the dropsy of chronic parenchymatous nephritis. 
Recently Cohnstein 4 experimented upon healthy rab- 
bits to determine the mode of action of calomel, without, 
however, succeeding in solving the question. He used 
a solution of calomel in hypophosphite of sodium. When 
this was injected into the subcutaneous tissue or into the 
jugular vein a decided increase of diuresis resulted, 
showing conclusively that calomel acts as a diuretic in 
healthy rabbits. When before the injection he had 
placed the animals under the influence of chloral in order 
to depress the vaso-motor centre, no increase of the urine 
took place ; so, also, no augmentation of the urine re- 
sulted from one of the kidneys when, before the injec- 
tion, its nerves had been severed. But in both series of 
experiments, after calomel had failed, the administration 
of caffeine decidedly increased the quantity of urine. 
From these experiments Cohnstein concluded that some 
change in the circulation is a necessary condition of the 
diuresis, and that calomel does not act by stimulating 
the epithelium of the kidneys. In some of his experi- 
ments Cohnstein determined the blood-pressure after 
small doses of calomel, and found that simultaneously 
with the increase of diuresis an augmentation of arterial 
pressure took place, but this was slight and evanescent, 
and could not have caused the heightened secretion of 
urine. 
Diuretin.-The term diuretin is applied to a prepa- 
ration of theobromine, as a convenient substitute for the 
unwieldy chemical name sodio-theobromine salicylate. 
As this chemical name indicates, diuretin is a double 
compound of sodium theobromine, Ci^Na^Os, and so- 
dium salicylate, C6H4(OH)COONa. 
Diuretin is a white, odorless powder, having a bitter 
taste. It dissolves in less than its weight of water when 
warmed, and remains in solution on cooling. It is a very 
unstable compound, and when exposed to the air gradu- 
ally decomposes, the theobromine separating from the 
sodium. On account of this instability aqueous solu- 
tions undergo change in a few days, and, when adminis- 
tered soon after meals, become decomposed by the acid 
of the gastric juice. 
W. von Schroeder5 discovered, in experiments upon 
rabbits, that theobromine greatly increases the secretion of 
urine by acting directly upon the epithelium of the kid- 
neys, and that it has no action on the vaso-motor centre, 
in this respect differing from caffeine. As the human 
kidneys are affected in the same manner as the kidneys 
of the rabbit by caffeine, he supposed that theobromine 
would in man also produce a very decided diuretic effect, 
and, on account of its slight action on the nerve-cen- 
tres, in many cases be preferable to caffeine. 
Chr. Gram,6 at the suggestion of von Schroeder, tried 
free theobromine in cases of dropsy. It acted effectively 
as a diuretic, but frequently caused vomiting, and was 
inconstant in its diuretic action, owing to its slow and 
uncertain absorption. After unsuccessful trials of vari- 
ous preparations of theobromine, he finally found one 
that is easily absorbed, namely, diuretin. 
Gram administered diuretin in cases of dropsy in which 
other diuretics, digitalis and strophanthus, had failed. 
He states that he purposely selected cases in which as a 
rule we are utterly helpless. Diuretin always increased 
the quantity of urine, except in those cases in which the 
renal epithelium was so degenerated that no action could 
be expected. In some cases a relative cure resulted, or 
at least decided improvement, a result that may be called 
a good one when it is considered that in severe organic 
heart disease and in chronic nephritis only a relative cure 
can be attained. Gram says that the therapeutic results 
of his experiments were not very remarkable, but yet, 
as the patients were in such a desolate state that other 
diuretics (cardiac tonics) could not act efficiently, these 
results appear to have been very favorable. The usual 
dose of diuretin was 1.0 (fifteen grains), which was given 
five or six times daily. No changes in the circulation took 
place, and hence the increase in diuresis resulted from 
a direct action upon the kidneys. The remedy never 
produced disagreeable incidental effects, and only once, 
in a very cachectic patient, did it cause slight giddiness. 
A. Hoffmann 7 tried diuretin in numerous cases. In four 
cases of cardiac dropsy he employed it on fourteen dif- 
ferent occasions, and always obtained good results. Usu- 
ally diuretin was not given until digitalis had failed to 
act. The polyuria began on the first day of administra- 
tion, augmented gradually, and reached the maximum in 
from two to six days. It rapidly diminished when the 
diuretin was withdrawn, or when the dropsy had sub- 
sided. Sometimes the diuretic action was delayed for 
several days, perhaps on account of slow absorption. 
The quantity of urine voided depended upon the extent 
of the dropsy ; when this was very decided the quantity 
at the maximum amounted to five or six litres a day. 
Hoffmann agrees with von Schroeder that diuretin acts 
directly upon the kidneys, but he supposes that it also 
influences the heart. He observed that the pulse often 
became regular, stronger, and slower ; that dyspnoea was 
relieved before the disappearance of the dropsy ; and 
that quiet sleep ensued without the use of hypnotics. 
No incidental effects took place, except some vomiting in 
a few cases; but this soon ceased. In several cases a 
light, painless diarrhoea occurred, but stopped although 
the medicine was continued. Excitement, such as some- 
times occurs from caffeine, was never observed. Hoff- 
mann concluded that diuretin is a powerful diuretic in 
general dropsy, but has little effect upon inflammatory 
exudations, such as that of pleuritis, and still less upon 
ascites from portal obstruction. 
Dr. Koritschoner8 employed diuretin in thirty-eight 
cases of severe dropsy of cardiac, renal, and hepatic ori- 
gin. In twenty-three cases the effect was better than 
from other diuretics, and in eight of them very remark- 
able, the quantity of urine having increased to ten or 
twelve litres. In ten cases the effect was moderate, but 
was not excelled or equalled by any other diuretic. Only 
in one case was complete failure observed. On the aver- 
age the action of diuretin was best in cardiac dropsy, 
next in portal obstruction, and least in nephritis. But 
this pertains only to the absolute action ; relatively to 
other diuretics the action in chronic Bright's disease was 
very satisfactory. Koritschoner supposes that diuretin 
acts directly upon the kidneys, as he observed no influ- 
ence on the heart. He knows of no contraindications to 
its use. Even when employed for a long time it proved 
innocuous. He began with 4.0 (one drachm) daily, and 
increased by one gramme daily until the quantity of 
urine, compared with the ingested fluid and the subsi- 
dence of the dropsy, gave a satisfactory result. In sixty 
per cent, of the cases 5.0 daily sufficed; in thirty per 
cent., 6.0 daily ; and in ten per cent., larger doses up to 
10.0. The medicine was given in solution, made with 
hot water, in tablespoonful doses, at intervals of one or 
two hours, beginning three hours after the principal meal. 
R. Demme 9 tried diuretin with good results in dropsy 
occurring in children. The dropsy of scarlatinous ne- 
phritis seemed, after the first stage of the nephritis had 
passed, to be removed more rapidly by diuretin than by 
all other diuretics. Anasarca and effusions in the serous 
cavities resulting from mitralinsufficiency subsided, after 
the valvular disease had been compensated by digitalis, 
very speedily when diuretin was given. The dose for 
children from two to five years old was 0.5 to 1.5, and 
from six to ten years old, 1.5 to 3.0 daily. Diuretin 
238 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Diuretics. 
Dyspepsia, Nervous. 
should not be given to infants under one year, as in them 
it easily causes irritation of the stomach and intestines. 
Von Schroeder states10 that some preparations of 
diuretin found in commerce contain only from thirty to 
thirty-eight per cent, of theobromine, as found in the 
analyses made by Vulpius. Knoll's preparation was 
found to contain forty-eight per cent., and hence should 
be preferred by the practitioner. Von Schroeder recom- 
mends the following formula : 
I). Diuretini (Knoll) 5.0-7.0 
Aq. destill.... 90.0 
Aq. menth. pip 100.0 
Syr. simpl 10.0 
M. S.: One tablespoonful every twro or three hours. 
Samuel Nickles. 
1 E. Jendrassik : Deutsch. Archiv f. klin. Medicin, Bd. xxxviii., p. 
499. 
2E. Jendrassik : Arch. f. kl. Med., xlvii., p. 226. 
3Benczur and Csatary : Arch. f. kl. Med., xlvi., p. 478. 
4 W. Cohnstein : Arch. f. exp. Path. u. Pharm., xxx., p. 126. 
6 Von Schroeder : Arch. f. exp. Path. u. Pharm., xxiv., p. 102. 
* Chr. Gram : Ther. Monatssh., 1890, p. 10. 
7 A. Hoffmann: Arch. f. exp. Path. u. Pharm., xxviii., p. 1. 
8 Dr. Koritschoner : Ther. Monatssh., 1892, p. 559. 
' R. Demme : Ther. Monatssh., 1892, p. 96. 
10 W. von Schroeder: Ther. Monatssh., 1890, p. 374. 
DIURETIN. This name was given by Dr. Christian 
Gram, of Copenhagen, to the salicylate of theobromine 
and sodium which he introduced as a substitute for caf- 
feine. Professor Schroeder, of Strasbourg, had experi- 
mented with the alkaloid theobromine, and had reported 
upon its important diuretic properties at the meeting of 
the German Medical Congress in 1889. He had found that 
caffeine in small doses often failed to produce diuresis, 
and where the vascular tension of the kidneys was in- 
creased, the flow of urine sometimes diminished on ac- 
count of the increased blood-pressure produced by the 
caffeine. Large doses overcame this effect, but they were 
liable to cause nervousness and insomnia, and other dis- 
tressing symptoms. Theobromine he found to be an 
equally efficient diuretic without producing any nervous 
symptoms or affecting the blood-pressure ; chemically, it 
differed from caffeine by containing one equivalent less 
of methyl, it being the dimethyl-xanthine and caffeine 
the trimethyl-xanthine. The difficulty in using the alka- 
loid was its insolubility, it requiring 1,600 parts of water 
for its solution. At his suggestion Dr. Gram instituted 
a series of experiments, and succeeded in producing a 
soluble salt by combining it with salicylate of sodium. 
It is said to be prepared by dissolving one molecule (180) 
of theobromine in one molecule (40) of soda hydrate, 
and adding to the solution one molecule (160) of salicy- 
late of sodium ; when evaporated to dryness it should 
yield 362 parts of the double salt, which theoretically 
contains 49.7 per cent, of theobromine and 38.1 per cent, 
of salicylic acid. It is a white powder with a slightly 
bitter and disagreeable taste, very soluble ; by the aid of 
heat it dissolves in less than half its weight of water, and 
no precipitation occurs upon cooling. Its solution is 
very unstable and rapidly decomposes. It burns with- 
out leaving any residue. 
To estimate the amount of the alkaloid an aqueous 
solution is acidified, then made alkaline with ammonia, 
and the precipitated theobromine collected on a filter, 
washed, and dried. The amount of salicylic acid may be 
determined by treating the filtrate and ■washings with 
ether, separating the ethereal solution and evaporating. 
Theobromine exerts its diuretic properties by its direct 
action on the secreting tissue of the kidneys. It acts 
promptly and energetically, and its effect is maintained 
for a day or two after the cessation of the drug. Its ac- 
tion is not cumulative. The solids as well as the fluid 
are increased ; there is no marked change in the blood- 
pressure, but the heart becomes slower, stronger, and less 
irregular. An improvement in the general condition of 
the patient is also experienced. It does not produce any 
excitement nor influence the nervous system unfavora- 
bly, nor does it derange the digestive organs. Reports of 
its prolonged use, however, show that it may be accom- 
panied by diarrhoea and other signs of intestinal irrita- 
tion. In all forms of dropsy due to renal disease its ac- 
tion is most efficient; there is no irritant effect on the 
secreting cells, and no unfavorable results follow its use. 
It is of service in all dropsies accompanying heart-disease, 
but is said to be of greatest service where there is organic 
disease and failing compensation. Where digitalis and 
other cardiac tonics have been used without success, it 
will generally be found to succeed, by its action on the kid- 
neys following that of the other forms of diuretics. A 
combination of digitalis and diuretin will form a very 
active diuretic mixture in dropsies where the blood-press- 
ure requires to be raised. It has not been found of so 
much value where the dropsy arises from inflamed serous 
membranes, or where the liver is congested. The follow- 
ing are the conclusions of Dr. Dujardin-Beaumetz : 
(1) When given in doses of fifteen grains it is a much 
stronger diuretic than caffeine ; (2) when there is con- 
siderable cardiac .degeneration it should be used with 
some caution, especially when there is albuminuria; 
(3) under its influence the cardiac contractions are 
scarcely affected ; (4) diuretin rapidly increases the 
quantity of urine passed, and the diuretic effect lasts 
twice or three times as long as that produced by caffeine ; 
(5) the activity does not wear off as the patient becomes 
accustomed to the drug ; (6) micturition is not rendered 
difficult or painful ; (7) diuretin has no action on the 
central nervous system. 
The dose is from sixty to ninety grains daily. It has been 
found most active in fifteen-grain doses every two or three 
hours, in water with some aromatic essence to disguise 
its bitter taste. Care should be observed in selecting the 
remedy, on account of its instability. When exposed to 
the atmosphere it absorbs carbonic acid and separates the 
alkaloid, which is insoluble. The addition of acids or 
acid vegetable juice also decomposes the solution by throw- 
ing down the alkaloid. It has been found a safe remedy 
for children above one year of age, and has proved of 
marked benefit in scarlatinal nephritis. At the age of 
from twro to five years the dose may be from eight to 
twenty-five grains in the day, and at the age of from six 
to twelve, from twenty-five to forty-five grains. The to- 
tal amount for the day may be dissolved in four ounces 
of water with ten or twelve drops of brandy and a little 
sugar. It has been given for wreeks without producing 
any ill effects or lessening its therapeutic action. 
Beaumont Small. 
DROITWICH. A watering-place chiefly noted for its 
brine baths, in Worcestershire, England. 
Location.-Droitwich is pleasantly situated, about 3| 
hours by rail from London. The town itself is dull. Its 
saline waters are among the most powerful known, and 
are now extensively used in the form of brine baths. 
Analysis.-It is claimed that the Droitwich brine is 
stronger than any other European water of similar kind. 
It is fully ten times as rich in salts as the ocean, and has 
four times the density of the waters of the Dead Sea. 
Indications.-Like the famous baths of Kreuznach, 
the Droitwich brine has been found useful in rheumatic 
gout, rheumatoid arthritis, muscular rheumatism, in- 
flammatory exudations and periarticular thickenings, 
sciatica, neuralgia, nervous debility, pelvic cellulitis, 
uterine derangements, bronchitis, and various conditions 
of cachexia. 
Accommodation.-A large sw'imming-bath has been 
recently added to the other conveniences of the town. 
The Royal Brine Baths Hotel, in connection with the 
above, lias been placed under an experienced man- 
ager, and the comforts of home are now insured to in- 
valids and others. It affords warm and comfortable 
winter quarters. The St. Andrew's Baths is the oldest 
establishment. Edmund C. Wendt. 
DYSPEPSIA, NERVOUS. We will give the personal 
history of aggravated cases of the special form under 
consideration, which being of extreme gravity-the 
symptoms of some of them almost unparalleled-and the 
239 Dyspepsia, Nervous. 
Dyspepsia, Nervous. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
treatment being successful, the chief features of the 
disease will be clearly indicated. One of these resulted 
in violent temporary insanity, another in threatened 
softening of the brain, a third in absolute loss of mental 
control, and others in melancholia, nervous depression, 
diplopia, etc. ; in all of these cases the trouble being de- 
pendent solely upon malassimilation of food. 
Case 1 is that of a young man whose time had been 
devoted chiefly to literary pursuits. In a personal sketch, 
which we give briefly in his own words, he states : 
" My sufferings increased daily ; I often felt that I 
was dying, while the terrors of death at such moments 
were intensified a hundred-fold. In the meantime a per- 
ceptible change was going on in my heart and mind, 
and friends united in censuring me for my eccentric con- 
duct. They did not and could not understand that the 
morbid effects of the disease were slowly but surely gain- 
ing complete control over my thoughts and feelings, nor 
that when the functions of the nervous system are per- 
verted the victim becomes, to a certain extent, an irre- 
sponsible agent and suffers complete transformation of 
character. I can truthfully say, from dreadful experi- 
ence, that there are stages of this disease when the vic- 
tim, like the drowning man grasping at a straw, will 
swallow anything in the shape of- anodynes or stimulants 
for relief. Finding that alcoholic beverages mitigated my 
sufferings, I used them liberally at times ; but knowing 
that such excesses must end in insanity or death, and not 
being able to use spirituous liquors at any time in modera- 
tion, I determined to discontinue them altogether. But 
without a stimulant I could not walk fifty yards without 
being seized with a nervous attack and dizziness. I could 
attend to no regular business, and had diminished in 
weight from 135 to 117 pounds." 
He reported that he suffered severely from vertigo after 
any exertion, and had constant torpor of the bowels, with 
inability to sleep at night without recourse to stimulants 
or anodynes. 
As the first step an immediate abstinence from tobacco, 
which he used to excess, was required ; alcohol was al- 
lowed in moderation, and a hepatic stimulant and alter- 
ative, consisting of stillingia, belladonna, nux vomica, 
and physostigma, was prescribed. The improvement was 
marked and continuous; he now no longer suffers from 
vertigo, and sleeps without any anodyne. 
Notwithstanding that some physicians inveigh against 
the use of lactopeptine, and deny to it the possession of 
any value whatever, we would say here that for such 
symptoms, namely, defective or complete loss of appe- 
tite, indigestion, and deficient activity of the digestive 
organs-whether in adults or children,-we find no 
remedy to compare with the following combination, to 
which we have recourse incessantly : 
B. Lactopeptine (Am. Pharmacal Co.)... 3 ij. 
Subnitrate of bismuth 3 ij. 
Comp, tinct. of gentian | j. 
Simple syrup § j. 
Ess. peppermint 3 ij- 
Water to § iv. 
M. Dessertspoonful in a wineglass of water before 
meals. 
A half grain of strychnia added to the above, when 
indicated, increases its efficacy.. 
Case 2. Nervous Dyspepsia, Due to Poor Assimilation 
in Old Age.-Mrs. B., a lady, aged eighty, had during her 
whole life been noted for ceaseless industry, physical 
activity, and mental soundness. She was a highly culti- 
vated woman, of unusual good sense and excellent judg- 
ment ; her digestion was always good, with no constipa- 
tion, no malarial poisoning, nor any other disturbance of 
the system. She had during the war and of late years 
been subject to much harassment of mind-with, at 
times, more or less poor nutrition. 
The first indication of the approaching attack was a 
tendency to garrulity, with a certain wilfulness of man- 
ner. She next exhibited extreme excitement ; and, 
strange to relate, it was invariably most violent upon 
awakening in the morning just after sleeping soundly for 
hours, or at any time after sleeping ; at such times she 
frequently screamed aloud. Her talk was incessant, co- 
herent and incoherent, generally of a pleasant character ; 
in her disordered fancies she would enjoy and describe 
visions of flowers, of bright parterres, decorated tapes- 
tries ; she would repeat poetry and long reminiscences 
of her earlier life, all delivered in pleasant, but in 
highly figurative language. But at times she was be- 
yond control, and may be said to have lost her mind, so 
entirely irresponsible were her actions. 
Knowing the calming and soothing effect which sleep 
usually exerts upon violent inebriates with delirium and 
persons with various neurasthenise, we were forced to 
the conclusion that she could not stand the depressing 
effects of sleep, which left her a prey to the uncontrollable 
excitement and loss of mental balance ; all of these symp- 
toms depending upon a lack of assimilative power, to- 
gether with the absence of full and suitable nourishment. 
All hypnotics were therefore discontinued ; she certainly 
did not require sedatives, for the compound " bromidia," 
and others freely used, had failed to give any relief. 
A complete change in treatment was ordered, as fol- 
lows: Fellows's syrup of the hypophosphites, C. P., ter 
indie; spiritus frumenti in substantial amounts,frequent- 
ly repeated ; beef extract, and other concentrated nour- 
ishment, with hot coffee upon first awakening. She 
yielded surprisingly well to these measures, which were 
kept up without any interruption until complete and en- 
tire control of herself was obtained. 
The attacks have returned several times, at long inter- 
vals, and each time have yielded to the liberal use of 
stimulants, food, and the syrup of hypophosphites with 
strychnia ; and the correctness of the diagnosis was abso- 
lutely proved by the almost immediate relief afforded 
by the treatment. She lived long afterward-dying at 
eighty-six,-having been, during these last years, in per- 
fect health of mind and body. 
Case 3.-A gentleman in middle age, after having 
passed through a great affliction, and being extremely 
imprudent in eating-indulging freely in nuts, raisins, 
and other indigestible substances in the intervals of his 
regular meals,-began to suffer from complete loss of ap- 
petite, and a train of nervous symptoms. He had attacks 
of dizziness to such a degree that he w'ould have to lie 
prone upon the floor, or the ground, as the case might be ; 
he could stand none of the ordinary draughts upon the rea- 
son or the intelligence, being unable to perform the daily 
duties of his calling ; he could not write a letter, and 
feared to walk around the square upon which he lived. 
This culminated in such a low condition of the nervous 
system that he was twice prostrated, thought that he was 
about to die, and once asked a friend " if he did not know 
better than to look at him-that he could not stand it ; " 
surpassing in this the weakest and most nervous female. 
Complete recovery of appetite, health, and strength 
took place after a month's absence in a Northern city for 
rest and change of scene, with the prudent use of stimu- 
lants taken with the most nourishing food, but without 
any medicines whatever. 
Case 4.-A gentleman, aged twenty-five, was so 
much afflicted with dyspepsia and ill-health, after pro- 
longed confinement to books at school and college, that 
he repeatedly believed that he was dying, saw visions by 
night and day, was so timorous and fearful that he 
would not sit in the open seat of a vehicle without the 
grasp of some one's hand, neither would he leave a room 
for fear that he would die before his return. 
These and other exhibitions of groundless apprehension 
and timidity were presented by a man who had previ- 
ously, and has since, given striking instances of his man- 
liness and courage. Dyspeptic symptoms so marked 
and violent, some of them approaching closely to those 
of hysteria, were also complicated with spermatorrhoea 
caused by ascarides. 
He became much reduced in flesh and strength, but re- 
covered perfectly after two operations by Lallemand's 
porte-caustique, efficiently applied, and some tonic reme- 
dies. 
240 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Dyspepsia, Nervous. 
Dyspepsia, Nervous. 
Case 5.-A patient, aged thirty-eight, after about a year 
of suffering from insomnia, constant constipation, and 
extreme nervousness, was thought by his friends to have 
softening of the brain and to be doomed to the lunatic 
asylum. It was at once apparent that his mind must be 
set at rest and some hope instilled into him. This was 
done by assuring him in the most confident manner that 
there was no serious organic disease present, that his 
nervous symptoms, being functional and neurotic, could 
be controlled, and that he would surely recover under 
judicious management. 
An occasional mercurial laxative was given, his diges- 
tive organs were strengthened, and the tonic hepatic 
stimulant referred to in Case 1 was administered. As a 
result, his insomnia, general depression, and all fears of 
hereditary disease disappeared, and he is now in com- 
plete possession of health and strength. 
Case 6.-The patient, a gentleman over fifty years of 
age, was strictly temperate in his habits ; he had never 
any constitutional, malarial, or other disease, except at 
an early period, when he suffered from bronchitis, from 
which he recovered perfectly. He had once also expe- 
rienced a severe attack of dyspepsia. Double vision, 
lasting each time from three to six weeks, occurred 
repeatedly-there being four separate attacks at intervals 
of months and years,-apparently from digestive de- 
rangements due to overtasking the organs by too free in- 
gestion of some special article of food. There was no 
diarrhoea,- colic, or other disturbance ; no cerebral com- 
plication whatever, or any of the nervous symptoms 
characterizing the other cases reported here ; the whole 
ill effect being a reflex influence upon the muscles of the 
eyes. Without employing the scientific minuteness of 
the specialist, we only say that there were no degenera- 
tive changes of the cerebro-spinal system, no dissemi- 
nated spinal sclerosis, nor any diplopia such as is some- 
times seen in locomotor ataxia. Furthermore, there was 
no inherent paralysis of the ocular muscles, but simply 
a reflex functional paresis by which the power of ad- 
justment was lost. But when this occurs, be the cause 
what it may, then every object is duplicated. The man 
who walks upon the streets sees four lines of pavements 
stretching away in the distance instead of two, and the 
temporary loss of this habitual power of adjustment, 
which has been unconsciously possessed and exercised by 
him all his life, suffices to throw every visual object into 
confusion. 
Each attack came on gradually, increasing in inten- 
sity, until each eye acted independently, every object be-, 
yond near reading distance, at which vision was normal, 
being seen separately, and one eye had often to be closed 
to relieve the inconvenience caused by the diplopia. In 
some of the attacks there was moderate strabismus ; in 
one it was marked. 
On the first appearance of the trouble, years ago, the 
reflex effects upon the eyes seemed to result from weak- 
ness of the entire system following an attack of bron- 
chitis. The later attacks occurred in the midst of robust 
health, being directly connected with the stomach. As 
in two of these he had suffered from severe lumbago and 
rheumatism of the muscles of an arm lasting for weeks, 
it was thought that the condition might be dependent- 
as has been claimed by some authors-upon a gouty or. 
rheumatic diathesis. It is susceptible of proof that all 
the attacks were not complicated by a rheumatic ele- 
ment. 
The following prescription completely relieved every 
attack, when given in repeated doses and persevered 
with : 
R. Potassii iodid 3 ij. 
Tinct. cinchonas comp § j. 
Aquae ad § iv. 
M. S. : Dessertspoonful in wineglass of water, t. i. d., 
between meals. 
Fellows's syrup of the hypophosphites, one drachm, in 
water, before meals, was used simultaneously. 
In two of the attacks when the rheumatism was promi- 
nent, the wine of colchicum and the tincture of guaiac 
were added to the above combination. Recovery was 
always gradual, and double vision for distant objects 
was always the last symptom to be relieved,-a picture 
on the wall being seen single, when a distant steeple or 
star was perceived as two objects far apart. By pressing 
on the left eye or slightly closing it the double vision 
could be prevented. Good appetite and general health, 
save in the attacks complicated by rheumatism, were 
maintained throughout, and, for the present, recovery is 
again complete. 
In our own experience, which embraces the care of 
hospitals for a very long period, cases of this affection 
are of extreme rarity. We have personal knowledge of 
but three. Reference may be made to a paper by Dr. 
George T. Stevens, of New York, on " Sudden Attacks of 
Diplopia," in the Annals of Ophthalmology and Otology, 
Kansas City, 1892. 
Such examples, which are met, doubtless, by every 
physician, show what a powerful disturbing influence dys- 
pepsia can exert upon the mind and body-producing 
bodily weakness and depression of the general powers ; 
lessening the energy, and even the inclination and the ca- 
pacity to will and to act; specially giving rise to unmanly 
fears, indecision, causeless scruples, and apprehensions 
of impending death ; and in many cases dizziness is a 
marked symptom. 
We believe that in the impaired condition caused by 
malassimilation, defective quantity and quality, and ir- 
regularity in the taking of food, and consequent anaemia, 
by which the blood becomes impaired and the nourish- 
ment and the integrity of the nerves and the brain fail 
to be maintained, will be found the true pathology of 
cases such as these, which give rise to so much loss 
of time, painful anxiety, and suffering to the patient 
and to his friends. The recoveries under judicious man- 
agement, change of air and scene, good nourishment, 
moderate use of stimulants-if they can be tolerated- 
strychnia, tonics, etc., support the correctness of this 
view. 
It will be noticed that the above cases, marked by ner- 
vous disturbance, mental excitement or depression, do 
not include dyspepsias of reflex, or cardiac, or ovarian 
origin, referred to by Fothergill and others ; nor is there 
any special implication of the liver or renal organs, no 
gastric catarrh, pyrosis, biliousness, vomiting of bile, or 
morbid deposits in excess in the urine, such as urates, 
phosphates, etc.-which morbid conditions are found so 
commonly in other types of dyspepsia. 
We are induced to add a brief notice of another and 
very common form of dyspepsia, which is in striking 
contrast with that described above, in cause, nature, 
symptoms, and treatment. This is the gastro-intestinal 
type, characterized by acidity, water-brash, fermenta- 
tion, distention, pain, etc., and which requires a distinct 
management with drugs quite different from those used 
in cases where there is simply malassimilation of food 
followed by marked nervous symptoms. 
We are indebted to a leading article in the Boston 
Medical and Surgical Journal, for March 17, 1892, for 
suggestions as regards the management of such cases as 
follows: 
"As this form of dyspepsia (intestinal dyspepsia) is 
generally predominantly a dyspepsia of starches, there is 
a leading indication to abstain from amylaceous and sac- 
charine articles of diet. There should be a maximum of 
albuminoids-meat, eggs, fish-and a minimum of car- 
bohydrates and fats. Brilliant results have been attained 
by a diet of raw meat-six to ten ounces of lean beef or 
mutton reduced to a pulp and cooked but slightly, if at 
all ; to be eaten, well-seasoned, with a little bread, but 
without vegetables. Three slices of underdone roast 
meat, fresh broiled fish, raw oysters and other shell-fish, 
soft boiled eggs, boiled ham, together with sour-crout, 
smoked herring, a little stale cheese, etc., have been 
recommended, the latter articles being particularly un- 
likely to undergo putrefactive decomposition. 
" Chronic indigestion of this type is the result," it is 
241 Dyspepsia, Nervous. 
Ear Diseases. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
added, " of long-continued dietetic errors, and in its treat- 
ment the dietetic plan marked out above should be ad- 
hered to as closely as possible. By way of medication 
intestinal antisepsis is indicated. For this purpose com- 
binations of chalk, bismuth, magnesia, salol, salicylate 
of soda and napthol are valuable. The patient may take 
after each meal a powder consisting of five grains each of 
prepared chalk, magnesia, and salol, or five grains each 
of salicylate of bismuth and naphthol; nux vomica and 
Colombo are also valuable. Diastases often are of service. 
Either malt or pancreatic diastases may be used. They 
are to be given during the meal. [They probably act by 
digesting the starch in the stomach and favoring absorp- 
tion of the resulting sugar before it reaches the intestine.] 
Laxatives often prove useful in emptying the bowels of 
its fermenting contents.'' 
Certain forms of dyspepsia require acids distinctly in 
their treatment, but this is beyond the province of this 
paper. F. Peyre Porcher. 
EAR DISEASES, NOMENCLATURE AND STATIS- 
TICS OF. The nomenclature herewith presented is 
based upon the one prepared and used by the aural sur- 
geons of the Massachusetts Charitable Eye and Ear 
Infirmary in Boston. Many changes and a goodly num- 
ber of additions have been made-some in the interest of 
a scientific nomenclature, others for statistical utility. 
On the whole it has suffered by these changes, but they 
were made necessary by the loose method of recording 
diseases in the various hospital reports, from which the 
statistical material for this article was gotten. As all 
additions are in brackets, the original can be seen practi- 
cally undisturbed. 
The statistical portion is based upon a study of 104,- 
412 cases of ear disease, taken from the thirty-two an- 
nual reports of the nineeye and ear hospitals, as indicated 
in the list given at the end of the article. The different 
nomenclatures followed in these reports, and their inex- 
act records of diseases, have added much to the labor of 
preparing, and have materially interfered with the scien- 
tific accuracy of, this article. 
The tables are self-explanatory. Each disease is cred- 
ited in the first column of figures with the number of 
cases of such affection found in the grand total of 104,- 
412 tabulated cases, while the second column shows the 
proportionate frequency of the affection in every thou- 
sand cases of ear disease in general. Where the frequency 
is less than one in a thousand the fraction expressing this 
small frequency will be omitted altogether. 
Total num- 
ber of 
cases. 
Number of 
times occur- 
ring in 1,000 
cases of ear 
disease 
general. 
i n 
Brought forward 
I. Morbi Auris Externa (Cont.) 
Auricula-cutis:-(Cont.) 
Eczema squamosum : 
369 
acutum vel chronicum. 
Herpes zoster 
[Impetigo contagiosa] 
Intertrigo 
Lupus exulcerans 
" hypertrophia 
" vulgaris 
Fibroma lobulte* 
Fissura lobulae 
[Pruritus] 
Syphilis gummosa 
" papulosa 
" pustulosa 
" squamosa 
Auricula-perichondrii et card- 
laginis: 
Inflainmationes: 
Htematoma iodiopathicum ... 
" traumaticum .... 
Perichondritis 
Deformitates: 
[Ectopia] 
Imperfecta?: 
Microtia 
Profusae : 
Polyotia 
1,575 
25 
2 
7 
0 
1 
0 
0 
9 
8 
0 
0 
1 
2 
48 
12 
48 
30 
3 
3 
8 
15 
Neoplasmata : 
Angioma 
Atheroma 
Calcificatio 
Cornu 
[Cystis] 
Enchondroma 
Epithelioma 
Fibroma 
Lipoma 
[Lympho-adenoma] ......... 
Myxo-fibroma 
Ossificatio 
Sarcoma 
[Trauma] 
[Ulcus] 
107 
4 
0 
0 
1 
66 
2 
80 
21 
3 
1 
1 
0 
0 
71 
12 
1 
Total 
Meatus-cutis: 
Anomalite secretionum : 
2,520 
Equal to a lit- 
tle over 
per cent, of 
all ear cases. 
Accumulatio ceruminis 
Diminutio ceruminis 
Inflammationes: 
16,897 
0 
159 
[Abscessus] 
Eczema papulosum 
" pustulosum 
" rubrum 
" squamosum 
" vesiculosum: acutum 
183 
5 
1 
2 
27 
2 
vel chronicum .... 
741 
7 
[Furunculus] 
Granulatio 
Herpes zoster 
1,537 
5 
1 
15 
Carried forward 
19,399 
I. Morbi Auris Extern.e : 
Auricula,-cutis: 
Congestiones, activae : 
Congelatio 
Total num- 
ber of 
cases. 
Number of 
times occur- 
ring in 1,000 
cases of ear 
disease i n 
general.* 
12 
6 
0 
0 
0 
0 
152 
53 
8 
20 
70 
11 
23 
4 
2 
8 
1.5 
Erythema 
Passivae : 
Angioneurosis 
Cyanosis ex corde 
" vaso - paralytica.. 
" ex e nip by se in a 
pulmonum .... 
Inflammationes: 
[Abscessus auricula?] 
Abscessus lobulae 
Dermatitis congelationis 
" erysipelatosa 
" phlegmonosa 
" traumatica .... 
Eczema papulosum 
" pustulosum 
" rubrum 
" vesiculosum 
Carried forward 
369 
* The cases of " ear disease in general " here referred to, are those 
represented by the grand total of 104,412. 
♦ See Neoplasmata, farther on. 
242 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Dyspepsia, Nervous. 
Ear Diseases. 
Total num- 
b e r of 
cases. 
Number of 
times occur- 
ring in 1,000 
cases of ear 
disease i n 
general. 
Brought forward 
19,399 
I. Morbi Auris Externa :-{Cont.) 
Meatus-cutis :-(Cont.) 
Syphilis; condyloma 
0 
" gummosa 
0 
" ulceratio 
2 
[Otitis externa circumscripta]. 
727 
7 
Otitis externa desquamativa.. 
56 
" " diphtheritica.. 
4 
" " diffusa: 
acuta 
1,058 
10 
chronica.... 
266 
2 
acuta v e 1 
chronica.. 
880 
8 
" " erysipelatosa .. 
1 
" " [granulosa].... 
1 
" " follicularis .... 
200 
2 
" " [furunculosa].. 
78 
" " haemorrhagica.. 
13 
" " parasitica 
71 
" " syphilitica 
9 
" " traumatica.... 
22 
Contractio membranosa: 
25 
' ' ossea 
3 
Corpus adventitium : 
675 
6 
animalis 
25 
inanimalis 
52 
Pruritus 
57 
Trauma: 
directa 
47 
indirecta 
1 
Verruca 
3 
Neoplasmata : 
cystis 
10 
enchondroma 
2 
epithelioma 
3 
[polypus] 
388 
4 
sarcoma 
0 
Deformitates: 
atresia acquisita 
16 
" congenita 
18 
fistula auris congenita 
11 
Meatus-ossis: 
Caries 
2 
Exostosis circumscripta 
41 
Hyperostosis circumscripta .... 
7 
Hyperostosis universalis 
0 
Periostitis 
10 
Total 
24,183 
Equal to near- 
ly 23 per 
cent, of all 
ear cases. 
Total num- 
b e r of 
cases. 
Number of 
times occur- 
ring in 1,(00 
cases ot 
disease 
general. 
ear 
in 
Brought forward 
329 
II. Morbi Auris Mediae :-(Coni.) 
Membrana tympani:-(Cont.) 
Trauma indirecta: 
ex fracture calvaria?. 
4 
ex ictu aerio 
9 
ex vi opposita 
3 
Tympani, Tuba Eustachii, ei Pot- 
tionis Mastoidea: 
Otitis catarrhalis secernens : 
mucosa acuta 1 
serosa acuta J 
6,616 
62 
serosa subacuta 
2,246 
21 
[mucosa chronica] / ex inflam- 
serosa chronica [ matione. 
28,221 
266 
ex tuba.. 
558 
5 
Otitis catarrhalis adhaesiva : 
ex secernente 
1,230 
11 
insidiosa : 
cum morbo labyrinthi 
161 
1 
sine morbo labyrinthe 
25 
Otitis media acuta simplei 
803 
8 
" [cum ostitide 
mastoideae]. 
24 
" [haemorrha- 
gica] 
39 
Otitis media suppurativa: 
acuta : 
7,487 
71 
cum perforatione 
2,150 
20 
sine perforatione 
40 
[cum ostitide mastoideae] .. 
37 
[subacuta] ; 
1,163 
11 
chronica : 
15,928 
150 
cum carie mastoidea 
98 
1 
cum carie meatus 
13 
cum carie ossiculae 
4 
cum carie tympani 
3 
cum exostose meatus... . 
7 
cum granulatione meatus .. 
162 
2 
cum granulatione membra- 
nae tympani 
65 
cum granulatione tvmpani. 
120 
1 
cum hyperostose meatus... 
0 
cum hyperostose universale. 
0 
cum ostitide mastoidea .. . 
251 
2 
cum periostitide mastoidea. 
28 
cum perforatione membra- 
nae flaccidae 
103 
1 
cum perforatione membra- 
nae tympani 
6,323 
60 
cum polypo tympani 
" " fibromatosa ... 
807 
8 
0 
" " mucoso 
0 
" " myxomatoso... 
2 
" " m e m b r a n ae 
tympani.... 
1 
Effectus otitidis mediae acutae 
simplicis : 
68 
cum perforatione 
75 
1 
cum perforatione conglutina- 
ta 
188 
2 
[Otitis media syphilitica] 
11 
[Otitis media traumatica] 
8 
[Otitis media tuberculosa] .... 
6 
Surditas senilis 
7 
Neuroses Auris Media : 
Sensoriae : 
Otalgia dentalis 
70 
" ex anaemia 
1 
Carried forward 
75,464 
II. Morbi Auris Medle : 
Membrane tynpani; 
Abscessus 
Total num- 
b e r of 
cases. 
Number of 
times occur- 
ring in 1,000 
cases of ear 
disease i n 
general. 
5 
17 
2 
14 
1 
62 
3 
5 
220 
2 
Atrophia ... 
Cystis 
Myringitis acuta 
" chronica 
acuta vel chronica.. 
haemorrhagica 
traumatica 
Trauma directa 
Carried forward 
329 
243 Ear Diseases. 
Ear Operations. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.. 
Brought forward 
II. Morbi Auris Mediae (Cont.) 
Neuroses Auris Medice:-(Cont.) 
Otalgia ex carie calvariae 
' ' ex carie vertebrae.... 
" ex ictu aerio 
" ex tumore cerebri.... 
" perineuritide 
" ex pressu nervi 
" hysterica 
" laryngealis 
" nasalis 
" [neuralgica] 
" pharyngealis 
Motorise : 
Contractiones musculorum au- 
riculae 
Total nnm- 
b e r of 
cases. 
Number of 
times occur- 
ring in 1,000 
cases of ear 
disease i n 
general. 
75,464 
0 
0 
0 
0 
0 
0 
3 
0 
0 
1,412 
0 
0 
0 
2 
0 
14 
Contractiones musculorum au- 
riculae tubae 
Contractiones musculorum au- 
riculae tympani 
Vaso-motoriae: 
Congestio vaso-affecta 
Total 
75,881 
Equal to near- 
ly 73 per 
cent, of all 
ear cases. 
V. [Morbi Mastoide^J : 
[Abscessus] 
Total num- 
b e r of 
cases. 
Number of 
times occur- 
ring in 1,000 
cases of ear 
disease i n 
general. 
141 
4 
4 
1 
1 
77 
5 
133 
66 
1 
1 
[Caries].. f 
[Fistula] 
Fractura] 
Herpes] 
Necrosis] 
Neoplasmata] 
[Osteitis] 
[Periostitis] 
Total 
432 
Equal to 
about '/u °t 
1 per cent, of 
all ear cases. 
V. Unclassified : 
Cholesteatoma 
[Keratosis obturans] 
[Luxatio mallei] 
[Presbyacousis] 
[Surditas artificis lebetum 
[Surditas totalis congenita' 
[Surditas totalis acquisita 
meningitide] 
[Tinnitus aurium] 
[Vertigo ab aure Isesa].... 
Total num- 
b e r of 
cases. 
Number of 
times occur- 
ring in 1,000 
cases of ear 
disesse i n 
general. 
ex 
5 
56 
1 
52 
19 
15 
36 
152 
2 
1 
Total 
338 
Equal to near- 
ly % of 1 per 
cent, of all 
ear cases. 
II. Morbi Labyrinthi et Acus- 
tici : 
Anaemia labyrinthi 
Total num- 
b e r of 
cases. 
Number of 
times occur- 
ring in 1,000 
cases of ear 
disease i n 
general. 
5 
Cochlitis 
5 
Concussio: 
9 
ex fractura calvariae 
8 
ex ictu aerio 
3 
ex vi opposita 
4 
Haemorrhagia 
3 
Hyperaemia labyrinthi....... 
1 
Labyrinthitis : 
107 
1 
acuta 
primaria 
1 
secundaria 
3 
chronica: 
8 
primaria 
1 
secundaria 
9 
Morbus acustici 
786 
7 
Neoplasmata in labyrintho... 
0 
Neuroses acustici : 
Hyperaesthesia 
5 
Paralysis 
30 
angioneurotica 
3 
hysterica 
4 
rheumatica 
2 
Panotitis : 
diphtheritica 
1 
idiopathica 
0 
scarlatinosa 
3 
Proprite notae Meniere 
41 
Trauma labyrinthi: 
9 
directa 
0 
indirecta 
1 
Total 
1,058 
Equal to a lit- 
tie over 1 
per cent. 
of a 11 ear 
cases. 
Reports Consulted. 
Massachusetts Chronic Eye and Ear Infirmary, Boston, 1885, 1886 
1888, 18S9, 189-1, 1891. 3 ' ' ' 
New York Eye and Ear Infirmary, New York city. 1882 1884 1885 
1887, 1888, 1889, 1890, 1891. ' ' ' 
Presbyterian Eye, Ear. and Throat Charitable Hospital, Baltimore 
Md., 1877 to 1891, inclusive. 
Brooklyn Eye and Ear Hospital, Brooklyn, N. Y., 1869 to 1892 In- 
clusive. 
Manhattan Eye and Ear Hospital, New York City, 1885 1886 1887 
1888, 18S9, 1890, 1891. J ' 
New York Ophthalmic and Aural Institute, New York City, 1885, 1886, 
1891. 
Newark Charitable Eye and Ear Infirmary, Newark, N. J. 1887 1888 
1889, 1890, ' ' ' 
Buffalo Eye and Ear Infirmary.. Buffalo. N. Y., 1887. 
Maine Eye and Ear Infirmary, Portland, Me., 1892. 
James Lancelot Minor. 
EAR: OPERATIONS UPON THE MIDDLE EAR. 
Ever since Sir Astley Cooper, in 1801, improved the hear- 
ing of a patient by perforating the membrana tympani, 
surgical procedures upon the middle ear have afforded a 
fruitful field for study, speculation, and argument. In 
no other branch of surgery, probably, have certain pro- 
cedures been so strenuously advocated for a short time, 
and, upon further investigation, been found to be dis- 
appointing in their results, and consequently abandoned 
for other measures equally useless. A glance at the his- 
tory of middle-ear surgery will, I think, partially explain 
this, by disclosing the fact that every new procedure was 
employed without proper discrimination, in a large class 
of cases where more care in defining exactly the indica- 
tions for the operation would have prevented its perform- 
ance. It is not strange, therefore, that every advance in 
this branch of our art is looked upon with suspicion, and 
that its efficacy must be proven beyond a peradventure 
244 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Kar Diseases. 
Ear Operations. 
(SUPPLEMENT.) 
before it is adopted. Clearly before any operative meas- 
ure can stand this test the indications for its application 
must be distinctly defined, and the determination of these 
indications very often proves to be more difficult than the 
operation itself. 
It is evident that operations upon the tympanum can 
be of benefit only when the pathological process is limited 
entirely, or almost entirely, to this part of the auditory 
apparatus, and has not involved the adjoining parts 
secondarily. To be more clear, we can hope to relieve 
an impairment of hearing or a distressing tinnitus by 
operation upon the tympanic structures, only when we 
are assured, by a careful examination, that the receptive 
apparatus is in a fairly normal condition, thus locating 
the disease in the conducting apparatus. Again, if we 
are questioned as to the probable result of such a pro- 
cedure in a case of long-standing otorrhoea, it must be 
determined by careful examination that the bony necrosis 
is confined to those parts of the middle ear which can be 
reached by instruments introduced through the meatus; 
otherwise a complete removal of the affected parts would 
be impossible, and the result of an operation unsatisfac- 
tory. 
The above suggestion seems almost unnecessary, but 
one has only to study the reports of cases operated upon 
to be convinced that often the exact location of the patho- 
logical process was undetermined before the operation. 
Operative measures within the middle ear are under- 
taken : 
1. For the improvement of hearing. 
2. For the relief of subjective noises, or certain nervous 
phenomena, such as giddiness, etc. 
3. For the relief of a persistent discharge. 
Any one of these conditions may exist alone, or all or 
any two may occur together and demand relief. 
As before stated, the success of operative treatment de- 
pends primarily upon our ability to locate the pathological 
process in the tympanum. I shall therefore preface what 
is to be said concerning the surgery of the tympanum by 
a few suggestions as to how we are best able to determine 
that, in any particular case, the middle ear is the part of 
the auditory apparatus at fault. If the purpose of our 
operation is to relieve a persistent discharge, careful ocular 
inspection and manipulation with the probe will enable 
us, in many instances, to determine the extent of the mor- 
bid process ; more will be said upon this point when we 
come to consider the operative methods for the relief of 
discharge. Most frequently, however, aid is sought for 
an impairment of the hearing, or a persistent tinnitus, 
and physical examination alone, in many instances, may 
mislead us as to the result of operative measures. It is 
not enough to find, in such a case, that the tympanum is 
the seat of a chronic inflammation, or that as the result 
of a preceding inflammatory affection the tympanic 
structures have been bound down to such an extent that 
they cannot transmit the sound-waves, but we must be 
certain that the receptive apparatus is in a fairly normal 
condition before a favorable prognosis can be given as to 
the result of relieving the tension of the conducting ap- 
paratus by surgical means. 
For this determination a series of tuning-forks has 
been found of great service. In my own work six forks 
are used, as follows : one, the lowest (C-') making 32 
vibrations per second ; the next (C) making 128 vibra- 
tions per second ; the other four (C1, C2, C8, C') being C 
forks of the next four octaves, the highest registering 
2,048 vibrations per second. The last five forks consti- 
tute the series used by Hartmann,1 and are really all that 
are necessary for determining the probable outcome of 
operative procedures, although the other fork (C-l) is 
so'metimes of use. 
It is well known that any rigidity of the conducting 
mechanism so alters the relation of air-conduction to 
bone-conduction that in affections of the middle ear the 
duration of bone-conduction, as compared with that of 
air-conduction is increased, and frequently may be greater. 
Further observation teaches us that the change begins 
with the lowest notes of the scale, and that as the parts 
become more rigid the higher notes are affected. Thus 
in a slight rigidity of the middle-ear mechanism, conse- 
quent upon a temporary narrowing of the Eustachian 
tube, or congestion of the lining of the tympanum, the 
lowest fork of the series will be heard longer from the 
mastoid than when held in front of the meatus, while all 
the other forks may be heard better through the air than 
through the bone. If now, instead of a slight rigidity, 
we have the conducting apparatus bound down by adhe- 
sions, either as the result of a chronic purulent inflamma- 
tion (with more or less complete destruction of the mem- 
brana tympani) or as the result of a non-suppurative 
inflammation of long standing, the membrana tympani 
being present and partaking perhaps in the pathological 
process, to the extent of being thickened in places, and 
even adherent here and there to the inner wall of the 
tympanum, we shall find as the power of audition be- 
comes more and more impaired, that the bone-conduc- 
tion for the successive higher forks of the scale will 
gradually become equal to, and at last better than, air- 
conduction. In other wrords, the degree of impairment 
of hearing, and the increased duration of bone-conduction 
for the higher forks, as compared with air-conduction, 
always bear a direct relation to each other, if the lesion is 
located in the conducting apparatus. If the hearing dis- 
tance for speech was so reduced that loud voice Was only 
heard close to the ear, and the duration of bone-conduc- 
tion exceeded that of air-conduction for the first two or 
three octaves only, we should not be justified in locating 
the lesion in the conducting mechanism alone, but should 
conclude that the receptive apparatus was affected as well. 
Especially would such a conclusion be warranted if, in 
addition to the above, bone-conduction for the fork C2 
was appreciably reduced below the normal standard of 
bone-conduction, or if the fork C3 was not heard at all by 
bone-conduction, or if the fork C4 was perceived by 
neither bone- nor air-conduction. In such a case the 
chances would be that the receptive apparatus had be- 
come involved secondarily, and that although an opera- 
tion might successfully relieve the tension in the trans- 
mitting mechanism, this relief might not greatly improve 
the hearing on account of the condition of the deeper 
parts, which would be unaffected by operation. 
In applying these tests certain facts must be remem- 
bered. Thus, the age of the patient plays an important 
part in the determination of this question. Bone-conduc- 
tion in individuals past middle life is relatively reduced 
as compared with this power in youth and early adult 
life. This has been demonstrated by Urbantschitsch2 
as due to senile torpidity of the auditory nerve, and can 
be confirmed by any one who makes use of the tuning- 
fork in a large number of cases. It is also to be remem- 
bered that secondary involvement of the receptive appa- 
ratus is less likely to have occurred when the cause of 
the impaired hearing or tinnitus has been a suppurative 
otitis, than when the tympanic affection has been of the 
sclerotic form. The duration of the malady is also to be 
taken into consideration ; but as operative measures would 
only be adopted after all other plans had failed to give 
relief, this need scarcely be mentioned. 
The above tests may be applied equally well to cases 
in which the membrana tympani has been partially or 
almost completely destroyed, or when it is intact. More- 
over they are not based upon theory, but are deduced 
from the comparison of the results, after operations, by 
the author, in a number of cases in which the tests have 
been made. Almost without exception success or failure 
could be predicted by a careful study of the results of the 
tuning-fork examination, and the cases where these tests 
indicated a probable unfavorable result were subjected 
to operation only at their own request, that they might be 
allowed to have every possible chance for improvement, 
however slight this might be. 
Preparations Preliminary to Middle-ear Op- 
erations.-While the remarks included under this head- 
ing may be, to a certain extent, superfluous, I have re- 
solved to enter into detail, for the reason that I believe the 
suggestions may be of value to some whose experience in 
this branch of otology has been limited. 
Instruments.-Most of the instrument-makers are pre- 
245 Ear Operations. 
Ear Operations. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT. 
pared to furnish instruments designed for this special 
work ; many of the instruments are designed for the 
purpose of performing one particular operation, and 
usually have been modelled according to the idea of some 
one individual operator, and represent his personal pref- 
erences. It should be remembered, however, in this 
branch, as in general surgery, that individual preference 
for any one instrument does not of necessity indicate 
that it alone is adapted to the special procedure, but 
simply that in the hands of one familiar with its use it 
gular handles is again a matter of personal preference. 
For my own use I prefer to have most of the instru- 
ments so modelled that the shaft forms an angle of 30 to 
45 degrees with the handle ; but as it is sometimes more 
convenient to use a straight instrument, it is well, in case 
the universal handle is to be used, to have one extremity 
adapted to receive the instrument at an angle, while by 
fitting the knife into the other end of the handle a 
straight instrument is obtained (see Fig. 156). For rapid 
operative work it is better to have each instrument in a 
separate handle, but as this increases the bulk of the case, 
as well as the cost of the instruments, the universal handle 
is often used. Of late I have made use of the ex- 
cellent suggestion of Prout,3 that the shank of the 
knife be left untempered, and in this manner its shape 
can be changed at will. Knives made in this way, 
and provided with simple octagonal metal handles, into 
which the shaft screws, can be obtained at a much less 
price than those of a more elaborate design, and as from 
their extreme delicacy instruments of this kind must be 
frequently replaced, this form certainly commends itself. 
At any operation all cutting instruments should be 
duplicated, and even a greater number of each variety 
is an advantage, as they soon become too dull for delicate 
work. It is important that in all knives the back of the 
blade should be of sufficient thickness to permit of its 
being honed to a very fine edge ; it being impossible to 
secure a keen cutting edge in a very thin knife. All 
knives should be as sharp as skill can make them, and 
when even slightly dull should be laid aside. It seems 
absurd to state this, but I have frequently had great dif- 
ficulty in impressing its importance upon instrument- 
makers, and consider it a point of the greatest impor- 
tance. The structures to be divided are extremely deli- 
cate, and unless the blade be very keen, may often be 
pushed aside by the knife, instead of divided, or undue 
force may be necessary in order to effect section, and im- 
portant structures may thus be damaged. Again, the 
field of operation being small, any failure to expose the 
parts as fully as possible, or the production of hemor- 
rhage by harsh manipulation, seriously hampers the 
operator. 
Immediately before the operation all instruments to 
be used should be sterilized by submersion in boiling 
water or exposure to steam for about ten minutes. 
Preparation of the Field of Operation.-In order to 
diminish the probabilities of suppuration, and reduce the 
reaction to a minimum, the field of operation should be 
rendered as aseptic as possible. In cases where there is 
no discharge from the ear, and the canal is clean, there 
is very little danger of infection from this source. It is 
safer, however, to order that the ear be syringed with a 
solution of bichloride of mercury, 1 to 5,000, twice daily 
for several days before the operation, and that after each 
syringing the canal be closed by a pledget of aseptic 
cotton. Of course, any cerumen or dead epithelium 
which may have collected in the canal must be thoroughly 
removed before the syringing is done. Upon the day of 
the operation the ear is not to be syringed, owing to the 
congestion which it causes ; Blake4 suggests that it may 
be wiped out by means of a pledget of cotton saturated 
with the antiseptic solution. 
In cases where there is discharge, the previous cleans- 
ing of the ear is of great importance, especially if 
there is to be any interference with the stapes, since in- 
fection of the labyrinth is among the possibilities. In 
all cases, therefore, where there is a purulent discharge, 
provided any operation is to be done beyond the simple 
division of adhesions, the ear should be syringed several 
times daily with an antiseptic solution in the manner 
already described. It is true that in many cases no harm 
comes from operating without carrying out these meas- 
ures, but it is only our duty to protect the patient in every 
possible way. 
When the middle ear has been the seat of a long-con- 
tinued suppurative process, we usually find considerable 
granulation tissue within the tympanum, or, if this is not 
the case, the remnants of the drum membrane, as a result 
of chronic myringitis, are much thickened, and richly 
Fig. 156.-Instruments for Intra-tympanic Operations, with Univer- 
sal Handle. 
has served a good purpose. Every operator will, from 
habit, develop a preference for a special device, and in 
his hands it undoubtedly is more serviceable than any 
other, but the aural surgeon upon entering the operative 
field should first obtain a clear idea of what is to be ac- 
complished, and then choose those instruments which 
seem to him best adapted to carry out the procedure. 
In a general way, then, the armamentarium should in- 
clude in addition to the ordinary instruments used in 
diagnosis and treatment, delicate knives, both sharp- and 
probe-pointed, and both curved and straight; knives 
curved on the flat, angular knives, the blade making an 
obtuse angle with the shaft, or a right angle, according 
Fig. 157.-McKay's Ear Forceps. (The blades should be 
about half an inch longer than in the forceps usually 
sold under this name.) 
to the topography of the parts upon which 
they are to be used, and it is well to have these 
also both sharp- and blunt-pointed. For the 
purpose of drawing parts which may be hidden 
from view into the field of operation, curved 
blunt hooks are useful. Curettes and spoons of various 
sizes and shapes-some dull, others sharp, and some 
placed at an angle with the shaft of the instrument- 
are exceedingly valuable for scraping away granulations 
and removing softened bone. For removing the parts 
detached during the operation, delicate forceps (Fig. 157) 
are necessary, and it is perhaps advisable that they should 
not be made too strong, as in this way the instrument 
may, by slipping, warn the surgeon that he is in danger 
of using too much violence. A good aural snare is also 
a convenient instrument to have at hand. As to whether 
the instruments should be mounted upon straight or an- 
246 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Ear Operations. 
Ear Operations. 
supplied with blood-vessels, bleeding freely upon the 
slightest violence. It is often advisable in such cases 
to employ a certain amount of local treatment before 
the operation, in order to reduce the turgescence and 
render the operation more simple. 
Anesthesia.-As to the question of anaesthesia only 
general rules can be given. In general it may be stated 
that as these operations require exceedingly nice manip- 
ulation for their performance, and it is necessary for the 
patient to remain absolutely quiet, general anaesthesia is 
in most cases preferable, and in many absolutely neces- 
sary. 
For the division of adhesions in old purulent cases, in 
which there is a large exposure of the tympanic cavity, 
the introduction of a few drops of a strong solution of 
cocaine will usually render the operation endurable in 
patients who have a fair command of themselves. In 
these cases it is often necessary to do repeated operations 
on successive days, each one occupying but a few sec- 
onds, and in such cases general anaesthesia would cause 
the patient more annoyance than the procedure itself. 
Usually where the membrana tympani is present and 
we wish to enter the tympanic cavity for purposes of 
thorough exploration and subsequent operation, a gen- 
eral anaesthetic must be administered. If possible, how- 
ever, it is advantageous to make the exploratory incision 
by means of local anaesthesia, as we can then determine 
the effect upon the hearing, and subsequently induce 
general anaesthesia for the purpose of conducting any 
further procedures which may be necessary. For the 
production of local anaesthesia I have used a ten per cent, 
ointment of cocaine and lanolin. A small quantity is 
smeared on a pledget of cotton, placed in contact with 
the membrana tympani and allowed to remain for about 
ten or fifteen minutes. A certain amount of anaesthesia is 
gained in this way. After the membrana tympani has 
been incised, a drop of a ten per cent, solution of cocaine 
in the tympanic cavity will produce a very decided anaes- 
thesia. 
Miot5 claims that he has been able to carry on very 
extensive manipulation of the intra-tympanic structures 
by instillation of cocaine after incising the membrana 
tympani. Although the actual pain of these procedures 
is not great, the tax upon the nerves of the patient is 
severe, and much will depend upon the self-control of 
the individual. I have found the anaesthesia following 
the use of the lanolin and cocaine ointment, and the in- 
stillation of an aqueous solution of cocaine after the first 
incision, amply sufficient to remove the cicatricial mem- 
brana tympani which often forms after excision of the 
membrana, malleus, and incus. As all the cases operated 
upon by this method have been delicate females, I am 
inclined to think that the procedure has not been at- 
tended with much pain, as they scarcely complained. 
Cholewa6 has obtained excellent results from the use 
of strong solutions of aluminium aceto-tartrate as a local 
anaesthetic in this region, but I have no personal experi- 
ence with the method. In general, I should restrict local 
anaesthesia to the division of adhesions in cases where the 
tympanum is freely exposed as the result of a previous 
purulent inflammation, or when the parts are covered 
by a thin cicatricial membrane only, or where they are 
endowed with slight sensibility ; to partial myringectomy 
by chemical agents ; and to exploratory myringotomy. 
In all other cases I decidedly prefer general anaesthesia, 
and in my own hands ether has been the agent employed 
exclusively. If the ordinary rules for preparing a pa- 
tient for ether, such as attention to the food taken upon 
the day of operation, the condition of the bowels, etc., 
are attended to, the unpleasant effect of the drug is in a 
large measure avoided, and is rarely very disagreeable. 
Position of the Patient. -As we habitually inspect the 
ear with the patient in the upright or semi-recumbent 
position, the operator is placed at a decided disadvan- 
tage if the horizontal position is employed at the time of 
operation. Another disadvantage of this position is that 
with the head low, or only slightly elevated, hemorrhage 
is much more profuse, and the field of operation more 
obscured, especially that portion of the field in which 
(SUPPLEMENT.) 
lie the structures of the greatest importance, the upper 
and posterior part, the blood collecting in this situation 
in obedience to the laws of gravity. A still further ob- 
jection lies in the fact that if the ossicles are to be 
removed, the horizontal position favors the dislocation 
of the incus toward the mastoid antrum. For the com- 
fort of the surgeon the head should be in such a posi- 
tion that it can be easily turned in all directions without 
the operator's manipulations being in the least interfered 
with. For all of these reasons I now always operate 
with the patient in the semi-recumbent position. This 
is easily secured by means of the head and-shoulder rest 
shown in Fig. 158. This device is clamped to any con- 
venient table, or to a bed, the head-rest is removed, the 
shoulder-frame let down, and the patient is anaesthetized 
in the horizontal position, care being taken that the 
shoulders are well up on the frame. When complete 
anaesthesia has supervened, the shoulder-rest is elevated 
to the required height and held in place by the ratchet, as 
seen in the figure. The head-rest is placed in position 
and supports the occiput. As the head-piece is supplied 
with a ball-and-socket joint, the head can be placed in 
any desired position, and maintained by turning a screw 
which renders the joint immovable. Straps passed under 
the arms prevent the body from sliding downward ; ele- 
vating the foot of the table or couch also serves the same 
purpose. By this simple device the head is as completely 
Fig. 158.-Head-and-shoulder Rest. 
under the control of the operator as when the patient is 
conscious, and the surgeon can manipulate from all sides, 
his movements not being interfered with by the patient's 
shoulders, the edge of the table or other obstacles. An- 
aesthesia is maintained in this posture with no more diffi- 
culty than with the patient in the ordinary position. 
Illumination.-Many prefer daylight for all work upon 
the middle ear, and there can be no doubt that a perfect 
north light affords an ideal source of illumination. The 
great objection to natural light is its uncertainty. For 
this reason 1 have never used it extensively, even in the 
examination of patients, and have become accustomed to 
make use of the ordinary argand gas-burner. The slight 
yellow tinge of the gas-flame modifies the appearance 
somewhat, but if used to the exclusion of other sources of 
illumination, of course does not mislead. When general 
anaesthesia is resorted to, the gas-flame becomes objec? 
tionable on account of the danger of igniting the ether, 
and if it is removed to such a distance that there is no 
danger, its rays, reflected from the surface of the head- 
mirror, are scarcely powerful enough for fine operative 
work. If great care is used the gas-burner may be 
brought near enough to furnish sufficient light; it 
should never be less than five feet away from the inhaler, 
and at a somewhat higher level. As an additional pre- 
caution, the face of the patient, and the inhaler also, 
should be covered with a wet towel. Since the use of 
storage batteries has become general, the incandescent 
electric lamp has been much used, and undoubtedly 
affords the most convenient source of illumination. The 
lamp is usually placed in a cylinder, one end of which is 
provided with a double convex lens for rendering the 
rays convergent, while behind the lamp is placed a metal 
247 Ear Operations. 
Ear Operations. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
reflector, which serves to direct all the rays through the 
lens. The apparatus may be worn upon the head by 
means of the ordinary head-band, or may be mounted 
upon a standard, and the head-mirror used in the usual 
way to illuminate the field of operation. If the first 
method is adopted the lens should have such a curva- 
ture as to bring the rays to a focus at a point about six 
or seven inches in front of the apparatus, while if the 
head-mirror is used the rays should simply be rendered 
parallel. As I habitually make use of the perforation in 
the head-mirror, I prefer to use the latter method ; this 
is simply a matter of personal preference, however. The 
use of the electric lamp does away with all fear of acci- 
dent from ignition of the ether, and permits the surgeon 
to give his entire attention to the operation. 
Classification of Operations.-The various opera- 
tions which have from time to time been suggested and 
performed upon the middle ear are quite numerous. 
While I do not propose to give a full history of all of 
these surgical procedures, it may be wise to men- 
tion them briefly, dwelling at length only upon those 
which seem to be of undoubted value. We may classify 
these measures as follows : 
1. Operations involving the membrana tympani alone, 
under which are to be considered : 
(a) Perforation of the membrana (myringotomy). 
(b) Excision or destruction of a portion of the mem- 
brana for the purpose of establishing a permanent open- 
ing (partial myringectomy). 
(c) Single or multiple incisions through the membrana 
for correction of anomalies in tension. (Under this 
head we include division of the posterior fold, or plicot- 
omy.) 
2. Operations involving the soft parts within the 
tympanum, under which we include : 
(«) Tenotomy of the tensor tympani muscle. 
(b) Tenotomy of the stapedius muscle. 
(c) Section of the anterior ligament of the malleus. 
(d) The division of adhesions, the result of suppurative 
or non-suppurative inflammation. 
3. Operations involving the ossicular chain, compris- 
ing : 
(a) Excision of a portion of the malleus. 
(b) Disarticulation of the incudo-stapedial articulation, 
or division of the long arm of the incus and mobilization 
of the stapes. 
(c) Plastic operations for the purpose of uniting either 
the incus or stapes with the membrana tympani. 
(d) Removal of the ossicular chain in its entirety, or 
the excision of individual ossicles. 
1. Operations Involving the Membrana Tympani Alone. 
(a) Myringotomy.-Puncture of the tympanic mem- 
brane became a recognized surgical procedure chiefly 
through the investigations of Sir Astley Cooper.1 Per- 
formed primarily for the improvement of hearing, it was 
found that it was of permanent benefit only in those 
cases in which the hearing had been impaired by collec- 
tions of fluid within the tympanum. Its efficacy in such 
cases has been already discussed in the portion of this 
work devoted to otitis media, and need not be commented 
upon here. Under other conditions, closure of the open- 
ing by cicatrization reduced the hearing to its former 
condition. 
To us incision of the membrana tympani is of use not 
only for the evacuation of fluids, but as affording us a 
means of exploring the tympanic cavity, and determining 
the mobility of the stapes in cases where adhesions have 
formed within the middle ear. 
Schwartze8 recommended the excision of a portion of 
the membrane for the purpose of determining the mobil- 
ity of the stapes, while De Rossi9 advises the formation 
of a flap from the membrana tympani, and after turning 
it aside to fully test the mobility of the ossicles. 
It should be remembered that an operation through 
the membrana enables us not only to test the mobility of 
the ossicular chain by means of a probe, but if the opera- 
tion is performed without the use of a general anaesthetic, 
and this is often possible, we are able to observe the 
effect of the artificial opening upon the hearing. In 
(SUPPLEMENT). 
cases of thickening of the membrana tympani itself, or 
when it has become much relaxed, and by its own weight 
acts as a load to the conducting mechanism, the hear- 
ing will improve after the perforation. It also gives us 
some information as to the condition of the membrane 
covering the round window, since the artificial opening 
allows the sound-waves to impinge directly upon this 
part. Exploratory incision, then, is, in certain cases, of 
aid in informing us how much of the impairment in 
hearing is due to the presence of the membrana tympani 
and also the extent of the rigidity of the stapes. It is of 
special diagnostic value in cases of tympanic sclerosis, 
resulting from non-purulent inflammation, in which the 
receptive apparatus is involved secondarily. In such a 
case the probable outcome of surgical interference can 
sometimes be determined by exploratory myringotomy, 
since if the stapes were found movable, and the hearing 
is not improved by the artificial opening, very little could 
be expected from further operative procedures. In a 
case of this kind, in which this opinion had been arrived 
at by means of the tuning-fork tests, an exploratory 
incision enabled me to confirm the diagnosis, and advise 
against further operative interference. 
Steps of the Operation.-In the cases in which such an 
incision is likely to be required, the membrana tympani, 
as the result of the preceding inflammation, has usually 
lost much of its normal sensibility ; but if the impact of 
a probe causes pain it is well to place a pledget of cotton 
saturated with a ten per cent, cocaine lanolin ointment 
against it for a few minutes before operating. With a 
sharp knife a curved incision is to be made from the 
lower border of the membrana flaccida downward, di- 
rectly over the incudo-stapedial articulation if this is in 
view, otherwise the incision is to be made close to the 
posterior margin of the tympanic ring. The incision is 
to be parallel to the periphery of the membrana tym- 
pani, and should extend downward nearly to the level 
of the tip of the long process of the malleus. Usu- 
ally the edges of the wound retract enough to permit 
the articulation to be seen, and the mobility of the parts 
to be tested by means of a probe; if not, a second in- 
cision may be made from the upper extremity of the 
first, and carried toward the short process of the malleus, 
until a sufficiently large flap is formed to permit of the 
exposure of the articulation. The upper incision should 
lie just below the border of the membrana flaccida ; 
should this membrane be incised, the resulting hemor- 
rhage might obscure the field of operation, while if the 
section is made as directed above, and care is taken not to 
wound the inner wall of the tympanum, no blood will 
be lost and the exposed parts will be clearly seen. The 
mobility of the stapes can now be tested by means of a 
fine probe passed through this opening. Any effect upon 
the hearing should also be noted. If further operative- 
steps are deemed unadvisable, the edges of the incision 
should be approximated with the cotton-tipped probe, and 
a pledget of sterilized cotton adjusted against the mem- 
brane. In case of a simple incision the insufflation of a 
little boric acid is usually all that is necessary. 
(b) Partial Myringectomy.-For the purpose of estab- 
lishing a permanent opening in the membrana tympani 
various methods have been resorted to, such as excision of 
a portion of the membrane as advised by Gruber,10 de- 
struction of the membrane over a limited area by means 
of the actual cautery, as advocated by Voltolini,11 or by 
a chemical caustic, as practised by Simrock.12 Schcr- 
munsky 13 advises that a crucial incision be made in the 
membrane at the desired location, and that the edges of 
the wound be then cauterized with chromic acid. Ac- 
cording to this author, a permanent opening will be left 
upon the separation of the eschar caused by the chromic 
acid. 
In my own hands this method has proved as useless as 
the others, and it has been the experience of all otolo- 
gists who have attempted this procedure, that in most in- 
stances the opening closes, though in some cases the inter- 
val is very long. To maintain a permanent opening, 
Politzer14 advised the insertion of a vulcanite eyelet into 
the perforation made either with the galvano-cautery or 
248 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Ear Operations. 
Ear Operations. 
with the knife. Experience has proved that even this 
method is ineffectual, and it has fallen into disuse. 
The only cases in which I can conceive of partial 
myringectomy as being advisable are those in which 
further operative measures are to be employed, in case 
an opening in the membrane improves the hearing. 
Here I believe that all the indications are better met by 
the exploratory myringotomy already described. In 
one case in which I attempted to establish a permanent 
opening in the membrane, the method of Simrock was 
employed, and as this seems to be rather simpler than the 
other procedures I will describe it in detail. 
A minute drop of concentrated sulphuric acid is 
carried into the canal on a cotton-tipped probe, and held 
against the membrane at the point where the perforation 
is to be made, care being taken not to touch the canal 
at any point. The acid at once destroys the membrane 
over the area touched, and perforation is readily effected 
by means of a blunt probe. In my own case very little 
reaction followed, and I am inclined to believe that the 
method accomplishes the purpose quite as well as the 
more complicated procedures. After the perforation has 
been made, the parts should be kept clean, either with 
the cotton pledget, or, in case a profuse discharge super- 
venes, the syringe may be used, although the less the 
parts are manipulated the longer the perforation remains, 
as a rule. 
(c) Multiple Incision of the Membrana Tympani.- 
This operation has been advocated both by Politzer15 and 
by Gruber,16 but, curiously enough, for exactly opposite 
conditions. Politzer recommends the procedure in cases 
when the membrana tympani is much relaxed, the result 
of the cicatrization of a large perforation, believing that 
the contraction following the healing of the incisions 
will correct the relaxation. In his hands the operation 
has met with a certain amount of success. On the other 
hand, Gruber finds that when the membrane has become 
tense or rigid from a chronic inflammatory process that 
several incisions made through it will, upon healing, re- 
lax the abnormal tension, and permit the parts to per- 
form their functions more properly. Gruber advises 
that the incisions be made from the centre toward the 
periphery, through the dense portions of the membrane, 
the adjacent lines of section being connected by trans- 
verse incisions, somewhat in the form of the letter H. 
I have had no experience with this procedure, and 
should be inclined to believe that when the operation 
was performed for relaxation the improvement would 
be at the most but temporary. The method of perform- 
ing the operation must of course vary in each individual 
case ; care should be taken that the inner wall of the 
tympanum is not wounded by the point of the knife, as 
any bleeding would obscure the subsequent steps. Cica- 
trices of the membrane are only slightly sensitive, and 
the incision of a membrane thickened by a chronic my- 
ringitis is also usually much less painful than when the 
membrane is normal; hence in an intelligent patient 
general anaesthesia is seldom necessary, although it 
would be advisable to employ it if the patient is ner- 
vous. 
. Plicotomy.-Division of the posterior fold of the 
membrana tympani was proposed by Politzer11 and 
by Lucae18 at about the same time. This measure was 
recommended when the membrana tympani was much 
retracted, the short process and posterior fold being very 
prominent. In such cases the contraction of the fibres of 
connective tissue forming the posterior fold increases the 
tension of the conducting apparatus, and interference 
with function is the result. 
The operation consists in the division of this fold by 
an incision midway between the short process and the 
peripheral extremity of the fold and perpendicular to the 
direction of the fold. Either the sharp-pointed knife 
may be used, or, as Politzer advises, the extremity of the 
instrument may be rounded, so as to diminish the dan- 
ger of dividing the deeper structures. The same author 
advises that the incision be made from above downward. 
Gruber19 has found better results from incising the fold 
longitudinally. In either case, if the operation has the 
desired effect, the manubrium will assume a less horizon- 
tal position, showing that the tension has been relieved. 
The immediate effect seems to have been to diminish the 
subjective noises, and in some cases to improve the hear- 
ing, but the improvement has almost always been tem- 
porary. My own experience has been limited to but 
one case, and here no improvement resulted. The op- 
eration is devoid of danger ; if the chorda tympani is 
wounded the effect upon the sense of taste will be but 
transitory, and with proper care suppuration should not 
follow the operation. It is well to allow the wound to 
heal slowly, and for this purpose daily inflations for a 
few days after the section has been made may be prac- 
tised. Locally, the insufflation of a minute quantity of 
boric acid is probably the best treatment for the w'ound. 
The operation is so uncertain in its results that it cannot 
be strongly advocated, since it will be the exception to 
find the increase in tension limited to the posterior fold. 
Usually the presence of similar constricting bands in 
other parts of the tympanum render the outcome of the 
procedure unsatisfactory. 
The next group in our classification comprises : 
2. Operations in which Various Muscular or Fibrous 
Structures within the Tympanum are Divided. 
(a) Tenotomy of the Tensor Tympani Muscle.-This op- 
eration was proposed by Hyrtl,20 but was first performed 
upon the living subject as a therapeutic measure by F. E. 
Weber.21 The indications for performing this operation 
have never been definitely given, as it is manifestly im- 
possible to be certain that in a given case the increased 
tension of the conducting apparatus depends entirely 
upon a shortening of the tensor tympani muscle. The 
most prominent indication for its performance seems 
to be a temporary improvement of the hearing or relief 
of tinnitus immediately after inflation, the symptoms 
soon reappearing, however, as the membrane becomes 
depressed. It is argued that in such cases the muscle 
has become permanently shortened, either by participa- 
tion in the tympanic inflammation or from the fact that, 
on account of Eustachian obstruction of long duration, 
the aeration of the tympanum has been imperfect and 
the membrane sinks inward upon the promontory. The 
function of the tensor is thus ablated, and the muscle soon 
becomes atrophied from disuse and is converted into a 
tense fibrous band which prevents the membrane from 
resuming a permanent normal position, even when the 
patency of the tube is restored. In addition to this, it is 
supposed that by the tension of the muscle the manu- 
brium is pressed upon the inner wall of the tympanum 
with considerable force, thus mechanically adding to the 
inflammatory process already present in the middle 
ear. It will be seen that if such is really the case a di- 
vision of the tendon of the muscle would remove one of 
the causes of the tympanic inflammation. Since the 
operation was first proposed valuable contributions to the 
subject have been made by Green,22 Pomeroy,23 Hart- 
mann,24 Schwartze,24 Cholewa,26and Muller.21 It is hardly 
necessary to say that in addition to the objective signs al- 
ready given, as indicating the advisability of the opera- 
tion, the result of the tuning-fork tests should also be 
considered and should indicate unquestionably a lesion 
of the conducting apparatus as the prominent pathological 
condition. Cholewa states that the forks C and C1 should 
be heard at least eight seconds by bone-conduction, and 
that the air-conduction for the forks C1, C2, C3, C4, should 
not fall much below one-fourth the normal duration of 
air-conduction for these tones. 
Steps of the Operation.-Most authors agree that general 
anajsthesia is seldom necessary, and Cholewa states that 
in many of these cases the sensibility of the membrana 
tympani is much diminished. The same author advocates 
the induction of local anaesthesia by strong solutions of 
aluminium aceto-tartrate or by ether, a pledget of cotton 
saturated with the agent being placed in contact with the 
membrane and the fluid allowed to evaporate. The oint- 
ment of cocaine and lanolin may also be used in the same 
manner. In the very few cases in which I have resorted 
to this measure it was rather difficult to control the pa- 
tient as perfectly as might have been desired, and I believe 
249 Ear Operations. 
Ear Operations, 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
that a general anaesthetic will add much to the complete- 
ness of the operation. 
With reference to the method of dividing the tendon 
there is considerable difference of opinion. Weber-Liel 
and Cholewa have advised that it be accomplished by the 
introduction of the knife in front of the short process of 
the malleus. Both of these operators have devised special 
instruments for the purpose, differing from each other 
only in the shape of the blade. These instruments were 
constructed in such a way that the hook-shaped knife 
could be rotated upon the long axis of its shaft by sliding 
a button upon the handle. The technique with an instru- 
ment of this kind is as follows : The membrana tympani 
is incised just in front of the processus brevis, the hook- 
knife introduced into the tympanic cavity, and by de- 
pressing the handle of the instrument and carrying it 
somewhat forward the blade is made to press upon and 
partially encircle the tendon ; by sliding the button upon 
the handle downward the hook-blade is rotated, thus 
dividing the tendon ; by again manipulating the slide the 
blade assumes its original position and the instrument is 
carefully withdrawn from the tympanic cavity; a forcible 
inflation and the insufflation of a little boric acid to cover 
the wound complete the procedure. 
Much simpler are the methods of Schwartze, Hart- 
mann, Gruber, Pomeroy, Green, and Urbantschitsch, 
who divide the tendon without the aid of the complicated 
instrument above described. With the exception of 
Gruber,28 all of the above writers prefer entering the tym- 
panic cavity behind the malleus handle, and Gruber states 
that in some cases, where the anterior segment is very 
small, this may be advisable. Almost every operator has 
devised a special instrument which, in his hands, has ap- 
peared more satisfactory than any other, from which we 
may infer that, bearing in mind the anatomy of the parts, 
almost any instrument -with the blade curved on the flat 
may be used for the purpose. Schwartze, Pomeroy, and 
Green prefer a blunt knife, curved on the flat, similar to 
that represented in Fig. 156, D, with the exception that 
the curve should be a little sharper than represented. 
Gruber's knife is less curved and is pointed. Hartmann's 
knife is pointed, and, in addition to the curve on the flat, 
the sharp point is curved upward, so that when the knife 
is inserted the point passes well up into the tympanic cav- 
ity. Urbantschitsch29 uses a knife with a double cutting 
edge, the blade being short and making an obtuse angle 
with the shaft; an instrument similar to that shown in 
Fig. 1, C, with the exception that it is blunt instead of 
sharp. 
The position of the puncture and the manipulation of 
the instrument after the blade has entered the tympanic 
cavity will vary according as the tendon is to be divided 
from above downward, or from below upward ; and here 
again I believe the operator should be allowed a certain 
amount of latitude, depending upon the conformation of 
the parts in each special case. If the division is to be 
made from above downward, as advised by Schwartze 
and Urbantschitsch, the membrana tympani is punctured 
immediately behind the short process, and the curved or 
angular blade of the knife is carried high up into the 
tympanic cavity by depressing the proximal end of the 
instrument, which at the same time should be carried a 
little backward, thus causing the blade to apply itself 
closely to the malleus. The blade is then rotated forward 
and downward through an angle of 90°, the tendon being 
severed by a slight sawing motion, and by pressing the 
knife downward, at the same time withdrawing it. As 
the tendon is divided the operator feels the resistance 
which it offered suddenly overcome, and frequently a 
sharp snap is heard at the moment of division. 
Hartmann and Pomeroy divide the tendon from below 
upward. Hartmann advises that the membrane be in- 
cised just below and behind the short process ; upon 
entering the tympanic cavity the knife is advanced for- 
ward, inward, and slightly downward, the shaft remain- 
ing almost horizontal and the flat surface of the blade be- 
ing close to the handle of the malleus until the blade has 
nearly traversed the breadth of the tympanic cavity, 
when the handle is depressed, thus carrying the curved 
point of the knife high up in the tympanum ; the instru- 
ment is then withdrawn, upward pressure being con- 
tinually exerted, and the tendon is divided from below 
upward. Just before the tip of the knife emerges from 
the tympanum, the handle is elevated to avoid injury to 
the parts in tlie region of the posterior fold. Pomeroy 30 
first punctures the membrane behind the manubrium and 
near its tip, and then introduces a blunt curved knife, 
with its concave side looking forward and being closely 
applied to the handle of the malleus. The tendon is di- 
vided by depressing the handle of the knife and extend- 
ing the incision upward to the short process. 
Green 31 enters the tympanic cavity with a myringo- 
tome, behind and below the short process of the malleus, 
and extends the incision upward to the margin of the 
ring. Through this incision the curved blunt knife is 
introduced and the tendon located ; it is divided either 
from above downward, or in the opposite direction, ac- 
cording to its attachment in each individual case. 
When it seems desirable to divide the tendon by an 
incision through the anterior segment of the membrana 
tympani, the curved knife is to be carried through the 
membrane somewhat below the short process, the con- 
cavity of the knife looking backward. On entering the 
cavity the instrument is advanced upward and back- 
ward, keeping the blade closely applied to the malleus 
handle. The tendon is thus divided from below' up- 
ward. Whatever method is used to effect a division of 
the tendon, the after-treatment consists in a forcible in- 
flation by means of the catheter or Pulitzer's method, 
after which the incision is covered with a little boric acid 
and the wound allowed to heal. 
Results.-The immediate effect of the operation is 
usually to diminish the subjective noises, and in some 
cases the hearing improves. It has been the experience 
of many observers, however, that the good results have 
been but temporary, and that after an interval the symp- 
toms have reappeared. This may be explained by the 
reunion of the cut ends of the tendon, or by the invasion 
of other parts of the conducting apparatus by the patho- 
logical process. My own experience with the operation 
has been limited to a few cases, in which the tendon was 
divided for the relief of tinnitus. In one case there was 
considerable improvement; in the others the final result 
is not known, but immediately after the operation there 
was no improvement. In making the section I ordinarily 
use the curved knife (Fig. 156, 1)), the membrane being 
first incised with a pointed knife, either in front or be- 
hind the manubrium, according to the shape of the canal 
and the amount of retraction present. 
I am not enthusiastic over the operation, for the reason 
that it is absolutely impossible in any given case to be 
certain that the tensor tendon is the only intra-tympanic 
structure affected. While our methods of determining 
that a lesion is located in the conducting apparatus are 
fairly perfect, we have no means as yet of assuring our- 
selves that the increased tension is due to a shortening of 
the tensor tympani tendon alone. My own choice, when 
operative measures are necessary, is usually for a pro- 
cedure which corrects the increased tension, no matter 
in what portion of the mechanism it is located. Of late 
the operation has been again brought to the notice of the 
profession by Cholewa39 and Muller.33 Cholewa strong- 
ly advises its performance in the cases variously called 
sclerotic, proliferative, or insidious, not only from the 
effect upon the ear operated upon, but also for the im- 
provement which he claims often results in the opposite 
ear. The poorer ear is always the one operated upon 
first, and even when its condition is not much improved, 
this author has found in many cases a remarkable im- 
provement in function upon the opposite side. I shall 
allude to this later, in describing my own experience in 
cases of ossiculectomy. 
Muller advocates the operation in cases of purulent in- 
flammation, in which the discharge continues in spite of 
careful cleansing and local applications. He believes that 
the contracted tendon, by crowding the articular surfaces 
of the ossicles together and binding them to the tympanic 
wall, is a prominent factor in keeping up the inflammation. 
250 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Ear Operations. 
Ear Operations. 
He reports a number of cases in which tenotomy was 
followed by a rapid cessation of the discharge. The 
effect upon the function of the organ and upon subjec- 
tive noises was also satisfactory. 
(b) Tenotomy of the Stapedius.-Division of the stapedius 
tendon alone scarcely deserves a place among the oper- 
ations, since when this muscle needs to be divided the 
section of its tendon is only one step in operative pro- 
cedures to free the stapes. With the other portions of 
the conducting mechanism normal, I can conceive of 
no condition which would indicate tenotomy of this mus- 
cle. Accordingly the description of the procedure will 
be given under those operations of which it really forms 
a part. 
(c) Division of the Anterior Ligament of the Malleus.- 
This measure was advised by Politzer34 in cases of 
marked retraction of the membrana tympani. It was 
found that, even after section of the tendon of the tensor 
tympani, the membrane in some cases would not retain its 
normal position upon inflation. If, however, the ligamen- 
tous structures of the anterior fold were divided the mem- 
brane could be made to resume its normal position. The 
operation consists in puncturing the membrane just in 
front of the short process with a short curved knife, 
carrying it nearly to the inner wall of the tympanum ; 
the handle is then depressed and the knife withdrawn, 
thus dividing the tissues in the anterior fold. In the cases 
in which this operation was performed by Politzer there 
was considerable relief to tinnitus, and the hearing was 
somewhat improved. The objection to the operation is 
the same as that mentioned in tenotomy of the tensor 
tympani, viz., that we are never certain that the increased 
tension is entirely dependent upon the anterior ligament. 
The procedure may, however, be made use of in cases of 
tinnitus, with but slight impairment of the hearing, in 
which more radical measures might be considered a 
menace to the auditory function. 
(d) The Division of Adhesions, the Result of Suppurative 
or Nonsuppurative Inflammation.-Under this general 
head we include a large number of procedures, differing 
from each other according to the precise local condition 
met with in the individual case. As the stapes is the 
part of the ossicular chain whose motion is a necessity to 
useful audition, the ultimate aim of all our efforts is to 
render motion of this ossicle possible. We have then 
two classes of cases : 
1. Those in which the rigidity depends upon adhesions 
about the stapes itself. 
2. Cases in which the rigidity is caused by adhesion of 
the malleus or incus to the inner tympanic wall, or by 
tense bands immobilizing the entire ossicular chain, the 
articulations between the various ossicles being intact. 
Naturally these conditions are more pronounced in 
cases of old purulent inflammation, although the same 
condition may obtain in cases of non-purulent otitis. It 
scarcely need be stated here that a diagnosis is much 
more simple in cases arising from a purulent inflamma- 
tion, as the result of which the membrana tympani is 
largely wanting, enabling the surgeon to see the location 
of the constricting bands, and to manipulate the parts 
with the probe, than in those cases in which the deeper 
parts must be viewed through the membrane, or if this 
is too opaque, through an artificial opening made for 
this purpose. It follows that operative measures of this 
character are much more successful in purulent cases 
than in the other variety. 
When the rigidity depends upon adhesions about the 
stapes itself, as a result of a purulent otitis, the incudo- 
stapedial articulation having been destroyed, we find the 
region of the oval window occupied by a mass of dense 
tissue, which frequently completely changes the appear- 
ance of the parts. Not infrequently the head of the 
bone is so buried as to be distinguishable only as a slight 
elevation upon the surface of tTie mass. Close inspection 
may reveal a preponderance of the newly formed tissue 
toward the posterior aspect of the region of the window. 
This is ordinarily due to the deposit about the stapedius 
tendon which sometimes can be seen as a bright line run- 
ning through this mass. To free the stapes (or what is 
left of this ossicle) in such a case I usually first incise 
directly downward close to the tympanic ring, so as to 
divide any bands which tend to pull the stapes out of 
the field of vision. In making this incision it is important 
that the knife be carried inward until the inner tympanic 
wall is encountered, and that in the downward stroke all 
the tissues be completely severed throughout their entire 
depth, otherwise some fibres of the stapedius may remain 
undivided, and pull the stapes out of view. The knife 
is next carried entirely around the area believed to be 
occupied by the stapes, thus freeing it from adhesions 
above, below, and anteriorly. When the knife is carried 
inward until the bony wall of the tympanum is encoun- 
tered, care must be taken not to insert it so deeply that, 
in case the entire stapes has come away, the labyrinth 
will be wounded. Taking the region of the oval window 
as a centre, several short radiating incisions are next 
made to permit the tissues to retract from the oval win- 
dow; the local depletion thus obtained is also an advan- 
tage, as it favors the rapid formation of a thin cicatricial 
membrane in place of a thick one. After the operation 
a little boric acid may be insufflated, and syringing 
should be avoided if possible, as moisture is objection- 
able. 
Frequently this procedure has to be repeated several 
times, for the process of cicatrization may partially re- 
produce the old condition, but by repeated incision, 
dividing the parts most tense, favorable results usually 
follow in a large proportion of cases. Of course here, 
as in other conditions, the tuning-forks should be used to 
locate the seat of the lesion in the conducting apparatus. 
In the second class of cases, where the motion of the 
stapes is impeded by pressure from other parts of the 
conducting apparatus, which are bound down by adhe- 
sions, relaxation of the tension of these parts frequently 
effects an improvement. Thus we frequently meet with 
cases in which there is a large perforation, involving the 
inferior half of the membrane ; the edges of the mem- 
brane may adhere to the promontory throughout their 
extent, or the adhesion may be confined to the region of 
the manubrium. In this latter instance I usually separate 
the structures with the flat curved knife (Fig. 156,D), al- 
though Politzer38 prefers to make vertical incisions 
through the cicatrix. In either case adhesions reform, 
but the tension is lessened, and improvement usually 
results. It is in such cases that MullerS6 advises division 
of the tensor tympani muscle. 
In still another class of cases, with considerable destruc- 
tion of the membrana tympani, the remnant of mem- 
brane in the upper and posterior quadrant will be found 
thickened and tense, its lower border forming a dense 
fibrous band, which binds the underlying structures 
firmly together, and may partially or completely hide 
the stapes or incudo-stapedial articulation from view. 
Dividing this band by an incision upward will fre- 
quently improve the hearing, or in exposing the stapes 
may reveal a condition here amenable to operation. 
Examples of all of these different conditions have 
come under my own observation, and the results have 
always been gratifying. A few of these cases were 
reported some time since,31 and subsequently I have met 
with many more cases in which the results have been 
gratifying. 
When adhesive processes are the result of the so-called 
otitis media insidiosa, the division of adhesions is not 
followed by such good results, for the simple reason that 
when divided through an artificial opening in the mem- 
brana tympani, any bands which reform during the 
process of healing can only be attacked by reopening the 
tympanic cavity, in fact, by repeating the original opera- 
tion. While in the class already considered the opera- 
tive field is always open to inspection, and the operative 
interference may be undertaken at intervals, according 
to indication, in the cases we are now considering, the 
ultimate success or failure depends entirely upon the 
single operation, and the result of faulty cicatrization 
cannot be corrected. Still in certain instances the divi- 
sion of adhesions has been of benefit in this class of cases. 
Thus De Rossi38 reports a case in which, after turning 
251 Ear Operations. 
Ear Operations. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
down a flap from the membrana tympani, a fibrous band 
between the malleus and incus was divided. The flap 
was replaced and held in position by means of a cotton 
pledget. The patient was much improved by the opera- 
tion. Prout39 operated upon a case in which the mem- 
brana tympani about the tip of the malleus was adherent 
to the inner tympanic wall. The instrument used re- 
sembled the knife shown in Fig. 1, C. By this means 
the adhesion was divided, that portion of the membrana 
which was adherent being cut away and either removed 
or left adherent to the inner tympanic wall. A perma- 
nent perforation resulted and the hearing was perma- 
nently improved. 
While I am heartily in favor of these procedures in 
cases dependent upon suppuration, I believe that they are 
to be advised only in special instances where there has 
been no suppuration. When upon an exploratory myrin- 
gotomy a condition is found, as in De Rossi's case, which is 
sufficient to explain all the symptoms, and in which a single 
operation promises every prospect of success, the simple 
division of the existing adhesion is all that is indicated. 
Most frequently, however, we find that the rigidity does 
not depend upon such a cause, but that the ossicular 
chain can be rendered normally movable only by the 
division of adhesions in several localities, especially about 
the stapes, and so located that subsequent cicatrization is 
almost certain to result in a return, to a certain extent, of 
the former local condition. In such cases I prefer to re- 
move the membrana tympani, malleus, and incus at once, 
the field of operation being then accessible for further 
measures in case of necessity. My reason for this is that 
when the membrana is intact, a prolonged intra-tympanic 
operation necessitates general anesthesia in most cases, 
and this cannot be resorted to again and again on account 
of the discomfort to the patient which it entails. With 
the tympanic cavity open, as in purulent cases, or after 
removal of the membrane, malleus, and incus, local anaes- 
thesia by means of a solution of cocaine suffices for all 
operative procedures of this kind. Hence in any non-sup- 
purative case where general anaesthesia is to be resorted 
to for the purpose of an exploratory myringotomy and 
the division of adhesions, the patient's consent for my- 
ringecto-ossiculectomy should be obtained, in case the con- 
dition revealed by exploration should render this advis- 
able. 
3. Operations involving the Ossicular Chain.-(a) Ex- 
cision of a portion of the manubrium mallei and a 
large part of the membrana was proposed by Wreden 40 in 
cases where it was deemed desirable to maintain a per- 
manent opening in the membrane. The procedure has 
fallen into disuse, and it is probable that it would not 
accomplish the end aimed at. 
(b) Disarticulation of the Incudo-stapedial Joint, or 
Division of the Long Arm of the Incus, with Mobilization of 
the Stapes.-This measure is one of the most satisfactory 
operative procedures which fall to the lot of the otologist. 
It is of especial value when there has been previously a 
suppurative inflammation with destruction of the mem- 
brana tympani in the upper and posterior quadrant, or 
when the articulation is covered by a thin cicatrix only, 
through which the parts can be easily seen. It is of less 
value in cases of otitis media insidiosa, since the closure 
of the opening made for the performance of the operation 
renders it impossible for the surgeon to relieve by second- 
ary operations any unfavorable results attending cica- 
trization. 
In cases where both the long arm of the incus and the 
posterior crus of the stapes are in view and uncovered, the 
joint maybe divided by inserting the angular knife (Fig. 
1, C) behind the long arm of the incus and cutting down- 
ward through the joint; any portions of the capsule undi- 
vided may be severed by inserting the point of the knife 
into the joint below and cutting upward, and also by 
hooking the instrument around the anterior aspect of the 
long arm of the incus and cutting downward. It is usu- 
ally advised that the knife be hooked around the posterior 
aspect of the long arm of the incus and the joint opened 
from above, downward and forward, the resistance offered 
by the stapedius muscle rendering this the simplest pro- 
cedure for disarticulating at the joint. This is theoreti- 
cally correct, but is open to several objections. In the 
first place, the long arm of the incus frequently lies so near 
the margin of the tympanic ring that the knife can only be 
inserted in this locality by the use of considerable force ; 
again, if the joint is divided before section of the stapedius 
tendon has been done, the pull of the stapedius muscle 
may so displace the stapes as to render its subsequent 
mobilization impossible. My own method of procedure 
is therefore to thoroughly divide the stapedius tendon 
and the adjacent adhesions as the initial step of the 
operation. This is done in the manner already described, 
by inserting the sharp straight knife behind and above 
the head of the stapes, between it and the tympanic ring, 
carrying it inward until the point touches the inner tym- 
panic wall and then cutting directly downward. By this 
procedure the stapes, and hence the articulation, is re- 
leased, and by the action of the tensor tympani and the 
elasticity of cicatricial bands located anteriorly the ar- 
ticulation is brought more clearly into view. The an- 
terior aspect of the descending crus of the incus is in such 
a position that by applying the angular knife to this, and 
cutting downward, the joint is easily divided, or it may 
be more convenient to enter the joint from below with 
the point of the knife, and cut upward, sweeping the blade 
anteriorly and posteriorly as a final step. If the knife is 
sharp no violence will be done, although the resistance 
afforded by the stapedius has been ablated. 
After the joint has been divided the long arm of the 
incus is pushed upward and forward, so that it cannot 
reunite with the stapes. Attention is next given to the 
condition of the stapes, and if this is not freely movable 
it is to be freed by passing the pointed knife about the 
foot-plate, dividing all bands which may be found in the 
manner already described in treating of adhesions about 
the stapes. If the ossicle remains firmly fixed after these 
incisions have been made, it may be mobilized by pressing 
upon it with a cotton-tipped probe, the pressure being ap- 
plied successively from below, from above, and upon the 
anterior and posterior crura. Care must be taken not to 
rupture the crura by this manipulation. 
I have in quite a number of cases obtained a marked 
improvement in hearing and a diminution in the tinnitus 
by the division of the incudo-stapedial articulation and of 
the stapedius muscle, together with fibrous bands about 
the stapes, and this is, I believe, the experience of all 
otologists who have made use of the method. In a cer- 
tain number of cases we find that the incudo-stapedial 
articulation has become ossified and division with the 
knife is impossible. In such an event Politzer41 divides 
the long arm of the incus with stout scissors and separates 
the fragments so that reunion is impossible. 
As before stated, mobilization of the stapes by division 
of the incudo-stapedial articulation and of adhesions about 
the ossicle is mostly of service in cases dependent upon a 
previous suppuration. In cases of otitis media insidiosa 
the mobilization of the stapes has been attempted, not- 
ably by Miot,42 who enters the tympanum by an ex- 
tensive incision along the posterior margin of the mem- 
brana tympani, and by means of a delicate instrument, 
the distal extremity of which is flattened into a small plate, 
mobilizes the stapes by pressure applied from below up- 
ward, from above downward, and upon the anterior crura 
backward. In certain cases also traction is made upon 
the long arm of the incus, to aid in the mobilization. The 
stapedius muscle and the incudo-stapedial articulation are 
left intact, unless the latter is ossified, when the long arm 
of the incus is divided. If adhesions exist between the 
incus, malleus, and the tympanic wall they are divided. 
The author claims that by frequent inflation by Valsalva's 
method the wound in the membrane can be kept open 
long enough to admit of several attempts at mobiliza- 
tion upon successive day§, if the first does not afford 
the improvement hoped for. General anaesthesia is not 
considered necessary, as after the first incision through 
the membrane the introduction of a solution of cocaine 
into the tympanic cavity produces sufficient anaesthesia. 
In cases following a purulent inflammation the same 
general plan is followed, the author preferring to over- 
252 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Ear Operations. 
Ear Operations. 
come the rigidity by stretching the adhesions rather than 
by dividing them, although in certain cases he uses the 
knife. I have never attempted this method of procedure, 
but in one case of otitis media insidiosa I entered the 
tympanic cavity, and after dividing the incudo-stapedial 
articulation severed the stapedius muscle, as well as all 
adhesions about the base of the stapes. There was a 
moderate amount of reaction, and after the closure of the 
opening in the membrane the hearing remained the same 
as before operation, although the tinnitus was somewhat 
improved. 
Although the method of Miot is certainly unique, and 
his results seem to have been good, yet I can scarcely 
believe that the operation will ever come into general use. 
There can, it seems to me, be no advantage in leaving in 
the tympanic cavity structures whose function has been 
so impaired by the inflammatory process that they are 
of little use, while by their presence they afford an ad- 
ditional opportunity for the recurrence of the condition 
for which operative measures have been, instituted. 
Stretching of the adhesions may give temporary relief, 
but the method which, theoretically at least, would be 
the best, would be the one which prevented all possibility 
of their reformation. This indication, in my opinion, 
is better met by the free use of the knife, and the re- 
moval of all parts not absolutely necessary to the func- 
tion of audition. 
(c) Plastic Operations for the Purpose of Uniting the 
Incus or Stapes with the Membrana Tympani.-By means 
of the above procedure vibrations falling upon the mem- 
brana would be transmitted directly to the stapes ; in cases, 
therefore, in which extensive adhesions existed, limiting 
the mobility of the malleus or incus, or both, or when, 
as the result of relaxation, the membrana tympani and 
one or both of the two larger ossicles by their own weight 
acted as a load to the conducting mechanism, this proced- 
ure, theoretically at least, should be beneficial. Blake43 
has performed operations of this character, but at pres- 
ent, in similar cases, he prefers stapedectomy. So far as I 
know, Dr. Blake has never published an account of these 
operations but refers to them incidentally in the above 
communication ; he was also kind enough to explain the 
method to the writer three years since. 
Operation.-A triangular flap from the posterior-su- 
perior quadrant of the membrane is turned aside, exposing 
the incudo-stapedial articulation ; by means of the probe 
the mobility of the incus and stapes is determined ; All 
tension due to adhesions about the stapes or to contrac- 
tion of the stapedius muscle is relieved by incision. If, 
now, the incus and stapes move freely, the triangular 
flap is pressed against the long arm of the incus, and 
held in place by a pledget of cotton. If the incus is not 
freely movable, disarticulation at the stapedio-incudal 
articulation is performed, and the flap applied to the 
head of the stapes instead of to the long arm of the incus. 
(d) Removal of the Ossicular Chain in its Entirety or 
the Excision of Individual Ossicles.-We come now to oper- 
ations in which either the entire ossicular chain or indivi- 
dual ossicles are removed. These operations have either 
been done for the purpose of improving the hearing or 
relieving tinnitus, or, in cases where the function of the 
auditory apparatus was not sufficiently impaired to 
necessitate interference of any kind, they have been 
called into requisition for the arrest of long-continued 
suppuration which had resisted all other forms of treat- 
ment. It is evident at once that as one or all of these con- 
ditions may be present in any given case, it may often 
happen that the decision for or against operation becomes 
an exceedingly delicate matter. Given a case in which 
the hearing is good enough to allow the patient to carry 
on his vocation in life without the least annoyance, and 
yet with a chronic discharge from the ear, which has 
failed to yield to skilful treatment, we must be certain 
that any operative interference which may be advised for 
the cure of the otorrhoea will not impair the function of 
the organ. In another case, in which impairment of the 
hearing or severe tinnitus has resulted from a chronic 
non-suppurative inflammation of the tympanum, or has 
been produced by a previous suppurative process, the ear 
(SUPPLEMENT.) 
at the time advice is sought having been dry for a long 
period, no measures for relief can be strongly advised 
which may result in long-continued suppuration. The 
surgeon must, therefore, not only be able to hold out a 
fair prospect of success for the operation, in accomplish- 
ing the purpose for which it is to be performed, but must 
also be able to assert that no disagreeable consequences are 
likely to follow its performance. 
The history of operations upon the ossicular chain is 
interesting, from the fact that it shows how the earlier 
operators hesitated to interfere with the parts intimately 
connected with the labyrinthine structures, and that it 
was only after a considerable period that it became a 
recognized fact that the labyrinth might remain unin- 
jured in spite of considerable traumatism inflicted upon 
the ossicular chain, or even its complete loss. 
As early as 1873 Schwartze44 advised the removal of 
the malleus and incus for caries, but stated that removal 
of even a portion of the stapes should be avoided for 
fear of a purulent infection of the labyrinth. lie also 
states45 that as early as 1873 he practised removal of the 
malleus and membrana tympani and disarticulation of 
the incudo-stapedial articulation in cases of chronic non- 
suppurative inflammation. In this condition he appar- 
ently did not remove the incus, but simply disarticulated 
it from the stapes. 
In 1876 Kessel,46 having several years before proved 
that the removal of the columella in birds was not attended 
by severe consequences, effected mobilization of the 
stapes in a patient in whom the malleus and incus had 
been destroyed by suppuration. The operation consisted 
in tenotomy of the stapedius muscle, and the division of 
adhesions binding the foot-plate in the oval window. 
From the reading of this report there can be but little 
doubt that the membrane covering the oval window was 
punctured and a certain amount of perilymph allowed to 
escape. There was some improvement in the hearing 
and a diminution of the tinnitus, but more important 
than this, no severe symptoms followed. The same au- 
thor,41 at a later date, excised the membrana tympani, 
malleus, and incus, and mobilized the stapes in a case of 
complete closure of the Eustachian tube. While it had 
been demonstrated quite early that removal of the two 
larger ossicles was not a dangerous or difficult operation, 
but one which was frequently indicated in caries, and 
followed by good results, even when no suppuration had 
been present, yet it was not until several years later that 
these measures were practised to any extent. In 1885 
Lucae48 published an account of fifty-three operations in 
cases of sclerosis, and called attention to the necessity of 
excluding serious labyrinthine involvement by means of 
testing the hearing with a series of tuning-forks before 
holding out a hope of improvement from operative pro- 
cedures. While Lucae's published results are not as 
favorable as might be wished, they certainly demonstrate 
the fact that in certain cases such operative procedures 
are in the highest degree beneficial, and warrant placing 
them among the legitimate means for improving other- 
wise hopeless cases. 
In 1888 Sexton 49 reported a number of cases of chronic 
non-suppurative otitis media, in which excision of the 
membrana tympani, malleus, and incus had been bene- 
ficial. 
The removal of the ossicles for the relief of chronic 
suppuration has been continually gaining ground, and 
thanks to the contributions of Kretschmann,60 Stacke,61 
Ludewig,52 Grunert,53 and others, it is now looked upon 
as a recognized surgical procedure. All writers upon the 
subject of intra-tympanic operations, involving the re- 
moval of the ossicles, have until quite recently avoided 
interfering with the stapes, or at the most have recom- 
mended the division of adhesions about the ossicle, and 
subsequent mobilization by brisement force. Jack 54 and 
Blake55 have, during the last year, demonstrated that the 
entire stapes may be removed without danger, and in 
many cases the result has been a decided improvement 
in the hearing. Both of these surgeons, as the outcome 
of experience, advocate the removal of the stapes for the 
improvement of the hearing in cases where the impair- 
253 Ear Operations. 
Ear Operations. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
ment depends upon some lesion of the conducting mech- 
anism, resulting from either suppurative or non-suppu- 
rative inflammation ; the other ossicles are left in situ, 
unless carious. We have then to consider the following 
operative measures : 
1. Removal of the malleus and incus. 
2. Removal of the malleus, incus, and stapes. 
3. Removal of the stapes (stapedectomy). 
If the membrana tympani is present,'this is also re- 
moved as completely as possible in performing the first 
two operations above enumerated, while in stapedectomy 
the membrane is left. 
In cases where long-continued and uncontrollable sup- 
puration exists, or is the sole cause for operative in- 
terference, the two larger ossicles will certainly require 
removal; the advisability of removing the stapes will 
depend upon conditions which will vary with the indi- 
vidual cases. If carious, the affected bone should cer- 
tainly be removed ; if healthy, the question of its re- 
moval will depend upon the condition of the hearing 
before the operation, and the probabilities of improving 
it by the excision of this ossicle, as indicated by the 
careful functional examination of the ear before the 
operation, and the amount of rigidity of the stapes, as 
determined by manipulation after the two larger ossicles 
have been removed. 
When removal of any or all of the ossicles is to be 
practised for the improvement of the hearing,-the pro- 
cess which has given rise to the impairment having been 
either non-suppurative inflammation or a purulent in- 
flammation which has ceased either spontaneously or as 
the result of treatment, leaving a rigidity of the conduct- 
ing mechanism,-advice as to the propriety of operative 
interference is a matter of no little moment. In the first 
place the lesion must be located in the conducting appa- 
ratus by the tuning-fork tests already alluded to. It is 
not enough that the inspection of the ear reveals a 
pathological condition of the conducting mechanism. It 
must be proved that this is at present the cause of the 
defective audition, since secondary changes may have 
taken place in the labyrinth which place the case beyond 
all hope of improvement by any operation upon the con- 
ducting mechanism. Evidence of such involvement of 
the labyrinth can only be excluded by a careful func- 
tional examination, and the method which has served me 
the best purpose has already been given in the early part 
of this paper. Both Lucae and Kessel have called at- 
tention to the necessity of such an examination before 
undertaking operative interference for the purpose of 
improving audition, and the tests used by these observers 
are in the same line as those already described. 
As to the choice of operation, much is to be said. In 
all the operative procedures previously described, the 
object has been to reduce weight or tension in the con- 
ducting apparatus, by the division of muscles, adhesions, 
ligaments, folds of the membrana tympani, etc., or to 
establish a communication with the middle ear by 
a permanent opening in the membrana tympani, thus 
admitting sound to the oval window more directly, 
this end being still further carried out, in certain cases, 
by disarticulation at the incudo-stapedial articulation. 
Each individual procedure has, in certain cases, been of 
undoubted benefit, and the lack of enthusiasm with which 
they have been viewed has been due to the fact that it 
has been impossible to declare positively that the rigidity 
was the result of a limited lesion, such as contraction of 
the tensor tympani, tension of the posterior fold or similar 
localized conditions, and experience has shown that the 
same pathological process which has caused any of 
these conditions, in the large majority of cases, has ef- 
fected changes in other parts of the conducting appa- 
ratus as well, which would be uninfluenced by opera- 
tions affecting one portion only of this mechanism. In 
other words, we can be pretty certain of rigidity of the 
conducting mechanism as a whole, but as yet cannot de- 
fine the exact limits of the lesion. It seems rational, 
therefore, that removal of the membrana, malleus, and 
incus, by affording direct access of the sound waves to 
the oval window or head of the stapes, should meet the 
(SUPPLEMENT.) 
indication better, or that the evulsion of the stapes itself, 
by removing the effect of increased tension of the laby- 
rinth caused by the binding down of the other structures 
within the tympanum, should be a rational method of pro- 
cedure in cases demanding operative interference. When 
the two larger ossicula are excised, the operator usually 
endeavors to maintain a permanent opening into the tym- 
panic cavity, while when the stapes alone is removed, this 
end is not aimed at ; but if the membrana tympani is 
present every attempt shoidd be made to restore it to its 
integrity after the operation. 
While I do not favor criticism unsupported by personal 
experience, I cannot help feeling that the removal of the 
stapes alone, in cases where the membrana tympani is 
intact, the wound made by the operation being closed as 
quickly as possible, is not a commendable procedure. 
The two larger ossicles certainly perform no function, 
after removal of the stapes, while they certainly increase 
the probability of serious reaction following the proced- 
ure, since they aid in shutting off the atrium from the 
fornix tympani not only by their own presence but also 
by the preservation of the numerous folds of mucous 
membrane found in this region, which reduplications 
are obliterated by the removal of the two larger 
ossicula. Again, the presence of the membrana tym- 
pani itself must present a certain amount of obstruction 
to the entrance of waves of sound, while if the mem- 
brane, malleus, and incus are taken away, it will be 
possible, certainly in most if not all cases, to maintain a 
permanent opening into the tympanum. Still further, 
cases are met with in which complete anchylosis of the 
foot-plate of the stapes renders removal of the ossicle in- 
advisable or impossible, and the surgeon can only divide 
all adhesions about the foot-plate, in the hope of securing 
a slight amount of motion. In such an event it would 
certainly be of advantage to be able to divide, subse- 
quently, any adhesions which might form during cica- 
trization, after the first operation. If the membrane and 
the two larger ossicles have been removed, access can be 
easily gained to the stapes without resort to general 
anaesthesia, even if the membrane has reformed, as the re- 
sulting cicatricial membrane is only slightly sensitive, and 
may be easily removed under local anaesthesia. More than 
this, by the obliteration of the folds of the mucous mem- 
brane lining the vault of the tympanum, no reaction fol- 
lows repeated operative interference in these cases, and as 
these folds must, on account of their density, tend to reduce 
the amplitude of sonorous vibrations, their preservation 
cannot be urged for the purpose of improving the function 
of audition. The desirability of leaving the membrana 
tympani for the purpose of protecting the tympanum is 
not clearly proved, since the mucous lining of the middle 
ear, after exposure to the air for a short time, ceases to 
be sensitive, and secretes almost no fluid. If, however, 
the protecting influence of the membrana tympani is 
deemed important, this can be secured, even though the 
malleus and incus have been removed ; for a large portion 
of the membrane maybe left intact and made to adhere to 
the inner tympanic wall, thus affording a cutaneous cov- 
ering, while at the same time access can be easily had to 
the oval window. That the operation of removing all 
of the ossicula is more prone to be followed by serious 
reaction than removal of the stapes alone, I am not pre- 
pared to admit. Certainly my experience has been that the 
reaction following the removal of the malleus and incus 
has been practically nothing. Stapedectomy, then, would 
be the operation of election in a case in which the stapes 
was easily accessible, but was bound so firmly by adhesions 
(due to a former otitis media purulenta) that disarticula- 
tion from the incus and the division of adhesions would 
produce no permanent effect, while at the same time the 
region of the stapes had been shut off from the other parts 
of the tympanic cavity by the previous inflammation. In 
such a case, removal of all of the ossicles would hardly 
be called for, while removal of the stapes would be sim- 
ple, and the thin cicatrix would afford easy access to the 
region for the purpose of further operative procedures. 
In non suppurative inflammation, if the portion of the 
drum membrane covering the stapes were very thin, 
254 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Ear Operations. 
Ear Operations. 
(SUPPLEMENT.) 
fected with the angular knife (Fig. 156, C). The knife, 
inserted into the handle in such a way that the point is 
directed backward, is carried into the tympanic cavity in 
front of the long arm of the incus, ami the blade passed 
to the inner side of this process ; by slight traction out- 
ward and pressure backward the instrument is made to 
hug the descending process of the incus, while, at the 
same time, the articulation is divided with a downward 
stroke. Any fibres of the capsular ligament which may 
have escaped division may be severed by inserting the 
point of the knife into the articulation from below, and 
sweeping the blade backward and forward. If fibres 
still remain undivided posteriorly, the angular knife is 
to be turned in an opposite direction, the point directed 
forward, when by passing it behind the long process of 
the incus, a downward stroke will complete the division. 
If these steps have been carried out as indicated, it will 
be the exception if more than a drop of blood has been 
lost. 
Next, with the pointed knife, a short, horizontal incision 
is made through the membrana tympani at its most de- 
pendent part, close to the insertion into the annulus tym- 
panicus ; the pointed knife is quickly laid aside and the 
probe-pointed knife (Fig. 156, E) is inserted, and the mem- 
brane is divided along its posterior periphery from below 
upward, until the exploratory incision is encountered. In 
the same manner the anterior segment of the membrane 
is divided from below upward with the probe-pointed 
knife, the incision extending as far as, but not into, 
Shrapnell's membrane. Up to this point no blood has 
been lost and the field of operation is as clear as when we 
started. There remains to be divided the membrana flac- 
cida and the ligaments which bind the malleus externally, 
in front, and behind. The pointed knife is again used for 
this section, which should be made rapidly ; the knife is 
held so that the flat surface of the blade looks toward the 
roof of the canal, the cutting edge being directed back- 
ward ; the point of the knife is entered just above the 
short process of the malleus and is pushed inward and 
upward, the handle being depressed so that the shaft often 
touches the margin of the speculum. In this manner the 
knife is made to enter the fornix tympani; it is now made 
to cut its way out, downward and backward, thus sever- 
ing the external and posterior ligaments of the malleus 
and dividing the membrana flaccida posteriorly. The 
knife is then quickly turned and made to cut in the 
opposite direction, being carried forward over the short 
process, dividing the anterior segment of the membrana 
flaccida, some fibres of the external ligament, and the 
strong anterior ligament of the malleus. The malleus is 
now held only by the superior ligament and the tendon 
of the tensor tympani, neither of which is strong. The 
hemorrhage from the last incision may be free, and may 
obscure the field, but, usually, owing to the elevated 
position of the head, the upper part of the field is not ob- 
scured, and the short process of the malleus can be dis- 
tinctly seen. The ossicle is quickly grasped, just below 
the short process, with the forceps (Fig. 157), and by press- 
ure inward to dislodge the neck of the bone from the 
projection on which it rests, followed by traction down- 
ward and then outward, the ossicle is extracted ; no force 
is required to rupture the tendon of the tensor tympani 
or the superior ligament, as they offer very little resist- 
ance. 
It will be necessary now to wipe out the blood which 
has followed the removal of the malleus, but in most 
cases a single pledget of cotton will dry the cavity com- 
pletely. The incus is next sought for, and, if in sight, is 
grasped with the forceps and removed, traction being 
exerted at first downward and then outward. Most fre- 
quently when the incus is in view, the long process will 
be seen, not in the normal location but lower down, and 
lying close to the border of the tympanic ring, so close, 
frequently, that it is easily overlooked, apparently con- 
stituting a part of the ring. Manipulation by means 
of a probe reveals its identity, and the ossicle can be 
extracted in the manner already described. This dis- 
placement of the incus downward and backward is due 
to the fact that in the removal of the malleus the capsu- 
making it probable that, after removal of the ossicle, the 
flap of the membrane would fall inward and adhere to 
the tissues over the oval window, thus affording no bar- 
rier to the entrance of sound, here again stapedectomy 
might be chosen ; it is also applicable to certain cases 
in which, for any reason, general anaesthesia is objection- 
able, the patient possessing sufficient self-control to per- 
mit of the operation being done under local anaesthesia. 
As before stated, the membrana tympani is often par- 
tially or completely anaesthetic, and, after an opening has 
been made into the middle ear, perfect local anaesthesia 
can be obtained by the introduction of a ten per cent, so- 
lution of cocaine. Much will here depend upon the com- 
mand which the patient has over himself, and the opera- 
tor is certainly working at a disadvantage, but special 
circumstances may make the trial advisable, the possibil- 
ity of failure having been explained to the patient before 
the attempt is made. In all other cases, however, I be- 
lieve it is much simpler to clear away the other structures 
first, and then to decide whether the stapes should be re- 
moved or left in situ. 
The technique for the removal of the membrana tym- 
pani, malleus, and incus is the same whether the stapes 
is to be removed or left in position ; hence, to describe 
both operations separately, would be but a repetition. 
I shall give, therefore, the steps for the removal of all the 
ossicula, the reader understanding that, in case the stapes 
is to remain, the steps to be carried out up to this point are 
exactly the same. The method of operating differs some- 
what, in cases where the membrana tympani is intact, 
from that employed when it is partially or almost com- 
pletely destroyed, and the technique in each will be given. 
Technique of the Removal of the Membrana Tympani 
and the Ossicles when the Membrana Tympani is Intact. 
-With the sharp knife (Fig. 156, F) an incision is made 
through the membrana tympani in the upper and pos- 
terior quadrant, commencing just below the point where 
the posterior fold meets the tympanic ring, and, following 
this curve, is carried downward to about the middle of 
the posterior border of the ring. This incision is made 
close to the insertion of the membrana, but should lie 
entirely in the clear membrane, for the reason that if this 
is done no hemorrhage results. For the same reason 
care must be taken not to wound the inner wall of the 
tympanum with the point of the knife, as any bleeding 
greatly obscures the field of operation, and renders the 
succeeding steps more difficult. The edges of the in- 
cision are now separated, and the incudo-stapedial artic- 
ulation is usually clearly and easily exposed. If suf- 
ficient space is not gained, a horizontal incision may be 
made from the upper extremity of the first, forward 
toward the short process of the malleus, the section fol- 
lowing the course of the posterior fold, and lying just 
below it, thus avoiding the more vascular tissues. In this 
way a flap is formed, which, on being turned downward, 
enables the operator to see the incudo-stapedial articula- 
tion clearly. The next step is the division of the stape- 
dius tendon ; this may sometimes be seen, running from 
the neck of the stapes backward, disappearing behind 
the tympanic ring ; frequently, however, the head of 
the stapes lies so close to this structure that the tendon 
cannot be seen ; in such a case the pointed knife used in 
dividing the membrana tympani is inserted close to the 
head of the stapes, and slightly above it, and carried in- 
ward until the inner wall of the tympanum is reached ; 
a short cut downward is then made, carrying the knife 
between the head of the stapes and the tympanic ring, 
while the point is still firmly pressed upon the inner wall 
of the tympanum. In this way the muscle is thoroughly 
divided. When the tendon can be seen, its division is 
perhaps more simple, but in either instance the point of 
the knife should be firmly pressed against the inner wall 
of the tympanum, in order that the tendon and any ad- 
hesions about it may be thoroughly and completely sev- 
ered. 
As soon as this has been done, the action of the tensor 
tympani will bring the incudo-stapedial articulation and 
the stapes more clearly into view. The next step is the 
division of the incudo-stapedial articulation, which is ef- 
255 Ear Operations. 
Ear Operations. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
lar ligament binding the two ossicles together must be 
ruptured. The incus itself is attached to the tympanic 
wall simply by means of a single ligament running from 
the short process of the incus to the wall of the fornix 
tympani. Traction downward on the malleus displaces the 
incus downward and also revolves it backward, the short 
process being the fixed point. Thus, frequently, after the 
malleus has been removed, careful inspection of the field 
of operation fails to reveal any trace of the incus, it hav- 
ing been rotated entirely out of sight behind the tym- 
panic ring. To effect its extraction is not always easy, 
and yet in cases where there has been no suppuration it 
will rarely happen that the ossicle will escape. When 
not in sight, the long process of the incus can be easily 
brought into view by means of the incus hooks (Fig. 156, 
H). These hooks are curved in opposite directions for 
the right and left ear, the concavity of the curve looking 
anteriorly in each case when the instrument is inserted 
into the handle with its angular extremity directed up- 
ward. The incus hook is passed into the tympanic 
cavity, and the angular portion passed behind the tym- 
panic ring close to the floor of the canal, the hook being 
inserted in such a way that the concavity of the hook 
looks upward. When the angular portion of the instru- 
ment has entirely disappeared behind the ring, the in- 
strument is drawn outward until it is felt to press closely 
upon the inner surface of the tympanic ring, when it is 
rotated forward, at the same time being carried a little 
upward. Usually this manipulation swings the long 
arm of the incus into view. The difficulty sometimes 
met with in securing the incus usually lies in the fact 
that the operator is inclined to search for the ossicle too 
high up in the tympanum and to forget that the long 
process lies close to the margin of the ring ; the hook is, 
therefore, frequently carried too deeply into the tym- 
panic cavity and fails to engage the long process. This 
manoeuvre is to be repeated several times in case the first 
effort is not successful. If no free body is felt with the 
hook posteriorly, it is then inserted into the tympanum, 
at the anterior inferior portion, with the curve of the 
hook directed posteriorly ; the hook is now rotated, 
sweeping the extremity which hugs the tympanic ring 
closely, backward, and at the same time carrying the in- 
strument somewhat upward. This manipulation will 
bring the incus into view in case the posterior ligament 
of the incus was ruptured during the removal of the 
malleus, allowing the ossicle to fall into the lower part 
of the tympanic cavity, an event which may sometimes 
happen. 
If the ossicle is not found in either of these situations 
the hook should be swept upward and forward through 
the postero-superior and superior portions of the tym- 
panic cavity, keeping it still pressed firmly against the 
internal margin of the ring. Care is to be taken in this 
manipulation that the hook does not pass between the 
crura of the stapes or fracture them as it is carried 
forward. If the ossicle still remains hidden, the hook 
having the opposite curve should now be used, being 
carried into the fornix tympani, with the concavity di- 
rected backward, the angular portion of the instrument 
being hooked behind the inner extremity of the superior 
wall of the meatus ; the instrument is now rotated 
backward, and at the same time is carried downward, 
rotation being continued through an angle of 180°. The 
object of this manipulation is to dislodge the incus, 
in cases -where its posterior ligament is very strong, or 
where the long process has been rotated far backward out 
of reach of the hook. After this downward sweep it is 
well to repeat all of the steps for dislodging the incus in 
the order named, as this last manipulation may displace 
the ossicle downward, although it may still remain hid- 
den from view. The objection to beginning the search 
in the manner last mentioned lies in the fact that if the 
ossicle is already free, or nearly so, the manipulation 
is apt to displace it so far toward the mastoid an- 
trum as to render it entirely inaccessible. I have writ- 
ten upon the method of extracting this ossicle some- 
what at length, because I believe it to be extremely im- 
portant to remove it if this be possible, and I feel certain 
(SUPPLEMENT.) 
that the advantages gained in its extraction are more than 
enough to warrant prolonging the operation for this pur- 
pose. 
After the incus has been removed the cavity is thor- 
oughly dried, and the region of the round window in- 
spected. Any thickening in this situation should be 
overcome by cutting away the hypertrophied tissue, if 
present in sufficient amount to permit of this. Usually, 
however, we find simply a thickening of the mucous 
membrane about the fenestra. Stellate incision of this 
thickened tissue, by means of the angular knife (Fig. 156, 
B), most frequently relieves the tension. 
The stapes is next inspected and its mobility tested. 
If rigid, all adhesions about it should be divided ; if its 
motion is now free, the operation may be considered 
completed. If, on the other hand, the motion of the stapes 
is still impeded, or if the adhesions have been found so 
extensive that, after these have been divided, cicatrization 
will probably render the ossicle rigid again, the stapes 
should be removed. All soft tissues binding it down 
should be carefully severed with the sharp knife passed 
around the foot-plate, after which a delicate hook is 
passed between the crura and the ossicle is removed by 
traction. It is often more easy to grasp the head of the 
bone with the forceps, and remove it in this way than by 
making use of the hook. 
In cases where difficulty is experienced in finding 
the incus, and it is deemed necessary to remove the 
stapes, this ossicle being easily seen, it is often wise not 
to delay the removal of the stapes until the incus is 
found, since in the manipulations necessary to displace 
the incus the crura of the stapes might be accidentally 
broken, or the head of the bone be so displaced as not to 
be easily seen. Hence, if the incus is not readily found, 
the stapes may be removed as the second step of the op- 
eration, and the incus subsequently searched for. If the 
stapes is removed at this stage of the procedure, care must 
be taken in searching for the incus that the incus hook 
is not passed through the oval window, thus injuring the 
labyrinth. This may seem a needless precaution, but 
any one who has studied the parts upon the cadaver will 
appreciate how easily the incus hook could be passed 
through the thin membrane covering the fenestra ovalis. 
The reason of this lies in the fact that the plane of the 
oval window is not vertical, but inclined downward and 
outward. When this opening is situated high up, and is 
almost hidden by the tympanic ring, the incus hook may 
be easily carried under its upper margin and through 
the membrane covering the opening, the operator mis- 
taking the resistance offered for that of the tympanic 
ring. If the posterior wall of the canal is closely fol- 
lowed, and the incus hook made to enter the tympanum 
low down, and it is made afterward to hug the tympanic 
ring closely, this accident cannot occur, 
In some instances the margin of the tympanic ring 
hides the stapes so completely that this ossicle can 
hardly be seen, and it is impossible to form an intelligent 
opinion as to its condition, or to effect its removal. In 
such an event the margins of the ring in this situa- 
tion may be cut away by means of the forceps shown in 
Fig. 159. These forceps are so constructed that when 
open the distal extremity of the lower blade can be passed 
up behind the tympanic ring. Upon closing the instru- 
ment the chisel blade cuts away a small chip from the 
overhanging wall. By repeating this procedure, enough 
space can be gained to permit of access to the stapes 
and oval window. 
Occasionally the foot-plate of the stapes will be found 
to be so firmly fixed in the oval window that it cannot 
be loosened, and that after dividing all adhesions its 
removal is impossible, the crura sometimes being broken 
in the attempt at extraction. In such an event the oper- 
ator should proceed with the greatest caution. All the 
soft tissues should be carefully removed from the oval 
niche by means of the short angular knife (Fig. 156, B) 
and a delicate curette. If the outline of the foot-plate 
can now be made out, a pointed knife should be carried 
around its periphery, in the hope of making an opening at 
some point where the union is less firm ; through such 
256 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Ear Operations. 
Ear Operations. 
an opening a delicate hook can be introduced and a part 
at least of the foot-plate brought away. If complete 
ossification has taken place, I should advise the cautious 
use of a small guarded drill, which might be made to 
perforate the foot-plate at its centre, after which portions 
might be removed with the hook. I have never had oc- 
casion to do this upon the living subject, but should not 
hesitate to do so, using, of course, great care ; it would 
be possible to carry out this step without evacuating the 
perilymph, but even if a small quantity of the fluid 
should be lost, Kessel's66 observations have proved that 
no harm results. 
After all the operative steps deemed necessary have 
been carried out, the cavity is to be dried with pledgets 
of cotton, and a tampon of iodoform gauze introduced. 
This is packed rather firmly into the tympanum, while 
the canal is but loosely filled. The object of the gauze 
is to check any oozing which may occur, and prevent the 
formation of a blood-clot within the middle ear, for if 
this is allowed to form it may give rise to considerable 
pain, by preventing the escape of secretion during 
the first days after the operation, at which time its 
removal is apt to be somewhat painful. A few hours 
after the operation, this tampon is removed, and the 
ear douched with a warm weak antiseptic 
solution, such as a saturated solution of boric 
acid, ora solution of bichloride of mercury, 
1 to 8,000, after which the tam- 
pon is reinserted. When the 
odor of iodoform is objection- 
able, sterilized or borated gauze 
(SUPPLEMENT.) 
of discharge after the operation will depend upon the 
habit of the patient, and also upon the condition of the 
mucous membrane of the tympanum. In cases of ad- 
vanced sclerosis, the amount is frequently insignificant, 
especially if the patient is not of a full habit. On the 
other hand, when the tympanic cavity or the fornix 
tympani has been full of connective tissue rich in blood- 
vessels, the discharge following the operation will be 
more profuse. It is probable, also, that prolonged ma- 
nipulation within the cavity at the time of the operation, 
favors a more profuse discharge, although this is cer- 
tainly not so in all cases, and should not deter the oper- 
ator from doing a deliberate and thorough operation. 
I have written somewhat at length about the manage- 
ment of the cases after operation,' because I consider this 
an important point. In a general way, the less that is 
done after the operation, the more likely we are to obtain 
a permanent opening into the tympanic cavity, a condition 
always to be desired. Hence, the aim should be to keep 
the ear clean with as little manipulation as possible, and 
to avoid the use of astringents or caustics 
to stop the discharge, since they will cer- 
tainly promote the reformation of the 
tympanic membrane. 
With reference to the amount of dis- 
turbance caused by the above procedure, this is 
very slight. In forty cases, both purulent and 
non-purulent, all, with the exception of five, left 
the hospital twenty-four hours after the operation, and 
resumed their regular daily work without the least 
trouble ; and quite a number returned home upon the 
evening of the same day, the operation having been 
performed in the afternoon. Of course the stapes was 
not removed in all of these cases, and when the ossi- 
cle is taken away, I prefer to confine the patients to the 
house for twenty-four hours at least; yet in three cases 
of stapedectomy the patients returned home in less time 
than this, without any unpleasant effects, while in two 
cases in which this ossicle was left in situ, but had been 
subjected to considerable manipulation in securing the 
incus, dizziness persisted for several days after the opera- 
tion. As a rule, the patient can be assured that any 
general disturbance, sufficient to incapacitate him for 
work, will not last more than twenty-four hours, an item 
of importance among those who find it impossible to 
obtain a longer respite from their daily vocation. Of 
this we can be as certain as in allotting the same period 
for the disappearance of the unpleasant effect of general 
anaesthesia, and the surgeon is justified in promising 
that the effects of the operation will not detain the pa- 
tient, after the disturbance due to the anaesthetic has 
passed away. When the stapes is to be removed, how- 
ever, the dizziness may make locomotion difficult for a 
somewhat longer1 period, and if there is a probability 
that this will be necessary, it is not wise to promise that 
the giddiness will not interfere with locomotion for sev- 
eral days, although in quite as many cases the reverse 
has been true. If the malleus and incus alone are re- 
moved it will be decidedly rare for any such disturbance 
to follow. 
Pain or severe local inflammation I have never met 
with as the result of these operations, for the reason, I 
believe, that such perfect drainage exists that no reten- 
tion of secretion is possible. In this respect I feel certain 
that the complete removal of the ossicles and membrane 
commends itself, wdien compared with some of the intra- 
tympanic operations, in which less apparent violence is 
done, but in which free drainage is not secured. 
As regards the partial or complete reproduction of the 
membrana tympani, my experience has been that, as a 
rule, the membrane will reform, although this is not 
always the case. For dealing with this result the re- 
moval of the two larger ossicles is of great advantage. 
The membrane which reforms is usually thin, and not 
as sensitive as the normal membrane, and its removal is 
but a trivial matter, both for the patient and surgeon. 
Again, its reproduction does not always impair the result 
of the operation. In cases, however, in which, after the 
membrane has been reproduced, the hearing becomes 
Fig. 159.-Cutting Forceps for the Removal of a Portion of the Inner Ex- 
tremity of the External Auditory Canal. 
may be used. This second tampon is allowed to remain 
for from twelve to twenty-four hours. The subsequent 
treatment depends upon the amount of local reaction fol- 
lowing the procedure. If there is but little discharge, the 
cleansing of the ear once daily by the surgeon, followed 
by the insufflation of boric acid, dermatol, or some kin- 
dred powder, will be all that is necessary. If the patient 
cannot be seen daily, as is usually the case in dispensary 
practice, gentle syringing of the ear once or twice daily, 
according to the amount of discharge, is all that will be 
required, and I have never thought it wise to trust the 
insufflation of any powder to the patient. When the 
discharge is only slight, even the syringing is objection- 
able, and an intelligent patient may be allowed to cleanse 
the ear, by simply wiping it out with a pledget of cotton 
wound upon an appropriate cotton-holder. On the other 
hand, if at the end of a week there is still considerable 
secretion, the patient is directed to instil a few drops of a 
solution of boric acid in alcohol, of a strength of twenty 
grains to the ounce, after each syringing. The amount 
257 Ear Operations. 
Ear Operations. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
worse than while a perforation was present, it should 
be removed. General anaesthesia, in iny experience, 
has never been necessary; a pledget of cotton smeared 
with a ten per cent, ointment of cocaine in lanolin, ren- 
ders the membrane sufficiently anaesthetic for incision ; 
after which a drop of a ten per cent, aqueous solution of 
cocaine, introduced into the tympanic cavity, renders 
the remainder of the operation painless. The operation 
is best performed by passing the straight knife (Fig. 156, 
F) through the membrane close to the tympanic ring 
and just above the head of the stapes, and dividing 
the posterior attachment of the membrane close to the 
ring for a short distance, great care being taken not to 
wound the mucous membrane of the tympanum. The 
probe-pointed knife should then be substituted, and 
the attachment followed downward to its lowest point. 
It will then be found that the tissue is so relaxed that 
division of the anterior attachment is difficult; to over- 
come this, the sharp knife is again passed through the 
membrane at its upper part, just in front of the original 
puncture. A little pain is usually experienced from the 
incision, but it is only momentary. The anterior at- 
tachment is now divided downward with the blunt knife, 
until the incision meets that which severed the posterior 
attachment. Usually the relaxation interferes with the 
complete section. The membrane is now held by a thin 
strip of tissue above and below. A touch with the sharp 
knife severs these attachments, or weakens them to such 
an extent that the entire membrane can be easily removed 
with the forceps. The procedure is so simple that if at- 
tention is given to the aseptic condition of instruments 
and field of operation, no reaction results. The opera- 
tion may be performed safely at the office of the phy- 
sician, and the patient at once allowed to resume his 
usual duties. It is well to protect the ear by the insertion 
of a cotton pledget, which need not be worn for more 
than twenty-four hours after the removal of the new 
membrane. The patient should be cautioned to guard 
against taking cold, but, further than this, no special pre- 
cautions are necessary, The procedure is not likely to 
be followed by any discharge, and all syringing of the 
ear is to be avoided, unless pain or profuse discharge su- 
pervene, as disturbing the parts in any way may excite 
enough reaction to cause a reproduction of the mem- 
brane. 
One point is worthy of special attention, and that is, 
that the removal of a membrane which has formed after 
operation should not be undertaken until all traces of in- 
flammation have disappeared. The surgeon must wait 
until the newly formed tissue is pearly white and glis- 
tening, and until the mucous lining of the tympanum 
has also assumed its normal condition, as evidenced by 
the absence of redness, engorgement of its vessels be- 
ing easily made out through the thin cicatricial mem- 
brane. If this rule is not observed the operation will be 
more painful, and reproduction is almost certain. If 
the membrane reform again, a second or third removal is 
still more simple, as the density of the tissue is less each 
time that it is reproduced. In one case this was so 
marked that after the first incision the edges of the 
wound retracted so widely that it was possible to re- 
move only a minute portion of the new-formed tissue, 
and yet the tympanum was freely exposed, and no re- 
production has followed at the end of several months. 
In plethoric individuals a persistent reproduction of 
the membrana tympani after excision can be prevented 
by a restriction of the diet for a few weeks previous to 
and following the secondary removal of the structure. 
This is suggested by Sexton,* and I have proved its 
efficacy. 
In certain instances it may be found that the new 
membrane has become adherent to the inner wall of the 
tympanum, thus rendering its complete removal diffi- 
cult. In one such case, in which the stapes had been left 
in situ, the hearing remaining impaired, apparently on 
account of the stapes being bound down by the newly 
formed membrane, this structure was divided first be- 
hind the head of the stapes and the incision carried 
downward close to the tympanic ring for a distance equal 
to about one-third its posterior margin. The stapes 
then lay free while in front there was a flap, attached 
by adhesions to the inner tympanic wall ; this flap was 
turned forward and the underlying wall of the tympa- 
num was scarified, after which the flap was replaced 
and pushed down upon the wall of the middle ear, care 
being taken that the free margin lay below the tympanic 
ring. Adhesion at once resulted, leaving the stapes pro- 
jecting into the canal, while the tympanic cavity was 
largely obliterated from the adhesion of the membrana to 
its inner wall. Thus the middle ear was thoroughly 
protected by a cutaneous covering, while the parts essen- 
tial to audition remained accessible for further operative 
procedure. The patient, though better, is still under 
treatment, and I hope for still further improvement fol- 
lowing the division of remaining bands which bind the 
stapes. It may be advisable in certain cases to preserve 
the anterior portion of the membrana tympani in re- 
moving the malleus and incus, and, after scarification of 
the inner wall of the tympanum, to attempt to secure 
adhesion of the anterior segment of the membrana to 
this. In this manner we might shut off the anterior part 
of the tympanic cavity from the posterior portion, which 
contains the structures concerned in audition. The pos- 
terior portion would in this manner become covered by 
epithelium from the surface of the membrana tympani, 
and the objection of having an exposed mucous surface 
would be avoided. In this manner we could by care 
secure a thin epithelial covering for the round and oval 
windows, the stapes being removed, or not, according 
to indications. 1 have never performed the operation 
with this object in view, but from the fact that nature 
occasionally succeeds in doing this unaided, it may not 
be out of place to suggest it here as worthy of trial. 
Technique of Operation where the Membrane is Partially 
or Almost Completely Destroyed.-When a purulent in- 
flammation has resulted in the destruction of a consider- 
able portion of the membrana tympani, the method of 
procedure must be to a certain extent modified. In some 
of these cases we shall find the lower portion of the mem- 
brana wanting, the membrana flaccida thickened and 
highly vascular, binding the ossicles down and concealing 
them more or less completely; we may be able to rec- 
ognize by inspection only the prominent short process 
of the malleus and a portion of the manubrium, the lat- 
ter lying almost horizontal, its tip bound firmly to the 
upper part of the inner tympanic wall. Behind the 
short process examination with the probe reveals the 
incus and stapes as present, but whether in their entirety 
or not cannot be determined. In other cases, while 
there may have been extensive destruction of the mem- 
brana tympani, the posterior superior segment is cov- 
ered with a thin cicatricial membrane through which 
the incudo-stapedial articulation is plainly seen, or this 
joint may be completely exposed, no covering being pres- 
ent. My rule has been in all cases where the incudo- 
stapedial articulation is visible, or where this region is 
covered by a non-vascular membrane whose division 
will not lead to annoying hemorrhage, to first divide the 
stapedius muscle and then the incudo-stapedial artic- 
ulation, in the manner described when considering the 
method of operation in cases in which the membrana 
tympani is intact. When, however, it is evident that an 
incision in this region will be followed by hemorrhage, 
such a step only serves to complicate the operation, as 
the bleeding will render it impossible to see the incudo- 
stapedial articulation and divide it with certainty, and 
will frequently completely obscure the field of operation 
and hide even that most prominent and inlportant land- 
mark, the short process of the malleus, and considerable 
difficulty may be experienced in removing this ossicle 
even. Experience shows us that when this condition 
exists there is very little hemorrhage after the mem- 
brana flaccida has been completely freed from its attach- 
ments and removed, together with the malleus. Our 
first step, then, must be to insert the straight pointed 
knife above the short process, pushing it inward and 
* The Ear and Its Diseases, New York, 1889, p. 392. 
258 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Ear Operations. 
Ear Operations, 
upward until the inner wall of the tympanum is en- 
countered, where it is made to divide rapidly the 
attachments of the remnant of membrane to the tym- 
panic ring by directing its edge backward and incising 
close to the margin of the ring, and then, without re- 
moving it from the wound, to turn the edge in the op- 
posite direction and divide the anterior attachments. 
In cutting backward the operator must bear in mind 
that the incudo-stapedial articulation has not been sev- 
ered, and in this region as little force as possible should 
be used ; for this reason also the posterior incision should 
be first made as above directed. Almost immediately 
the fundus of the canal fills with blood, but for a few 
seconds at least the short process is plainly visible, and 
if examination has shown us that the manubrium is not 
firmly bound to the promontory, the malleus is at once 
seized with the forceps just below the short process and 
removed in the manner already described. If, however, 
firm adhesions are known to exist, or if the malleus is 
found to be firmly fixed upon grasping it with the for- 
ceps, no force should be used to effect its removal, but 
the canal should at once be tamponed firmly with cotton 
by carrying an elongated plug to the tympanic cavity 
with the forceps and pressing it firmly upon the tympanic 
wall, the remainder of the plug being then forced inward. 
Upon this tampon a second and third are crowded until 
there is no bleeding about the plugs. If held in position 
for a few moments and then removed with the forceps, 
the field of operation will be found to be dry, the bleed- 
ing having been entirely checked. Any given area can 
be more completely cleansed by touching it with a small 
pledget wound upon a cotton-holder. The adhesions 
binding the malleus to the promontory can now be di- 
vided with the blunt knife curved on the flat (Fig. 156, D), 
after which the ossicle is removed by means of the for- 
ceps. If the malleus is still firmly fixed, manipulation 
by means of the probe will determine the situation of the 
undivided attachments, and their section can be effected. 
When it has been possible to divide the incudo-stape- 
dial articulation as the initial step, I frequently remove 
the malleus in the manner above described as the second 
step of the operation, in place of first freeing the rem- 
nant of the membrane from its peripheral attachments 
below, anteriorly, and posteriorly ; this, of course, ap- 
plies to cases in which the greater portion of the tym- 
panic membrane has been destroyed. When only a com- 
paratively small portion of the membrana vibrans is 
wanting and excision is deemed proper, it may be 
well, after dividing the incudo-stapedial articulation, to 
sever the peripheral attachments of the membrane from 
below upward, by means of a blunt knife introduced 
through the perforation. As a rule, however, so many 
adhesions exist between the inner tympanic wall and 
the lower portion of the membrana that such a proced- 
ure is unadvisable ; moreover, the parts are frequently 
so vascular that the attendant bleeding may complicate 
the more important part of the procedure-the division 
of the superior attachments and the removal of the mal- 
leus. It is usually wiser, in these cases, to divide the 
upper segment first, the knife being carried into the 
perforation in terminating the posterior and anterior in- 
cisions. 
It may seem hazardous to subject the stapes to the 
possibilities of violence attendant upon removal of the 
malleus before the incudo-stapedial articulation has been 
divided. A moment's reflection will convince one, how- 
ever, that the increased formation of connective tissue 
which renders the procedure necessary also fixes the 
stapes so firmly that intelligent manipulation can scarcely 
■displace it, while the danger of inflicting such an injury 
is much greater if an attempt is made to divide the artic- 
ulation with the field of operation partially obscured by 
blood. Again, it frequently happens that the long pro- 
cess of the incus has become necrotic, and the articula- 
tion destroyed, so that no connection between the two 
ossicula exists. 
After the malleus has been removed, the stapedius 
muscle and incudo - stapedial articulation should be 
sought for and divided, unless this step has already 
(SUPPLEMENT.) 
been performed, after which the incus is sought for in 
the manner already fully described. It should be re- 
membered that as caries more frequently attacks the 
incus than any other ossicle, it may be partially or com- 
pletely destroyed. In the former case its removal is 
often difficult, while it is important to determine with 
certainty the latter condition, to avoid overlooking it if 
present, or a prolonged search if it is absent. It should 
also be borne in mind that the pathological process may 
have resulted in a bony union between the incus and mal- 
leus, and that both ossicles may be extracted together. In 
case both ossicles were intact, the operator could not over- 
look such an occurrence, but when one or both have been 
partially destroyed, careful inspection of the portions 
removed may be necessary, to determine simultaneous 
removal of the malleus and incus. The operator should 
then, upon extracting what he supposes to be the mal- 
leus, carefully examine it, in order to assure himself that 
the body of the incus is not attached thereto. If nothing 
but the malleus is found, the field of operation should be 
dried and inspected carefully. If no portion of the ossi- 
cle is seen, special attention should next be given to the 
posterior-superior segment of the field. It sometimes 
happens that the incision has not been close to the tym- 
panic ring in this region, a circumstance not easily recog- 
nized unless the parts are touched with the probe, when 
it will be found that a small curtain, or flap, of tissue 
remains undivided. A destruction of a small part of the 
ring at this point, as the result of caries, also gives rise 
to a similar appearance. It quite frequently happens 
that the incus is adherent to this flap, or completely con- 
cealed by it ; division of the soft parts close to the bony 
margin will, in such a case, bring the incus into view. 
If not found in this situation, the ossicle must be searched 
for with the incus-hook, in the manner already described 
while considering cases with intact membrana tympani. 
If all of these manipulations fail to bring the incus into 
view, or if it has not been felt, and the incus-hook can 
be carried freely, from behind forward, through the 
vault of the tympanum, the operator may decide that the 
ossicle has been destroyed by caries, or that it has suffered 
partial destruction, and the remaining portion has become 
amalgamated with the tympanic roof. If, however, it 
has been seen or felt at any time, its subsequent loss will 
mean dislocation into the mastoid antrum. 
The management of the stapes and the region of the 
round window is conducted in the manner already de- 
scribed. 
Any parts of the membrana tympani which may re- 
main in the lower portion of the fundus are to be re- 
moved with the knife and forceps if they are the seat 
of an hypertrophic process, as evidenced by considerable 
thickening and increased vascularity, as they may conceal 
areas of bony necrosis. If, however, the appearance of 
the lower portion of the membrane is healthy, we may 
feel certain that the bony structures are unaffected, and 
that there is no indication for the removal of the lower 
portion of the membrane ; in fact, its presence will hasten 
cicatrization. 
After drying the tympanum thoroughly we should 
next search for softened bone, both by inspection, which 
will often reveal here and there unhealthy granulation 
tissue indicative of the presence of dead bone, and with 
the probe, which should be made to explore thoroughly 
the entire inner wall of the tympanum, and should also 
be bent at a right angle at the tip, to enable the sur- 
geon to thoroughly explore the tympanic vault. The 
curette should then be freely used, and all granulation 
tissue and softened bone should be removed. For the 
atrium, the straight curette (Fig. 156, A) will be found 
serviceable, but for the vault the sharp spoons, bent at a 
right angle (Fig. 156, G), must be called into requisition. 
This procedure of thoroughly removing and curetting 
the entire cavity is of the greatest importance, and should 
be conducted with special care, as the ultimate success of 
the operation often depends quite as much upon this step 
as upon the removal of the ossicles. An area of softened 
bone in the vault of the tympanum will keep up the dis- 
charge for a long time, and render the result of the opera- 
259 Ear Operations. 
Ear Operations. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
tion far from satisfactory. Hence quite as much attention 
should be given to this procedure as to the removal of the 
ossicula. After the bony walls of the tympanum have 
been thoroughly curetted, the margins of the tympanic 
ring should receive attention. It frequently happens, 
when long-continued suppuration has existed, that the 
margin of the ring becomes involved. This is particu- 
larly true of the superior and postero-superior mar- 
gin, on account of its intimate relation to the ossicula, 
and because it is the floor of a portion of the vault of the 
tympanum. Any roughness or softening in this region 
should be dealt with in the same manner as in the case 
of a similar condition in other portions of the tym- 
panum ; all diseased areas should be removed with the 
curette, and a portion of the margin may be excised with 
the cutting forceps if necessary. 
After all these steps have been carried out, the treat- 
ment of the case for the first few days does not differ 
from the after-treatment of cases in which the membrana 
tympani was originally intact. The subsequent treat- 
ment, however, must vary with each individual case. 
While the discharge continues profuse, the ear must be 
cleansed with the syringe and mild antiseptic solution in 
the hands of the patient twice daily, or more frequently 
if this is necessary to keep the parts clean. At the end 
of a week, if there is considerable discharge, I recommend 
the instillation of the solution of boric acid in alcohol 
twice daily, after thorough cleansing. Any granulation 
tissue must be destroyed as it appears, by means of 
chromic acid, silver nitrate, the actual cautery, or any 
other destructive agent. If it is found that all carious 
bone has not been removed, lactic acid, applied by means 
of a cotton-tipped probe to the affected areas, is frequently 
sufficient to determine the formation of healthy granula- 
tion tissue, and effect complete cicatrization. Tl|,e con- 
centrated acid should be used, and should be thoroughly 
rubbed into the tissues. As the discharge becomes almost 
nil, the syringe may be dispensed with, and the patient 
allowed to cleanse the ear by means of pledgets of cot- 
ton wound upon any convenient probe, while the sur- 
geon may once or twice weekly insufflate a small quan- 
tity of boric acid, dermatol, or other mild antiseptic or 
stimulating powders, until all discharge ceases. It has 
been my good fortune, in all such cases, to either stop 
the discharge completely or to diminish it so much that 
it has ceased to be a source of annoyance. The length of 
time which must elapse after the operation, before the 
discharge will completely cease, must vary with each 
case, depending upon the extent of the original involve- 
ment. In general, from six to eight weeks will probably 
be the average time ; in some cases cicatrization may be 
perfect at the end of two or three weeks, while in others 
the same number of months must elapse. 
The technique given above varies in some particulars 
from that advocated by other operators. 
In the division of the incudo-stapedial articulation the 
ordinary direction is to enter the knife behind the long 
arm of the incus and divide the articulation by cutting 
downward and forward. Those who advocate this plan 
of procedure say that the pressure of the instrument 
is then opposed by the action of the stapedius muscle, 
and danger of in jury to the stapes is avoided, while at the 
same time the resistance of the stapedius renders the di- 
vision more easy. My own preference is to completely 
sever the stapedius tendon before attempting to disarticu- 
late, as by this means the articulation is brought more per- 
fectly into view by the action of the tensor tympani and 
tense ligamentous bands located anteriorly. If the stape- 
dius muscle is not completely divided as the initial step, 
the stapes, after disarticulation, is frequently pulled out of 
sight behind the margin of the tympanic ring. After divi- 
sion of the stapedius, disarticulation by the above method 
may dislocate the stapes, although this is not likely to 
occur. It is often difficult, however, to insert the knife 
between the tympanic ring and the long arm of the in- 
cus, and for this reason I prefer the method given in my 
description of the technique of the procedure-that is, to 
pass the angular knife in front of the long arm of the in- 
cus, and open the articulation by cutting downward and 
{SUPPLEMENT.) 
backward against the pull of the tensor tympani; or to 
open the joint at its lower aspect, and then to sweep the 
knife through it by carrying it backward and forward. By 
either of these methods the joint is more easily opened 
than when an attempt is made to carry the angular blade 
behind the long process of the incus, which frequently 
lies so close to the tympanic margin that considerable 
violence must be used in introducing the knife. 
In removing the incus Kretschmann,67 who was the first 
to formulate the procedure for removing this ossicle, 
made use of a hook which, in addition to the curve 
shown in Fig. 156, H, was bent outward at the distal ex- 
tremity, so that when the instrument was in position, the 
tip rested upon that small shelf-like structure of the 
superior wall of the canal which affords lodgement for 
the incus. He introduced the instrument with the con- 
cavity directed backward and brought the incus into 
view by rotation backward and traction downward. 
While this manipulation is no doubt of great value in 
certain cases, the backward rotation seems more likely 
to carry the ossicle far out of reach toward the mastoid 
antrum, in case it is not secured at once, and the ma- 
nipulation of attempting to bring the long process into 
view by passing a hook behind it and rotating forward, 
has in my hands proved very satisfactory, while it cer- 
tainly lessens the danger of displacing the ossicle far 
backward. 
The teaching that it is not advisable to make a prolonged 
search for the incus, seems to me to be unwise. In non- 
suppurative cases careful manipulation will render fail- 
ure to secure it exceedingly rare. If it has not been dis- 
placed, it must occupy its original position, and failure 
to bring the long process into the field of vision will 
render it impossible for the operator to be certain of a 
complete division of the incudo-stapedial articulation ; or 
if the head of the stapes is seen lying free in the field it 
is certain that the incus has been displaced, and, by acting 
as a foreign body, may give rise to trouble if allowed to 
remain. If the long process is in view there is no diffi- 
culty in removing the ossicle. 
In purulent cases it is still more important that the os- 
sicle should be removed. Ludewig58 found the incus 
carious in eighty-five per cent, of the cases upon which 
he operated ; in my own twenty-nine cases of purulent 
otitis, the ossicle was carious in nineteen, while in eight it 
had been completely destroyed. Prolonged manipulation 
in searching for the ossicle has not, in my hands, in any 
way added to the reaction following the procedure, nor 
has it interfered with the results. I should therefore 
earnestly advise prolonging the operation for the purpose 
of securing the incus rather than to perform a rapid ope- 
ration and fail in its removal. 
Among the complications which may interfere with 
the operation, hemorrhage is the one upon which especial 
emphasis is laid. Since I have operated with the patient 
in the semi-recumbent position, rather than with the head 
low, annoying hemorrhage has been the exception, rather 
than the rule. If it is sufficient in amount to interfere 
with the manipulation, it can always be checked by tam- 
poning the canal firmly with cotton pledgets. It is im- 
portant, in executing this manoeuvre, that the first 
pledget of cotton should be carried well into the tympanic 
cavity, and also that the individual pledgets should not be 
too large, as upon withdrawing a large tampon, the force 
necessary for its removal is likely to lead to a recurrence 
of the hemorrhage. This objection is overcome if a 
number of small plugs are used instead of a few larger 
ones. It may be necessary to repeat the tamponing 
several times, but it will certainly effect its purpose if a 
little patience is exercised. A ten per cent, solution of 
cocaine is said to be useful in checking a slight oozing, but 
I have never had occasion to use it. Schmiegelow 59 has 
reported one case in which the hemorrhage following an 
attempt to excise the malleus was so severe that he was 
obliged to discontinue the attempt. 
My own experience with intra-tympanic operations, 
more especially the particular class now under discus- 
sion, has led me to consider them remarkably free from 
risk. It is possible, however, for unpleasant sequela: to 
260 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Ear Operations. 
Ear Operation**. 
follow such procedures. Among these the most impor- 
tant are injury to the facial nerve, deafness due to im- 
paction of the stapes into the oval window, injury to the 
labyrinth from accidental removal of the stapes, either 
by direct traumatism, or by infection, etc., and inflamma- 
tion of the mastoid process. 
The facial nerve is occasionally injured by the incus- 
hook. The cause of this accident is to be found either in 
a congenital defect in the Fallopian canal, or in the partial 
or complete destruction of its wall as the result of disease. 
With the exercise of a little care in manipulating the in- 
cus-hook, bearing in mind that great force is not neces- 
sary to displace the ossicle, the accident can usually be 
avoided. If the facial nerve is touched by the instru- 
ment, the twitching of the face immediately warns the 
operator of what has occurred, and subsequent caution 
will prevent serious injury. In one of my own cases, 
Switching of the face was noticed while attempting to 
locate the incus, and upon recovery from anaesthesia 
there was marked paresis of the corresponding side of the 
face ; the facial nerve had been slightly involved before 
the operation, but after this the signs were much more 
pronounced. Daily faradization for about ten days was 
followed by complete recovery. Facial paralysis con- 
secutive to a similar operation also occurred in a case re- 
ported by Ludewig.60 
Complete loss of hearing following removal of the 
ossicles has occasionally occurred. In a case reported by 
Buck 61 the operator believed that the stapes had been 
impacted in the oval window during the operation. In 
one of Ludewig's62 cases the stapes was accidentally re- 
moved and the hearing was entirely lost, while Wurde- 
inann63 reports a case of excision of the malleus in a pa- 
tient about sixty years of age, in whom total deafness 
followed the procedure. The stapes was not interfered 
with in this case, and as there was persistent vomiting 
upon recovery from the anaesthetic, it is supposed that 
this led to a labyrinthine hemorrhage causing a com- 
plete loss of the power of audition. • It seems mani- 
festly unfair to record this as due to the operation, as the 
same accident might happen after anaesthesia for any 
other purpose. As far as accidental removal of the stapes 
is concerned, I cannot understand how it could have re- 
sulted in the total loss of the power of audition in Lude- 
wig's case. The author expressly states that there was 
no evidence of purulent inflammation of the labyrinth 
from infection, and if this can be excluded, the only 
other event possible would have been direct injury of the 
labyrinth after the removal of the ossicle, which at the 
hand of so experienced an operator as Ludewig cannot be 
thought of. We know, furthermore, that the removal 
of the stapes alone is not followed by impairment of the 
hearing, even if considerable perilymph is lost. I am in- 
duced to class this case as one in which the result can 
hardly be attributed to the operation. 
I have twice removed the stapes unintentionally : once, 
when there was ossification of the incudo-stapedial joint, 
the incus-hook removed the stapes, the incus being subse- 
quently secured; in a second case, no force being used, 
the incus-hook, swept upward and forward, brought away 
the stapes, which upon examination proved to be necrotic. 
As no force was used here, I believe that the stapes had 
already been detached from the fenestra ovalis by long- 
continued suppuration. In both the above cases the hear- 
ing was not impaired, and in one it was improved. 
With reference to severe mastoid inflammation as a 
sequel to the operation, Randall64 reports a case in which 
this occurred ; the observer remarks that the mastoid 
empyema may have been the result of an attack of in- 
fluenza, which was almost epidemic at the time, but is 
inclined to believe that as the incus was not found during 
the operation it had been displaced toward the mastoid 
antrum, and by obstructing the escape of secretion gave 
rise to the mischief. That such accidents must occasion- 
ally happen no one can deny, but that they are very rare, 
so rare in fact that they can almost be looked upon as 
curiosities, is also true. This case also adds weight to the 
opinion already expressed as to the importance of re- 
moving the incus. Among my own cases there has not 
(SUPPLEMENT.) 
been a single instance in which unpleasant symptoms 
have followed the operation, with the single exception of 
giddiness, and this has been severe in live cases only. 
My own operations of ^excision of the ossicles" now 
number forty. In eleven cases the membrana tympani 
was intact, and of these two had previously suffered from 
purulent inflammation of the middle ear, ending in com- 
plete recovery. In ten instances the operation was done 
for the improvement of the hearing, being performed 
once for the relief of tinnitus, although the hearing was 
considerably impaired. In ten of these cases the malleus 
and incus were removed and all adhesions divided. In 
one case the incus was not found. Of this number great 
improvement followed in six cases, moderate improve- 
ment in four cases, while in the case in which the oper- 
ation was performed for the relief of tinnitus, the hear- 
ing was not improved and the tinnitus was not relieved. 
Of the cases much improved, in three a permanent 
perforation remained as the ultimate result of operation, 
although in two it was necessary to perform secondary 
operations under cocaine anaesthesia to secure this. In 
two the membrana tympani reformed completely, but the 
hearing remained so good that secondary removal was 
not required. In the remaining case the hearing was 
much improved so long as an opening remained in the 
membrana tympani, but returned to its original condition 
when this became obliterated. The patient passed from 
observation, as she resided in a distant city, and I have 
been informed that the physician in attendance has not 
been able to secure a permanent opening. In this case 
the incus could not be found, but the mastoid had been 
chiselled for an empyema one year before, and, as the 
ossicle was not seen during the operation, I am inclined to 
believe that it had been displaced during the treatment 
of the previous suppurative inflammation. In most of 
these cases an interval of many months has elapsed since 
the removal of the ossicles, and the improvement con- 
tinues. It is only fair to say, however, that even when 
a permanent opening has been secured the hearing is not 
as good after the cavity has become completely dry, as 
immediately after the operation when the parts are moist. 
In those cases where the improvement continues, not- 
withstanding the complete reproduction of the mem- 
brana tympani, the hearing distance has remained as 
good as before the complete closure of the opening, and 
hence there has been no indication for further interfer- 
ence. 
Of the cases slightly improved, in one the receptive 
apparatus was known to be involved before the operation, 
and only slight improvement was hoped for. In the sec- 
ond the stapes was anchylosed, and could not be mobil- 
ized (in a similar case I should now remove it complete- 
ly) ; in the third, the operative treatment was resorted to 
at the request of a colleague, and the exact condition of 
the receptive apparatus was not known. In the fourth 
case, although the hearing was only slightly improved, 
tinnitus, which had been present, disappeared, and the 
hearing upon the opposite side became very much better. 
To this last fact I wish to call special attention, as it con- 
firms the observations of Cholewa, already alluded to in 
considering tenotomy of the tensor tympani muscle. I 
have found this true in more than this one case, and on 
one occasion, after subjecting the opposite ear to opera- 
tive treatment, this improvement disappeared. Since 
this time I have exercised great care in advising the em- 
ployment of surgical measures upon the better ear, when 
this has improved after an operation upon its fellow. 
Whether the phenomenon is to be explained upon the 
theory advanced by Gelle,*5 to account for the modifica- 
tion of the hearing upon one side, when the air in the 
external meatus of the opposite side is compressed, or 
whether it depends upon the fact already proven by 
Edinger,66 that the auditory nerve of one side receives 
fibres from the nucleus of the opposite side, I am not 
prepared to state. The influence which a pathological 
process in one ear exerts upon the functions of the other 
lias long been recognized, and it is strange that more 
attention has not been given to this point, in the hope 
that one ear at least may remain useful as the result of 
261 Ear Operations. 
Ear Operations. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
the early treatment of the affection upon the opposite 
side. The observations of Wharton-Jones,61 Politzer,68 
Urbantschitsch69 and others prove conclusively that this 
"crossed action" exists, and it certainly deserves more 
consideration than it has received. It carries with it the 
suggestion, however, that in cases where the conducting 
apparatus of both ears is affected, the receptive appara- 
tus remaining intact or nearly so, surgical interference 
shall be first tried upon the poorer ear, and the effect 
be noted not only upon the ear operated upon, but also 
on the opposite side. From certain facts, I am inclined 
to believe that the rule is also applicable to cases in which 
the impairment upon the more affected side, or upon 
both sides, is the result of a chronic purulent otitis. Cer- 
tainly I grow more and more cautious in advising opera- 
tion upon the better ear, until considerable time has 
elapsed after the operation upon its fellow. 
The above results, while not as gratifying as might 
be desired, still place the operation among the means 
which it is the duty of every otologist to advise when 
other measures fail. In this line Lucae10 has probably 
operated upon more cases of chronic proliferative otitis 
media than any other single surgeon. It should be men- 
tioned, however, that although he selected his cases with 
great care, and only operated when careful tests with the 
tuning-forks indicated a lesion of the conducting appara- 
tus, he was content in the large majority of cases to leave 
the incus. As already stated, I believe that the removal 
of the incus is very important. Lucae reports 53 op- 
erations, with the following results : In 9 there was 
marked improvement ; in 19 slight improvement; in 18 
no improvement ; while in 7 the hearing was impaired 
by the operation. Of the 9 cases in which the improve- 
ment was marked, the membrana was completely repro- 
duced in 3, while a permanent opening remained in 14 
of the cases in which there was only slight improve- 
ment. In these 53 operations the incus was removed in 
but 6 cases. 
In cases where the membrana tympani has been par- 
tially destroyed, most of my own operations have been 
performed primarily for the relief of the purulent dis- 
charge, the hearing in a large number not being so seri- 
ously impaired that operative interference was sought 
for this cause alone. In cases of this character, then, our 
report must show the effect upon the suppurative process 
and also upon the function of the organ. When the 
operation is undertaken for the improvement of the hear- 
ing, an opinion as to the probable result should be based 
upon the result of an examination with the tuning-forks, 
according to the suggestions already given. It should 
be remembered, however, that the general results of oper- 
ative procedures are better in such cases than when the 
inflammatory condition has been of the proliferative 
variety. Another fact which it is important to con- 
sider is, that when the hearing is good, surgical interfer- 
ence for the relief of purulency is not likely to impair 
the function of the organ. Thus in 29 cases of this char- 
acter operated upon by the writer, in but one case has 
the hearing been impaired, and from a knowledge of the 
patient, and careful examinations, it is more than proba- 
ble that this impairment is simulated. 
Of these 29 operations, in 18 cases the hearing improved, 
and in 10 cases it remained the same as before operation. 
In but two of these last cases was the operation performed 
for the sole purpose of improving the hearing, and in one 
an unfavorable prognosis was given, and surgical treat- 
ment was resorted to only at the earnest solicitation of 
the patient. No improvement followed in this case, con- 
firming in every way the opinion based upon the func- 
tional examination. On the contrary, in the other case 
the examination indicated that the removal of the ob- 
structing conducting apparatus should improve the hear- 
ing. In this instance removal of the malleus, incus, and 
stapes, and the section of dense adhesions over the round 
window improved the hearing in the ear operated upon 
to such an extent that with the opposite ear tightly closed, 
conversation could be understood, this being impossible 
before the operation. The hearing in the opposite ear 
improved at the same time, but as other factors may 
have influenced this, it cannot be certainly credited to 
the operation upon the other side. 
Of the 29 cases the discharge stopped completely in 15 ; 
it was greatly reduced in quantity in 9, while 5 cases are 
still under treatment. 
In 14 cases the malleus and incus were removed, and in 
4 the malleus, incus, and stapes. In 2 cases the ossicles 
had been completely destroyed by caries and the tym- 
panic cavity was thoroughly curetted. In a single case 
the stapes alone was present, and as the head was carious 
this was removed, the foot-plate being left in position. 
In another case the malleus and incus were firmly adher- 
ent to the walls of the tympanum and could not be re- 
moved, but by the aid of the curette the carious areas were 
scraped away and the case was completely cured. In 7 
cases the malleus alone was removed ; in 5 of these the 
incus had undoubtedly been completely destroyed by 
caries ; in 1 case it was overlooked during the operation, 
and subsequently found but not removed, while in the 
other case I may have displaced it into the mastoid an- 
trum, as I felt certain of its presence early in the opera- 
tion, but finally failed to secure it. 
Ludewig11 reports the results of removal of the malleus 
and incus in 75 cases, in 42 of which the discharge was 
cured as the result of the operative interference, while 
in 16 it continued after the operation. In 9 cases the pa- 
tients were still under treatment at the time the report 
was written. In 5 cases no report was obtainable as to 
the result of the operation. Death occurred in 3 cases, 
but in no instance could it be traced to the operation. 
Grunert,12 in 28 cases operated upon, reports 13 cured. 
In 13 the discharge continued, and 2 cases were still un- 
der treatment at the time of writing. When it is remem- 
bered that the cases above reported represent those which 
have resisted all other means of treatment, there can be 
no question as to the advisability of undertaking the 
operation. The great danger is that the surgeon may 
mislead the patient as to the probable result of the pro- 
cedure. It is seldom possible, in a given case, to assert 
positively that suppuration will cease completely after 
the operation. If the ossicles alone are carious, then 
their removal will put an end to the affection, but when 
the condition has existed for a long time it is quite pos- 
sible that the adjacent tympanic walls have become in- 
volved, possibly in such remote situations as to be inac- 
cessible to instruments. In such an event the procedure 
is advisable, but a complete cure cannot be promised. 
The indication for operation in such an instance lies in 
the fact that by the complete removal of the contents of 
the vault of the tympanum free drainage is afforded, and 
the danger of pus becoming confined in this space is re- 
duced to a minimum. For this reason particularly, I 
insist upon the removal of the incus, as its presence in- 
terferes with drainage, and moreover it is the ossicle most 
frequently affected. Of the 75 cases of purulent otitis 
operated upon by Ludewig this ossicle was found carious 
in eighty-five per cent. Among my own cases I can re- 
member no instance in which a healthy incus was 
removed. The probe sometimes enables us to determine 
the extent of the caries, but more frequently we are 
obliged to be satisfied with the simple fact of the presence 
of softened bone, without being able to define the extent 
of the area involved. 
As to the question of impairment of the hearing when 
the procedure is adopted for the relief of suppuration, the 
hearing remaining fair, the results given above indicate 
that in very few instances has the hearing been rendered 
poorer by the operation. Out of Ludewig's 75 cases this 
occurred 6 times. 
In view of the fact that all portions of the tympanic 
cavity are not accessible through the canal, and in order 
that the procedure may be more directly under the eye 
of the operator, Stacke73 prefers to expose the parts by 
external incision. His method is as follows : An incis- 
ion is made down to the bone, just behind the attach- 
ment of the auricle, and, following this in direction, from 
the tip of the mastoid process to a point just above the 
tragus. With a small elevator the cartilaginous meatus, 
and as much as possible of the periosteum of the osseous 
262 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Ear Operations. 
Ear Operations. 
canal are separated from the bony parts. In this manner 
the superior, posterior, and inferior aspects of the margin 
of the bony meatus are exposed, the soft parts being held 
only anteriorly. The soft parts are now divided trans- 
versely downward and forward, as deeply in the canal 
as possible, and by traction upon the auricle the funnel- 
like mass is pulled out of the bony meatus. The perios- 
teum of the anterior wall is next divided, when the en- 
tire cartilaginous meatus and a part of the thin cutaneous 
lining of the osseous canal can, by traction forward, be 
so displaced as to leave the margin of the bony meatus 
entirely free. The tympanic structures can then be seen 
by direct light and all affected parts removed. By means 
of the gouge, the superior and posterior margins of the 
inner extremity of the bony meatus can now be removed, 
and the stapes being protected by a proper instrument, 
the curette can be freely used in the vault of the tympa- 
num, the manipulations being under ocular inspection. 
In this manner the entire cavity can be completely cleared 
of necrotic tissue, and the mastoid antrum even may be 
exposed. In case there is evidence of serious mastoid 
involvement the original incision is made a little farther 
back than directed, and the antrum entered in the ordi- 
nary way, after which the tympanic cavity is exposed and 
treated in the manner above described, and finally the 
canal and the artificial opening into the antrum are thrown 
into one. In this way the middle ear, mastoid cells, and 
canal are converted into a single cavity, all parts of 
which are easily accessible through the external meatus. 
After the operation the cartilaginous canal is replaced, 
and a drainage-tube, completely filling its lumen, is 
passed into the bony meatus, thus preventing displace- 
ment. The external incision is sutured, all drainage be- 
ing through the meatus. In cases where the mastoid 
antrum has been freely exposed, it is usual to incise the 
soft parts of the canal longitudinally along the posterior 
aspect, and press the flaps thus formed backward into the 
cavity, holding them in position with tampons of iodo- 
form gauze. In this manner a cutaneous lining for the 
mastoid antrum is secured. The same result is attained 
by cutting a quadrilateral flap from the cutaneous canal 
and carrying it into the antrum. 
Stacke seems enthusiastic over this method of opera- 
tion in cases of caries of the tympanum, but my own ex- 
perience would lead me to employ it only in the most un- 
promising cases, and 1 should then be induced to first try 
the effect of excision of the ossicles in the ordinary man- 
ner. If there is mastoid involvement there can be no 
question as to the efficacy of the procedure. It should 
be borne in mind that the amount of space gained by ex- 
posure of the bony meatus is not as great as might be 
supposed, and unless the caries is extensive enough to 
make a thorough opening of the mastoid antrum desira- 
ble, a surgeon accustomed to operating through the canal 
will do quite as well by employing this method as the 
one above described. 
Stapedectomy.-Accidental removal of the stapes has 
already been referred to as having occurred during the 
removal of the malleus and incus at the hands of differ- 
ent operators. Kessel14 partially detached the foot-plate 
from the oval window in one of his cases. A quantity 
of perilymph was lost, but no serious consequences fol- 
lowed. Later, the experiments of Botey 15 proved that 
stapedectomy was not a serious operation, and might be 
beneficial in certain cases. It remained, however, for 
Jack16 and Blake1' to establish the removal of this ossi- 
cle as a distinct surgical procedure. The results reported 
by Dr. Jack are certainly very promising, and it is to be 
hoped that subsequent observations may demonstrate its 
utility beyond a shadow of a doubt. I have already 
given my own views upon the question of removal of the 
stapes alone, having clearly stated that they are not based 
upon any extended personal experience with the opera- 
tion. On theoretical grounds, it seems that perhaps the 
removal of the entire ossicular chain might be preferable, 
but experience alone can determine this fact. 
The procedure would be applicable to cases in which 
the hearing was impaired as the result either of non-sup- 
purative inflammation, or of a suppurative inflammation 
which had been cured, leaving the stapes in an accessible 
position. If suppuration is present, then removal of all 
the ossicles would be the proper operation. 
Steps of the Operation, (a) When the membrana tym- 
pani is intact, the incudo-stapedial articulation is exposed 
either by a curved incision in the postero-superior quad- 
rant, close to the attachment of the membrane to the 
tympanic ring, or by a triangular incision in this situation, 
or by the incisions already described in the operation of 
exploratory myringotomy. After the incudo-stapedial 
articulation is brought into view the stapedius muscle 
should be completely divided ; the incudo-stapedial artic- 
ulation is then severed, and the long arm of the incus 
pushed forward so as not to interfere with the subsequent 
steps. If the presence of the incus still interferes with 
the separation of the stapes the long process may be seized 
with the forceps, and the ossicle removed. The stapes is 
then freed from adhesions binding it to the oval niche by 
means of the sharp straight knife, and is removed by gen- 
tle traction with the forceps, or by a hook passed between 
the crura. It is important to sever the stapedius muscle 
completely before disarticulation, as otherwise, after dis- 
articulation, the stapes may be pulled out of view. If 
the foot-plate is found anchylosed, this condition may 
be treated in the manner already suggested ; although in 
such a case, as the parts would be subjected to more vio- 
lence, it is probable that removal of the malleus, incus, 
and membrana tympani would diminish the chances of 
reaction after the operation. 
Blake18 has advocated the performance of this opera- 
tion under cocaine anaesthesia, a ten per cent, solution be- 
ing first introduced into the tympanum, through the cath- 
eter. After the first incision through the membrana tym- 
pani, the direct application of the cocaine solution to the 
middle ear, by means of a cotton-tipped probe, renders the 
subsequent steps painless. In three cases of this kind I 
have been able to clear the oval niche in the above man- 
ner, no pain being experienced after the first incision. 
I am inclined to think that the introduction of cocaine 
through the Eustachian tube has very little effect in miti- 
gating the pain of the first incision, and if a very sharp 
knife is used this is never severe. After this no pain 
need be felt if the cocaine is carefully applied. My re- 
sults have been very satisfactory, but I am inclined, at 
present, to employ this method more as an exploratory 
than as a therapeutic procedure, for the purpose of de- 
termining how much improvement can be hoped for by 
any operation upon the conducting mechanism. When, 
for any reason, general anaesthesia is objected to-unless 
great improvement can be assured,-the measure above 
detailed is of great value in deciding this point; but 
under general anaesthesia, much more exact work can be 
done if the membrana and two larger ossicles are first 
removed. 
After the removal of the stapes the flap is replaced and 
the meatus is occluded by a plug of antiseptic cotton, 
which is left in position for several days unless inflamma- 
tory symptoms supervene. The wound usually heals in 
a few days, and in no case has the reaction been severe. 
(b) When the membrane is partially destroyed, the stapes 
or the incudo-stapedial articulation may be already in 
view ; but if they be not visible, the appropriate incision 
for the exposure of these parts will vary in each case, 
after which the technique given above is to be carried 
out. In two cases operated upon under local anaesthesia, 
the stapes being clearly in view, extraction was easily 
accomplished and the results were flattering, in one in- 
stance the hearing for a low whisper increasing from 
seven to thirty feet; here the entire stapes was removed 
intact. In the second case only a portion of the ossicle 
was secured, yet the improvement was considerable. It 
is well to bear in mind that even slight hemorrhage will 
render the removal of the stapes difficult, and when this 
region is covered by dense structures which bleed freely 
when incised, it may be necessary to remove the malleus 
and incus and remains of the membrane to secure a suit- 
able field for the performance of stapedectomy. 
The after-treatment may be the same as in the preced- 
ing class of cases. It is well, however, to inspect the 
263 Ear Operations. 
Electro-Thera p. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
ear at the end of twenty-four hours, and if signs of in- 
flammation are present, to cleanse it frequently with a 
mild antiseptic solution. If, however, the parts are per- 
fectly dry, they should not be disturbed, for fear of inter- 
fering with the healing process. 
Edicard Bradford Dench. 
1 Die Krankheiten des Ohres, Berlin, 1889. p. 32. 
2 Lehrbuch der Ohrenheilkunde, Wien, 1890, pp. 43 and 438. 
3 Transactions of the Medical Society of the State of New York, 1872. 
4 Transactions of the American Otological Society, 1892, vol. v., pt. 2, 
p. 314. 
5 Revue de Laryngologie, 1S00, vol. xi., p. 119. 
6 Archives of Otology, voL xix., p. 151. 
7 Philosophical Transactions, London. 1801. 
8 Archiv fiir Ohrenheilkunde. vol. v., p. 270. 
9 Contribuzione allo Studio della Medicena operatoria dell' Orrechio, 
et'-., Roma, 1878. 
10 Wien. allg. med. Ztg., 1803, p. 305. 
11 Monatsschrift fiir Ohrenheilkunde. vol. i., p. 31. 
12 New York Medical Record. March 27, 1875. 
13 Verhandl. des X. Internat. Congress, Berlin, 1892, vol. iv., pt. 11, 
p. 113. 
14 Diseases of the Ear, Am. edition, Phil., 1883, p. 375. 
15 Wien. Med. Woch.. 1871, p. 9. 
16 Allg. Wien. med. Ztg., 1873, p. 2. 
37 Ibid., 1871, p. 384. 
48 Archiv fiir klin. Chir., vol. xiii., p. 122. 
12 Lehrbuch der Ohrenheilkunde, Wien, 1888, p. 552. 
20 Topographische Anat. 
21 Berlin, klin. Woch., 1871, p. 574. 
22 Transactions of the American Otological Society, 1873, p. 81. 
23 Ibid., 1874, p. 577. 
24 Archiv fiir Ohrenheilkunde, vol. xi., p. 127. 
24 Ibid., vol. xi.. p. 124. 
26 Archives of Otology, vol. xix., p. 151. 
27 Archiv fiir Ohrenheilkunde. xxxii., p. 85. 
28 Lehrbuch der Ohrenheilkunde, Wien, 1888, p. 562. 
22 Lehrbuch der Ohrenheilkunde. Wien. 1891, p. 58. 
311 Diseases of the Ear, N. Y., 1883, p. 185. 
31 Loc. cit. 
32 Loc, cit. 
31 Loc. cit. 
34 Diseases of the Ear, Am. edition, Phil., 1883, p. 379. 
34 Op. cit., p. 562. 
36 Loc. cit. 
37 Archives of Otology, vol. xx., p. 13. 
38 Archiv fiir Ohrenheilkunde, vol. xix., p. 85. 
33 Transactions of the New York State Medical Society, 1872. 
40 Monatsschrift fiir Ohrenheilkunde, vol. i., p. 22. 
41 Archiv. fiir Ohrenheilkunde, vol. xxii., p. 122. 
42 Revue de Laryngologie, 1890. p. 49 et seq. 
43 Transactions of the American Otol. Society, vol. v., pt. 2, p. 311. 
44 Archiv fiir Ohrenheilkunde, 1874, vol. viii., p. 230. 
44 Ibid., vol. xxii., p,.128. 
46 Ibid., vol. xi., p. 199. 
47 Ibid., vol. xiii., p. 69. 
48 Ibid., vol. xxii., p. 228. 
42 The Ear and its Diseases, N. Y., 1888, p. 385. 
40 Archiv fiir Ohrenheilkunde, vol. xxv., p. 165. 
41 Ibid., vol. xxvi., p. 115. 
42 Ibid., vol. xxix., p. 241 ; vol. xxx., p. 263. 
43 Ibid., vol. xxxiii., p. 207. 
44 Transactions of the American Otological Society, 1892, vol. v., part 
2, p. 283. 
44 Ibid., p. 306. 
47 Loc. cit. 
47 Archiv fiir Ohrenheilkunde, vol. xxv., p. 165. 
48 Loc. cit. 
43 Hospitals Tidende, 3, R. V., Nos. 22-26. 
40 Archiv fiir Ohrenheilkunde, vol. xxix., p. 259. 
61 A Manual of Diseases of the Ear, New' York, 1889, p. 328. 
42 Loc. cit., p. 260. 
43 Journal of the American Medical Association, October 22, 1892 (re- 
print). 
64 Transactions of the American Otological Society, 1892, vol. v., pt. 2, 
p. 325. 
65 Archiv fiir Ohrenheilkunde, vol. xxviii., p. 58. 
46 Anat. Anzeig., 1887, Nos. 6 and 8. 
47 Frank's Ohrenheilk., 1855, p. 133. 
"8 Diseases of the Ear. Am. edit., Phila., 1883, pp. 346 and 688. 
69 Lehrbuch der Ohrenheilk., Wien, 1890, p. 416. 
70 Archiv fiir Ohrenheilkunde, vol. xxii., p. 233. 
71 Ibid., vol. xxix., p. 241: vol. xxx., p. 263. 
72 Ibid., vol. xxxiii., p. 207. 
73 Ibid., vol. xxxi., p. 201. 
74 Ibid., vol. xi.. p. 199. 
76 Am. Journ. of the Med. Sciences, vol. ci., p. 632. 
76 Trans, of the Am. Otol. Society, 1892, vol. v., pt. 2, p. 284. 
77 Ibid., p. 306. 
78 Archives of Otology, vol. xxii , p. 78. 
EASTBOURNE. One of the most popular seaside re- 
sorts in England. It is situated on the Sussex coast, 
between Brighton and Hastings. Eastbourne is only 
sixty-five miles from London. Dr. Yeo (" Climate and 
Health Resorts ") speaks as follows concerning the merits 
of this place : 
" The roads and streets have been skilfully planned and 
laid out on a uniform system, so as to secure abundance 
of space, free ventilation, and the picturesque planting of 
trees throughout the streets of the town. Moreover, the 
streets and other residential parts of -the town are not all 
huddled together close to the shore as in some resorts, but 
spread out over a considerable tract of land extending 
toward the magnificent downs behind the town, for three- 
quarters of a mile or more from the sea-shore. This is a 
great advantage, for it enables the physician to make use 
of Eastbourne for many patients who are not comfortable 
when close to the sea, and for others to whom the excit- 
ing effect of strong sea-air might prove injurious, while 
the pure, bracing air of the downs, which are so readily 
accessible from the inland part of the town, might be 
advantageous. 
" The sanitary arrangements are as complete as they 
can well be made, and an abundant supply of pure, soft 
water is obtained from wells sunk through chalk into the 
green sandstone. Every house has a constant supply. 
The sewers are freely ventilated, and the sewage flows 
into the sea at a point three miles away to the east, where 
the tides carry it away without the chance of its return- 
ing to the bay. The death-rate is low, the annual aver- 
age for the last three years being 14.18 per 1,000." 
The same author also states that during the summer he 
has known phthisical patients to do extremely well at 
Eastbourne, especially if they begin their stay by living 
away from the sea. Cases of torpid scrofula, of slow 
convalescence from surgical operations or injuries, cases 
of anaemia and general want of tone, cases of depressed 
function, nervous or digestive, are all suited to this place. 
In houses built to the west of the town, and with rising 
ground between them and the east, the winter tempera- 
ture is not unpleasantly low, and there is more than the 
average amount of sunshine. But those parts of the 
town which are unprotected from the east suffer much 
from the prevailing winds in spring. 
The country surrounding Eastbourne is attractive, and 
the place undoubtedly deserves the growing favor with 
which it is regarded in England. The accommodation 
offered in numerous hotels and lodging-houses is fairly 
satisfactory. Edmund C. Wendt. 
ELECTRO-THERAPEUTICS. The advances in elec- 
tro-therapeutics since the first issue of this work have 
been important. In no department, perhaps, has there 
been more activity than in the relation of electricity to 
the diseases of women. The most extravagant statements 
have been made by extreme partisans as to the extraor- 
dinary efficacy of the new methods in dissipating fibroid 
tumors, and in curing almost every variety of uterine dis- 
order. There is a large class, however, who are ex- 
tremely pessimistic in their views as to the therapeutic 
properties of electricity, and who deny that it possesses 
any considerable value in gynecology. 
When, however, a man possessed of the experience of 
Keith, of Edinburgh, can say that many are prejudiced 
against electricity because they consider it quackery and 
know nothing about it, that his confidence in its power 
to relieve disturbing symptoms of uterine fibroids and to 
cure many chronic inflammatory conditions of the pelvis 
continues to increase, and that he has no fear for the 
future of electricity, we have testimony that must greatly 
outweigh assertions and opinions that are purely nega- 
tive. 
In a recent and animated discussion of the subject at 
the Societe de Chirurgie of Paris, equally favorable opin- 
ions were advocated by the majority of those engaged in 
the debate ; and the strength of these opinions was accen- 
tuated by the fact that the majority of those who hold 
them are signally distinguished as laparotomists. 
A word in regard to the faradic current in its relation 
to diseases of the uterus. Its effects are mainly me- 
chanical, and according to the construction of the helix 
and the length and thickness of the wire do we measure 
its action on the muscular tissues of the uterus. Applied 
directly to the uterus of animals in physiological ex- 
periments, the organ visibly contracts, although not to 
264 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Ear Operations. 
Electro-Tlierap. 
such an extent as the intestines, which, on application of 
the electrodes, can be seen to draw up gradually, very 
much after the manner of a woman's work-bag. Its ac- 
tion on the smooth muscular fibres of the human uterus, 
when applied therapeutically, is analogous to that of 
ergot, although manifestly more prompt and energetic, 
especially under the influence of the positive pole, which 
possesses a much greater power over the involuntary 
muscles than the negative. It is a current of alternation, 
of constant closing and breaking ; hence it produces a sort 
of interstitial massage, heightening the activity of the 
circulation, accelerating absorptive processes, and influ- 
encing favorably the nutrition of parts. 
Faradization, by its power over muscular contractions, 
sensibly increases temperature. According to the chem- 
istry of the development of heat during muscular con- 
tractions, muscular work is the result of the decompo- 
sition of nitrogenous substances, and the muscles grow 
at the same time that they work and develop heat. That 
the value of the faradic current is more limited than the 
galvanic in the treatment of uterine disease must be im- 
mediately manifest to all who appreciate the difference 
between them ; but in some conditions which come within 
the range of its physical and physiological activities, the 
faradic current may exceed in efficiency the galvanic. 
By its direct excitation of the smooth muscular fibres of 
the uterus we are enabled to combat that stasis of the 
circulation which is the beginning of uterine inflamma- 
tion. 
By this method we obtain a veritable interstitial mass- 
age,'that is potent in overcoming the primary inertia of 
the organ and in preventing an arrest of retrograde meta- 
morphosis, through which comes sub-involution with its 
inevitable and persistent sequela}. In its purely local 
influence, then, faradization would seem to be preventive 
rather than curative, so far as it relates to uterine dis- 
ease ; or rather it is preventive, so far as concerns the 
latter conditions of uterine engorgement, and curative 
only in its initial stage. When the processes that go to 
make up the graver and more chronic diseases of the 
uterine parenchyma and its lining membrane have con- 
tinued a long time, as is usually the case when medical 
interference is sought, the simple mechanical effects of 
the faradic current would be altogether misdirected. 
Here we resort to the electrolytic influence of the gal- 
vanic current, or rather to what may be more fitly termed 
its galvano-chemical cauterizing effects through which 
are destroyed the granulations and fungoid growths of 
the diseased mucous membrane. By the interpolar in- 
fluence of the current we correct a languid nutrition and 
hasten the absorption of exudations. 
Just as the positive pole of the faradic current has an 
action of its own, superior in effect to the negative in 
causing uterine contractions, so the positive pole of the 
galvanic current has an action peculiar to itself. Here 
oxygen is generated and acids accumulate which render 
this pole directly haemostatic. It is, therefore, indicated 
in all hemorrhagic conditions, as well as where there ex- 
ists an excess of the natural secretions. Owing, also, to 
the greater retractibility of cicatrices following positive 
galvano-cauterization, the results are more lasting in the 
treatment of fungoid growths, or vegetations, than could 
possibly be the case with the negative pole. 
At the negative pole, on the contrary, the alkalies pre- 
cipitate, imparting caustic properties and causing effects 
fluidifying rather than haemostatic. The absorptive pro- 
cess is undoubtedly more active under this pole than 
under the positive, and is especially indicated in indurated 
chronic metritis and for the resolution of fibroids. 
That the galvanic current often completely dissipates 
fibroid tumors of the uterus few will, I believe, affirm. 
In the treatment of scores of fibroids on the external sur- 
face of the body, I have never yet seen a single instance 
where one of them completely disappeared. As a rule, 
the reduction is comparatively slight, unless suppuration 
is excited, which may be easily done. External fibroids 
are simply unsightly, and for this reason we desire to be 
rid of them ; ami as it is not possible to obtain more than 
a reduction in size, the knife is to be preferred, and elec- 
(SUPPLEMENT.) 
trolysis has fallen into disuse. We treat uterine fibroids, 
on the contrary, not because they are unsightly, but be- 
cause associated with them are a train of symptoms some- 
times of the most distressing character. These symp- 
toms can, it is believed, be relieved to a greater or less, 
extent by electrolysis, and sometimes so completely re- 
lieved as to lead to the belief, so far as the patient is con- 
cerned, that the tumor has entirely disappeared. In the 
great majority of cases, however, it is simply a symp- 
tomatic cure. The tumor is still there, but reduced in 
size, and so far as pressure upon surrounding parts is 
concerned, or any hemorrhagic tendency, it is entirely 
harmless. I am a firm believer in the great utility of the 
galvanic current in the thickenings and infiltrations re- 
sulting from inflammation of the pelvic cellular tissue. 
For the absorption of old exudations in other parts of the 
body, this treatment has long been used with excellent 
results, and in pelvic exudations the results are even 
better. I have seen the treatment, persistently carried 
out, result not only in the absorption of large pelvic de- 
posits, but in the cure of the most obstinate and severe 
sciatica, and in the restoration of power to partially para- 
lyzed limbs. In such cases, both sciatica and paralysis 
are caused, undoubtedly, by pressure upon the pelvic 
floor, and can be relieved only through the dissipation of 
the morbid products. 
There are two methods of action through which we 
obtain results from electrolysis. The first and most ap- 
parent is the absolute destruction of tissue which takes 
place at the time of treatment. Some suppuration may 
follow, and thus, by actual loss of substance apparent to 
the sight, the tumor decreases in size. If, however, 
these were the only active forces in the electrolytic pro- 
cess, the method would lose much of its effectiveness. 
If this be not so, how can we account for the many well- 
attested cases where morbid growths have entirely dis- 
appeared under simple external applications ? Herein is 
the difference between the electrolysis of organic and that 
of inorganic substances. In the electrolysis of inorganic 
substances the effects cease as soon as the current ceases, 
the substances remaining in the condition in which the 
current left them. The electrolysis of organic substances, 
on the contrary, starts a process that continues long after 
the current ceases to flow. Besides this subsequent effect, 
the current penetrates the tissue and induces various 
important changes beyond and beneath the eschar, and 
these combined agencies do far more, in many cases, to 
diminish the size of morbid growths and prevent further 
development than an actual destruction of a limited area. 
Hitherto one important defect in the treatment of vari- 
ous uterine diseases, and especially morbid growths, has 
been the use of too weak currents. This has been due 
partially perhaps to a commendable caution in dealing 
with an agent so potent as electricity, but more to our 
lack of definite knowledge of the amount of current 
strength needed to accomplish certain ends, and our in- 
ability to readily command more than a certain limited 
working power from the apparatus in ordinary use. A 
third obstacle was the absence of any instrument by 
which the current could be accurately measured. The 
improved milliamperemeter has overcome this difficulty, 
and is indispensable in all electro-surgical operations, be- 
sides being a vast aid in all electro-medical applications. 
Instead of a strength of current equal to only ten to 
thirty milliamperes, which was commonly used, and 
which indeed was all that could be obtained from the 
appliances in use, it is now no uncommon thing to use 
currents of even several hundred degrees of strength. 
For this purpose the external electrode must not only 
be material of the best conduction possible, but of suit- 
able size and sufficiently flexible to be perfectly adjusted 
to every inequality of surface which it covers. The 
strength of current from a given number of cells is in 
proportion to the size of the electrodes, and therefore, 
when from a certain number of cells it is desired to get 
the greatest strength possible, the electrodes should be of 
the largest size convenient for our purpose. As to the 
quality of the electrodes, sponges are too bulky and offer 
too great resistance when our object is strength of cur- 
265 Electro- 
Therapeutics. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
rent. As a substitute Apostoli suggested sculptors' clay 
held in place by gauze. 
This material holds moisture fairly well, can be 
adapted closely to the skin, and is undoubtedly an ad- 
mirable electrode. An electrode that answers well, how- 
ever, for the ordinary purposes of local application con- 
sists of layers of absorbent cotton, spread smoothly over 
flexible metal backs of varying size. 
The material is easily obtained, and is so inexpensive 
as to warrant a fresh supply for every patient. 
In all this, reference is of course made to the exter- 
nal electrode, which, in the treatment of the uterus and 
its appendages, is usually placed upon the abdomen. 
The internal electrodes consist mainly of a small metal 
bulb attached to a long insulated stem, for applications 
to such portions of the uterus as can be reached per 
vaginam; of metal probe electrodes, for intra-uterine 
applications ; and of needles of varying size, for electro- 
puncture. It should ever be borne in mind that when 
the positive pole is applied to the interior of the uterus, 
the metal should be of some non-oxidizable metal, as 
platinum. In the electrolytic treatment of fibroids a 
good milliamperemeter is a necessity. The external 
electrode, whether of sculptor's clay or other material, 
is first placed upon the abdomen, and may be pressed 
upon and kept in position by the hands of the patient 
herself. 
An insulated needle is now introduced into the tumor 
either through the vagina or through the abdominal walls, 
and the current gradually increased without interruption 
until the required strength is obtained, which may vary 
from one to two or three hundred milliamperes. The du- 
ration of the seance may be from five to ten minutes, and 
even longer if the patient bears the operation well. Too 
much stress cannot be laid upon the necessity of an entire 
absence of any interruption of the current during the treat- 
ment. In trivial operations, where the tension is slight, 
this is not of such vital importance, but in the treatment 
of conditions where a very great strength of current is 
necessary, a shock would decidedly disturb a patient of 
even strong nerve, and inflict serious damage on many. 
No one would willingly do this, but there are so many 
possible disturbing factors to the steady working of the 
current, that from my personal knowledge of the con- 
dition in which physicians too frequently keep their 
electrical apparatus and appliances, these interruptions 
are liable to occur at any moment and when least ex- 
pected or desired. It is to be doubted whether many 
patients would submit to a second trial after having 
received a shock from a current strength of two hun- 
dred milliamperes. 
While the treatment of fibroid tumors by electro- 
puncture is liable to be attended with more unpleasant 
results, it is no more efficient in many cases of uterine 
myomata than the more simple method of intra-uterine 
applications ; and in our opinion the latter method should, 
as a rule, be attempted before resorting to puncture. 
If, however, in any case of fibroid it is impossible to en- 
ter the cavity with our electrode, or when a sub-perito- 
neal tumor is so situated as to be beyond the effects of 
intra-uterine applications, in these emergencies puncture 
is of course the only choice. Punctures may be made 
either through the vagina or through the abdomen. 
The former method is generally preferred. 
In the intra-uterine treatment of fibroids the strength 
of the current that may be used varies from 30 to 150 
milliamperes, and the negative pole, because of its supe- 
rior absorptive properties, is to be preferred. In hemor- 
rhagic cases the positive pole is indicated, and it cannot 
be too often repeated that, with this pole, platinum or 
some other non-oxidizable metal should always be used. 
In chronic cases the idea is, according to Apostoli, to 
destroy the mucous membrane and produce a healthy 
derivation. 
The faradic current, which is so valuable in simple 
uterine engorgements following abortions, and perhaps 
in the earliest stages of metritis, becomes useless in the 
presence of parenchymatous metritis. 
The chemical action of the galvanic current is alone 
serviceable in these cases. As in the treatment of fibroids, 
powerful currents are demanded, varying in strength 
from 50 to 150 milliamperes. Some good form of rheo- 
stat should be used, and as the current is gradually in- 
creased and decreased the utmost care should be exer- 
cised to avoid shocks. The operation is not electrolysis 
proper, but more correctly a chemical galvano-cauteriza- 
tion. The choice of the intra-uterine pole will be deter- 
mined by the symptoms in each individual case. 
At the positive pole the acids and oxygen accumu- 
late. This pole is therefore coagulating and haemostatic, 
and is indicated in all forms of hemorrhages and abnor- 
mal discharges. Another advantage possessed by this 
pole in hemorrhagic conditions is due to the greater re- 
tractibility of the positive cicatrices, which tend to pre- 
vent a return of hemorrhages. At the negative pole 
alkalies accumulate, producing some of the effects of 
caustic potash. It is sometimes called the fluidifying 
pole, and is more especially indicated in the non-hemor- 
rhagic forms of metritis. 
It is especially valuable in old, atrophic, or indurated 
forms of chronic metritis, where the connective tissue 
has become hard, fibrous, and devoid of blood. Far 
more effectually than the positive pole, it excites the 
languid or perverted uterine circulation and restores the 
menstrual flow. The caution never to use with the 
positive pole, in intra-uterine applications, any steel or 
other oxidizable electrode, cannot be too strongly em- 
phasized. 
Platinum is to be preferred, and, although it is expen- 
sive, it never wears out. A cheaper form of electrode is 
made of carbon so thoroughly polished as to render it 
non-irritant, or of steel subjected to certain processes by 
hydrogen which render it non-oxidizable. 
In time, however, both of these materials become 
roughened through the constant action of liberated ox- 
ygen. 
Peri-uterine haematocele, uterine hyperplasia, and sten- 
osis of the uterine canal, have also been successfully 
treated by the newer methods. Even salpingitis, through 
the depletion and drainage secured by electricity, has been 
decidedly benefited. 
Cataphoresis.-By this is meant the introduction of 
medical substances into the body by means of the gal- 
vanic current. It is a method that has long been known, 
but it is only within the last few years that it has been 
largely attempted. Its application is exceeding simple. 
In using cocaine, for example, for local anaesthesia, it is 
only necessary to place upon the absorbent covering of 
the positive pole a five to ten per cent, solution, and, after 
the current has passed for a few moments, marked anaes- 
thetic effects will be observed. 
In order to secure exact dosage it is convenient to have 
a flat metallic electrode, preferably of platinum, upon 
which is fitted a piece of tissue paper or some other com- 
pact absorbent material. Upon this is placed drop by 
drop the solution of any drug to be used, and the elec- 
trode is then applied to the skin. 
In this way the exact quantity of the drug is known. 
It is hardly necessary to exactly measure the strength of 
the current. 
As a rule a sufficient guide is to use the current only 
up to the point of easy endurance. Other remedies that 
have been used in this way with more or less success are 
aconitia, strychnia, and helleborin. 
The author has known cocaine to afford marked tem- 
porary relief in some cases of neuralgia, and in epilation 
it has enabled him to operate with little if any pain to the 
patient; but that there may be danger attending the use of 
the remedy in this way, admits of little doubt. A one 
per cent, solution of helleborin has been said to act even 
more satisfactorily than cocaine, producing deeper and 
more lasting, and accompanied by no constitutional, 
effects. The salts of lithium have been used for rheuma- 
tic and gouty swellings, and among mercurial remedies 
the imidosuccinate and bichloride of mercury are sug- 
gested. Before applying the medicated electrode to the 
skin it is a good plan to dissolve the oil-globules upon 
the surface by the application of ether. It is believed 
266 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Electro- 
Therapeutics. 
(SUPPLEMENT.) 
that the " effects of the galvanic current upon nutrition 
are in part due to the cataphoric transfer of molecules of 
protoplasm and liquid from one cell to another, or from 
a cell to a capillary vessel in the path of the anodal 
stream ; and since the diffusion takes place more readily 
and more quickly in direct proportion to the current 
strength, it behooves us to employ as many milliamperes 
as feasible in our galvanization of the atrophied and 
paralyzed extremities of poliomyelitis, chronic neuritis, 
and peripheral nerve-trauma. Moreover, there would 
seem to be a possible advantage in the use of nutritive 
emollients in conjunction with the labile application of 
the anode to the atrophied member, just as they have 
been combined from time immemorial in the exercise of 
the aliptic art (massage).'' 
The use of iodine by cataphoresis has been attempted 
in cases of goitre, and good results have been claimed 
for it. 
Bipolar Faradization.-By bipolar faradization is 
meant the localization of the faradic current by means of 
a single electrode, and the method is confined, for the 
most part, to the treatment of internal organs, such as the 
vagina, the uterus, the rectum, and the bladder. 
Bipolar faradization, more perhaps than any other form 
of electrical treatment, necessitates a knowledge of the 
varied physiological and therapeutical properties of the 
induced currents of electricity. A current from a short, 
thick coil of wire (No. 21, say, in size, and but two or 
three hundred feet in length) will be of comparatively 
slight tension, but of so-called large quantity ; while the 
current yielded by a long and thin coil is of little quan- 
tity but high tension, overcoming the greatest resistances 
with the utmost ease. When, therefore, it is desired to 
produce powerful mechanical effects in the external fara- 
dization of the body, a current of tension from a long 
and thin coil is needed ; while to obtain these powerful 
effects in the faradization of internal organs, where the 
resistance is slight, a current of quantity from a short 
and thick coil is necessary. Let one become but once 
convinced by personal experience of the striking differ- 
ence in the action of induced currents of quantity and 
tension on nerve and muscle, and he will hardly need 
the demonstration of clinical experience to convince him 
of their different therapeutical properties. The short, 
thick coil offers very little resistance to the passage of 
electricity, and so gives forth a current of little tension 
but large quantity. 
When applied externally its appreciable influence is 
very slight. Its tension is so low that it overcomes with 
exceeding difficulty the resistance of the skin that must be 
encountered in all external applications. 
The important practical point in connection with this 
current is the extraordinary increase in energy that is 
manifested when it is applied to parts within the body. 
When applied to the rectum, the vagina, or the uterus, 
not only are the contractions pronounced, in response to a 
current which is not strong enough to produce any observ- 
able effect when applied externally, but they may easily 
become exceedingly painful. When applied, indeed, to 
these internal organs by the bipolar method, its extraor- 
dinary action on motor and sensory parts will hardly be 
credited without actual demonstration. It is the easiest 
thing in the world to demonstrate this fact unwittingly, 
to the injury of the patient and to the operator's mortifi- 
cation. This is what may very readily occur :-An intra- 
vaginal or intra uterine application is being made with 
the current of tension. The patient complains of an 
uncomfortable sensation, which may or may not be due 
to the action of the current, and you exchange the cur- 
rent of great for one of lesser tension, which, according 
to all the experiences of external application, is infinitely 
weaker. Instantly a shock is occasioned, associated 
with the acutest pain and the most rigid contractions, 
that astonishes yourself and terrifies your patient. 
The advantages of the induced current of quantity 
from the short, thick coil of wire, over the current of 
tension from the long, thin coil, lie almost wholly in the 
effects of their internal application, and especially by the 
bipolar method. This current is capable of exciting con- 
tractions of the involuntary muscular fibres of the uterus, 
of every degree of severity. 
For this reason it is invaluable in cases of post-partum 
hemorrhage, and must, it seems to me, prove far superior 
to ergot for its suppression, since it acts instantaneously 
and with a force just sufficient to accomplish the object 
desired. Currents of tension, however, from very long 
and thin coils, while they overcome with great readiness 
the enormous resistance of the skin and produce effects 
of a most pronounced character, exert by no means the 
same influence over the contractions and sensibility of 
the vagina, uterus, rectum, or bladder. So tolerant, in- 
deed, are the internal muscular organs of the body to 
the induced currents of tension, that it is frequently a 
question of how to obtain a current of sufficient power 
from the batteries in ordinary use. Batteries that have 
been long in use, and that are allowed to get out of 
order, while perhaps yielding a current of sufficient 
strength for localized applications externally, are insuf- 
ficient for bipolar applications. 
Even if at first the current is appreciably felt in the 
uterus, the sensitiveness soon subsides, although its 
strength may have been very much increased ; and both 
physician and patient may be in doubt as to whether the 
current is being received at all. This phenomenon be- 
comes prominently apparent in hysterical cases with 
which is associated excessive hyperaesthesia of the ab- 
domen, and it has been no uncommon thing in my ob- 
servation to treat women with the current of tension for 
the relief of the most acute surface abdominal hyperaes- 
thesia, and at the close of a single seance to find the ab- 
domen insusceptible to any ordinary manipulation. 
Far different is it with the current of quantity. Toler- 
ance is not established, and what is painful in the begin- 
ning continues more or less painful throughout the 
treatment, and it frequently becomes necessary to de- 
crease rather than increase the strength of the current. 
A No. 21 wire, with a length of five or six hundred feet, 
constitutes a satisfactory coil for currents of quantity ; 
while No. 36 wire, with a length of three thousand feet 
and more, is necessary to obtain the best effects of current 
tension. Among comparatively new devices and sugges- 
tions connected with electrical apparatus and methods of 
application, may be mentioned the franklinic interrupted 
'current, electrodes for eliminating polar effects, and the 
various arrangements which enable us to directly utilize 
the current from the street. The static induction cur- 
rent is obtained from any machine that generates static 
electricity. The static discharge in the form of sparks 
becomes dynamic, and closely allied, in the effect that it 
produces, to the ordinary induced or faradic currents of 
electricity. 
The spark no longer directly affects the body of the 
patient, but occurs in some distant part of the circuit, 
thus obviating the shocks which are to some so disagree- 
able. There are two methods by which we obtain the 
static induction current: 1st, with the electrodes at- 
tached to the prime conductors either without or with 
the condensers ; 2d, with the electrodes directly con- 
nected with the condensers. On account of its high 
electro-motive force, and the readiness with which it 
overcomes the resistance of the skin, this current is 
often of great value in alleviating pain. It seems to me, 
however, to be inferior to the galvanic current in this 
respect, and yet it does relieve, as does the faradic, in some 
cases where the galvanic has failed. The differential 
indications for the use of currents of quantity and tension 
are, however, too wide a subject to be discussed here. I 
will only say that I have not infrequently found that the 
static induction current has proven more efficacious for 
the relief of pain than the ordinary faradic current. 
It is well known that what is called the faradic current 
of tension is far more efficacious in relieving pelvic pain 
than currents of quantity ; and the static induction cur- 
rent is a current of but little quantity but enormous ten- 
sion. 
When we consider that its voltage runs up into the 
thousands, it is not difficult to accord to it, despite its 
lack of quantity, special physiological and therapeutical 
267 Electro-Tlierap. 
Emotions. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
properties. In the remarkable rapidity of its interrup- 
tions and alternations, also, the static or franklinic inter- 
rupted current is unique. While the average induction 
coil gives but a few hundred vibrations per second, it is 
claimed by physicists that the oscillations of each spark 
of the static current amount to many millions per sec- 
ond, and that these sparks follow each other at the rate 
of two hundred per second. The superiority, then, of the 
static induced current over the ordinary faradic in reliev- 
ing pain is undoubtedly to be ascribed, first, to its su- 
perior tension ; second, to the inconceivable rapidity of 
each spark-oscillation, amounting to many millions per 
second. It should, however, be borne in mind that the 
vastly improved coils now obtainable have greatly in- 
creased the anaesthetical properties of the faradic current, 
and for the relief of uterine and ovarian pain these high- 
tension inductive currents are unsurpassed. 
A. D. Rockwell. 
EMBRYOS, HUMAN. Age.-It has been quite gener- 
ally accepted that the age of an embryo must be de- 
termined by the time of a certain cohabitation. In many 
cases it was attempted to locate the day exactly. After it 
had been shown that the ovum is extruded from the ovary 
at or before menstruation, it was then generally admitted 
that the egg could be fertilized at any point between the 
ovary and the uterus. The time required for the ovum 
to pass through the Fallopian tube was considered the 
time in which it was capable of being fertilized. Accord- 
ing to the above, these conclusions are not based on a 
sound footing, because of the difficulty in obtaining ac- 
curate observations, and also because they do not agree 
with the results obtained from the lower animals. Both 
Coste and His have shown that the eggs of the hen are 
fertilized ten or more days after copulation, and the 
former has shown that the egg is no longer capable of 
fertilization after it has passed through the after portion 
of the oviduct. 
Impregnation is nearly always marked by a cessation 
of menstruation, and it now remains to be shown whether 
the fertilization takes place during the last menstrual 
period, or at the time of the first cessation ; for it is known 
from post-mortem examinations that ovulation comes 
just before menstruation. Since it seems to be neces- 
sary to fertilize the egg just as it leaves the ovary, it is 
probable that impregnation takes place just before the 
menstrual period. To locate the menstrual period, from 
which to compute the age of an embryo, we must consult 
the following table, which is in great part copied from 
His. 
| Number. 
Observer. 
Len g t h 
of em- 
bryo in 
milli- 
metres. 
Beginning of 
last period. 
Last possible co- 
habitation. 
Time of first lapsed 
period. 
Day of abortion. 
Time between Abortion 
and 
Probable age 
of embryo. 
Last period. 
First lapsed 
period. 
Days. 
Days. 
Days. 
1 
Graf Spee 
1.54 
35 
7 (?) 
14 
2 
Riechert 
October 10. 
Early November. 
November 7. 
November 21. 
42 
14 
3 
Breuss 
x 
X + 28. 
X + 38. 
38 
10 
10 
4 
Thomson 
2.1 
x 
X + 28. 
X + 42. 
42 
14 
14 
5 
Thomson 
2.5 
May 24. 
August 15. (?) 
September 10. 
June 1. 
June 1. 
8 
8 (?) 
14 (?) 
12 
6 
His (S. R.) 
His ?Lg.) 
2.2 
End of September. 
October 8. 
October 14-15. 
60 (?) 
40 
M(?) 
12 
7 
2.15 
October 20. 
8 
Jantfsik 
3.0 
June 28. 
July 13. 
May 13-16. 
June 1. 
43 
15 
15 
9 
His (BB.) 
3.2 
March 26. 
April 4.+ 
April 23. 
May 28. 
48 
20 
20 
10 
4.3 
April 10. 
x 
53 
52 
22 
11 
Wagner .. 
His (a) 
4.5 
X + 20. 
20 
20 
12 
4.0 
October 4. 
November 1. 
November 24. 
51 
23 
23 
13 
His (W.) 
5.0 
March 5. 
March 26. 
21 
21 
14 
4.5 
x 
X + 21. 
21 
21 
15 
Stubenrauch * 
6.0 
July 1. 
April 1. 
October 6. 
July 8. 
April 14. 
July 28. 
April 28. 
November 3. 
August 14. 
May 20. 
November 27. 
17 
17 
16 
7.0 
51 
22 
22 
17 
Mall 
7.0 
52 
24 
24 
18 
His (SH.) 
7.75 
July 5-8. 
April 4. 
April 24. 
October 20. 
July 2O.t 
April 15. 
August 2-5. 
May 2. 
May 22. 
November 17. 
September 1-3. 
June 3. 
57 
29 
29 
19 
10.0 
60 
32 
32 
21 
His (Br,) 
11.0 
June 24. 
61 
33 
33 
22 
His (Br2) 
13.6 
End of October.t 
December 22. 
63 
35 
35 
23 
His (M^ 
13.0 
August 7. 
May 16. 
September 4. 
June 12. 
October 10. 
64 
36 
36 
24 
Stubenrauch * 
22.0 
July 16. 
62 
34 
34 
* I have not full confidence in Stubenrauch's data. Some very apparent errors have been corrected. t Earliest cohabitation, 
From a comparative standpoint we can easily de- 
termine the age of human embryos within four weeks. 
Counting from the last menstrual period, it is quite easy 
to see by the size of the embryo whether or not it is, say 
three or seven weeks old. The table shows that, by 
counting in this way, embryos of the same size may 
have a difference of four weeks in age (see Nos. 5, 11, 
13, and 14). In these cases the age corresponds to the 
other cases, if from their time twenty-eight days are 
subtracted. This already indicates that, as a rule, fertil- 
ization of the ovum takes place during the ovulation 
which precedes the first menstruation which has lapsed. 
After Reichert had shown that menstruation is only a 
method of clearing out the uterus after an ovulation, 
and after Leopold had shown that the mucous mem- 
brane of the uterus undergoes histological changes before 
ovulation, it is fair to assume that the latter changes are 
only preparatory to the reception of the ovum, and that 
when the unfertilized ovum reaches the uterus, menstru- 
ation is only a method of reducing the uterus to its for- 
mer condition. 
Only in four of the cases is it necessary to compute 
the age of the embryo from the last menstrual period, 
and it is not fair to assume that just these four embryos 
have grown too rapidly. All the rest must have twenty- 
eight days subtracted from the time in order to make 
them correspond with the above four. These are the 
main reasons for assuming that the fertilization of the 
egg takes place just before the first menstrual period 
which lapsed. It may be that a great many fertiliza- 
tions take place during the last menstrual period, but 
that when menstruation has once begun, the activity of 
the uterus destroys the ovum, and that, as a rule, only 
those are preserved in which menstruation does not fol- 
low the last ovulation. At least the embryological evi- 
dence speaks for this, and at present embryologists make 
their specimens correspond to one another when they 
reckon their ages from the last menstrual period, minus 
twenty-eight days. 
The table shows, in addition, that in certain pregnan- 
cies the first cohabitation followed the last menstrual 
period. It cannot be that in these cases the ovum of 
the last period could have been fertilized, for it is quite 
certain the ovum loses its power of being fertilized shortly 
after it leaves the Graafian follicle. In case No. 9 (B B), 
the first cohabitation of a newly married woman took 
place on April 4th, say about five days after the last 
menstrual period ; and the woman ceased menstruating 
at once, probably on account of the fertilization of the 
ovum of the following ovulation. If all the cases of 
268 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Electro-Tlierap. 
Emotions. 
newly married women in which there was an early preg- 
nancy were collected, it would, no doubt, be shown that 
in many of the cases the women did not menstruate at 
all after marriage. At present, although not being a 
practitioner, I know of four such cases. His has tabu- 
lated cases given by Harter, in which the first copulation, 
the last menstrual period, and the date of birth of the 
child are given. In all of these cases the age of the foetus 
is from two hundred and seventy to two hundred and 
eighty days, if the beginning of pregnancy is reckoned 
from the beginning of the first period which has lapsed. 
If the beginning of pregnancy is placed at the first co- 
habitation, the age of the foetuses varies fully a month 
according to the time of the cohabitation ; if the time 
which has elapsed between the cohabitation and the first 
menstruation which lapsed is subtracted from the dura- 
tion of the pregnancy, then the lengths of the pregnan- 
cies are practically alike. Assuming that the lengths of 
pregnancies should be about the same, it makes it highly 
probable that fertilization takes place at the time of the 
first menstrual period which has lapsed rather than at 
the time of cohabitation. 
In several of the cases given in the table, the last co- 
habitation took place several weeks before the cessation 
of menstruation, showing that the vitality of the sperma- 
tozoa within the female organs lasts for at least a few 
weeks. It is probable, however, that the spermatozoa 
cannot live in the Fallopian tubes or uterus for over a 
month, because authentic posthumous births always take 
place within two hundred and eighty days after the hus- 
band's death. 
The general conclusions formulated by Professor His, 
and accepted by embryologists, are as follows : 
1. The beginning of development is the time of im- 
pregnation, i.e., at that moment when the spermatozoon 
enters the ovum. 
2. The time the egg leaves the ovary is marked by 
menstruation, but it is not necessary for the Graafian 
vesicle to rupture during menstruation ; it may take place 
two or three days before or even during the hemorrhage. 
3. The egg is not capable of being fertilized at any 
point from the ovary to the uterus, but only shortly 
after it has left the ovary ; as a rule, as it is entering the 
Fallopian tube. 
4. The spermatozoa which have entered the female 
sexual organs must await the ovum in the upper part of 
the Fallopian tube, and can retain their vitality here 
several days, or possibly several weeks. The time of 
cohabitation is, therefore, not directly related to the age 
of the embryo. 
5. The age of the embryo is to be counted from the 
beginning of the first menstrual period which has lapsed, 
although it is possible to have a menstruation after fertil- 
ization of the ovum. 
6. The age of an embryo can be expressed by the fol- 
lowing formula : A = M + X - 28 x 3, in which M is 
the beginning of the last period, X the time which has 
elapsed before the abortion, and the 3 the time between 
ovulation and menstruation. 
There is no reason why the gynecologist should not 
add his share in determining the age of embryos. Any 
physician would add greatly to the subject if he would 
tabulate all cases in his practice after the plan of the 
above table. It would not be necessary to confine him- 
self to young embryos alone, but he might include chil- 
dren at full term ; especially those of newly married 
women would be valuable. Moreover, if the young 
specimens were carefully preserved, he could do a great 
work hand in hand with the embryologist. 
Preservation.-The human embryos which come 
into the hands of the embryologists are nearly altogether 
worthless for careful study, due to careless preservation. 
Of fifty embryos less than six weeks old, which have 
come into the writer's hands during the last few years, 
only four have proved to be valuable, and these came 
from two physicians. The main reason why specimens 
are destroyed, in nearly all cases, is that the ovum is 
placed in very dilute alcohol, and in so doing it is 
also handled very roughly. Yet poor specimens are 
(SUPPLEMENT.) 
better than none at all, and in all cases all ova should be 
preserved, even if there is but little hope for a good speci- 
men. The best and most convenient method of preserving 
young embryos is to place the unopened ovum, with the least 
possible handling, in a large quantity of very strong alcohol. 
The alcohol of druggists is in no case too strong, and, ac- 
cording to my experience, is as a rule too weak. Often 
the ovum is wrapped in a towel and then placed in a 
small quantity of alcohol and water. This may be a 
method of preserving museum specimens, but it practi- 
cally ruins every embryo which is preserved in this way. 
When an ovum is placed in, say four ounces of strong 
alcohol, the water of the ovum dilutes the alcohol to a 
proper strength. 
Those physicians who have the proper opportunities 
should place the specimen as soon as possible, and with- 
out opening the ovum, in seventy per cent, alcohol, i.e., 
absolute alcohol reduced by volume to seventy per cent. 
At the end of a day or two it should be placed in fresh 
alcohol of the same strength. 
A second convenient method is to place a specimen in 
quite a large quantity of Muller's fluid, to be changed 
once or twice during the first few days, after which it 
may be preserved in the same fluid indefinitely. The em- 
bryo is fully hardened in about a month, and then it can 
be washed in water for a day or two, after which it is to 
be preserved in seventy per cent, alcohol. 
Ten per cent, nitric acid is a convenient and a most ex- 
cellent method. The ovum is to be placed in four or 
six ounces of a ten per cent, solution and opened while 
in the fluid, care being taken not to injure the embryo. 
According to its size (if not over an inch long), it should 
remain in the acid for from thirty minutes to two hours. 
At the end of this time it is to be placed in seventy per 
cent, alcohol. 
Another excellent method is to employ saturated aque- 
ous corrosive sublimate. The specimen is to be treated 
as in the ten per cent. HNO3, only it is to remain in the 
sublimate longer. These specimens are then to be pre- 
served in seventy per cent, alcohol. 
There are many other methods, but if any of the above 
are employed there will be a sufficient supply of material 
to aid the study of human embryology. It is really won- 
derful to see what progress has been made in this study 
when we consider how difficult it is to obtain good ma- 
terial. Some of the most important discoveries have 
been made in the careful study of a few well-preserved 
human embryos, as a glance at the many papers of Uis 
and at the excellent text-book of Minot will show. 
A great work is done when the specimens are once 
obtained, but in order to make it complete they must be 
placed in the hands of a specialist, who can devote all his 
energies as well as all the additional necessary expense to 
these-the most precious of embryological specimens. 
Franklin P. Mall. 
EMOTIONS, THE PHYSIOLOGICAL AND PSYCHO- 
PHYSICAL BASIS OF THE. The practitioner of med- 
icine is not universally expected to command a minute 
or special knowledge of psychology, but he may, and 
should be, familiar with certain intimate anastomoses 
of this subject and physiology. At a time when so- 
called psychological healing offers active competition to 
medicine in certain quarters, it behooves the physician to 
understand and to be able, if need arises, to formulate 
the conditions of psychical influence upon the body. 
On the other hand, men who are daily brought face to 
face with abnormalities of psychical function in con- 
nection with diseased bodies, and whose attitude is es- 
sentially critical and practical, might exercise a most 
wholesome influence upon the development of that new 
psychology which lays claims to recognition as a natural 
science. 
The scholastic and convenient tradition which divides 
psychical manifestations into cognitions, volitions, and 
feeling, permits us to single out a class of so-called men- 
tal manifestations, which are conceived to be determined 
by a form of the receptivities of mind known as the sus- 
ceptibilities. The most careful writers have discovered 
269 Emotions. 
Emotions. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
in this group of "faculties" a perennial source of dis- 
pute and ambiguity. 
Older psychologists conceived of feeling as obscure or 
implicate thought, or as impotent or unexpressed im- 
pulse or will. 
Hoeffding defines feeling as "that in our inward 
states which cannot by any possibility become an ele- 
ment of a percept or an image;" as "an inner illumi- 
nation which falls on the stream of sensations and ideas." 
Both these expressions indicate the difficulty involved in 
isolating feelings, the one being negative, the other an 
illustration. Sibbern notices that feelings and will have 
this in common, that in both " the ideas involved have 
a personal hold and effect, so that we yield ourselves up 
to them and are incited to act and strive for their reali- 
zation." Recognizing the futility of the distinctions 
usually made, James has boldly used feeling as synony- 
mous with the word psychosis or subjective state, and 
made no attempt to distinguish it from thought. The 
emotions (German Effecte) are described as a bubbling up 
of feeling which may greatly influence the course of 
cognitions and volitions, or temporarily inhibit or stimu- 
late them. If emotions be strictly limited to feelings 
with psychical (cognitive) occasion or accompaniment, 
much ambiguity may be avoided, but it would still be 
necessary to insist on the essential similarity of these 
feelings to others with simple sensational basis. The fol- 
lowing classification may prove convenient: 
(SUPPLEMENT.) 
which bring us into closest relations with the lower 
special senses, olfaction and taste, and the diffuse sensa- 
tions on one hand, and subemotional processes, like 
elation, ennui, and depression, where total sensations and 
rudimentary feelings fuse. 
It must not be forgotten that pain and sense gratifica- 
tion are strong elements in the emotions and require a 
careful examination. Hoeffding says "feeling stands 
out plainly, as an element different from the actual sen- 
sation, in certain experiences, which prove that the pain 
caused by an excitation takes longer to be produced than 
the actual sensation, and that sensation may arise with- 
out the corresponding feeling, and vice versa." Bichet 
says " pain without memory and without radiation 
would be no pain at all." Often an interval of one or 
two seconds may elapse after the sensation is perceived 
before pain appears. These cases, so often quoted as 
proving the distinct nature of pain, are in one respect 
fallacious. When a nerve-fibre is penetrated by a pin 
the pain is nearly, if not quite, as promptly felt as the 
touch. When the finger is struck by a hammer the pain 
is frequently long delayed. But the acme of pain in that 
case is due to a reactionary process in the tissues, notably 
the vascular contractions, etc. There may be several 
oscillations of pain and a set of summations of a curious 
character. It is even possible, by bringing to bear coun- 
ter-irritants, to preclude these after-effects and mitigate 
the pain, as by rubbing or pinching the part. 
In the case of a burn the conductivity of the tissues 
and vascular responses are even more evident, and such 
attempts to differentiate pain from sensation as a modal- 
ity of feeling are futile. The fact that there may be 
analgesia without anaesthesia, and vice vers&, is tenta- 
tively explained by the recent suggestion, that thermic 
and painful sensations find their way to the cortex 
through the gray matter of the cord instead of the 
fibrous columns, and affords us added data for the gen- 
eralization for which we are now ready, viz.: Feeling is 
always composed of two sets of factors; first, a sensa- 
tional, and second, a cognitive or intuitional element. 
The sensations which directly participate in feeling are 
non-localized (general or total sensations), or are so acute 
as to irradiate, and thus ally themselves with total sen- 
sations. The cognitions or intuitions are primarily such 
as identify the subjective state with the empirical ego. 
The association of reflexes and instinctive responses con- 
verts the feeling into an impulse which is usually em- 
bodied in the so-called emotion. 
James identifies instincts and emotions as two forms of 
impulse, in this usage betraying German influence. He 
says that the class of emotional is rather larger than that 
of instinctive impulses. Its stimuli are more numerous, 
and its expressions are more internal and delicate, and 
often less practical. The physiological plan and essence 
of the two classes of impulse is the same. This identifi- 
cation of the expression of the emotion with the psychi- 
cal element (feeling) seems illogical, inexpedient. In- 
stincts may have an emotional origin, or may be of the 
nature of impulse deprived of its psychical element; but 
pure instinct is not emotional, though emotions may be 
awakened by a resistance to the gratification of the in- 
stinct. An impulse stands on a present or historical 
basis. 
With this difference in distribution, the theory of emo- 
tions proposed by Professors Lange and James goes far 
to place the emotions on a plane of scientific research. As 
expressed by the last named, this theory is about as fol- 
lows : Bodily changes follow directly the perception of 
the exciting fact, and our feeling of the same changes as 
they occur is the emotion. Objects excite bodily changes 
by a pre-organized mechanism, and these changes are so 
indefinitely numerous and so subtle that the entire organ- 
ism may be called a sounding-board, which every change 
of consciousness, however slight, may make reverberate. 
Everyone of the bodily changes is felt acutely or ob- 
scurely the moment it occurs. 
Jamessays: " If we fancy some strong emotion, and 
then try to abstract from our consciousness of it all the 
feelings of bodily symptoms, we find we have nothing 
I. Feelings. 
Sensations. 
Sense gratifica- 
tion and pain. 
General o r total 
feelings. 
11. Occasions. 
Normal (moder- 
ate) sensory 
stimuli. 
Super-normal stim- 
uli, with ten- 
dency to irradi- 
ate. 
Diffuse (somatic, 
especially " to- 
tal " ) stimuli. 
Emotion:'. 
Impulses. 
Sentiment. 
Disposition. 
Somatic changes 
occasioned or ac- 
companied by 
cortical activity. 
Reflexes excited 
by somatic and 
cortical activ- 
ity. 
Persi stent 
co r t i c a 1 
changes. 
Reactions of corti- 
cal residua on 
new data o f 
consciousness. 
This series of subjective states is not to be regarded as 
arbitrary, but capable of the most far-reaching inter- 
penetrations. Of course it may be claimed that there is 
a great gap between sensation, or even bodily pain and 
pleasure, and the emotions which depend chiefly upon 
data of a higher intellectual character. Between these 
two groups is another, which seems, in part at least, to 
bridge over the interval, the total or general feelings. 
Sensations, as the most direct responses of the con- 
sciousness to external irritations in which the bodily par- 
ticipation is more direct than in the subsequent processes 
(perception, etc.), afford the simplest data of conscious- 
ness. Even in this case, however, the nature of the 
response varies with the organ in respect to the amount 
of subjective participation. Thus, sensations are excen- 
trically projected or externalized ; the former in the case 
of tactile, gustatory, thermic, and algesic senses ; the 
latter in the case of special senses-visual, auditory, and 
olfactory. 
That this is not a primitive difference, but is devel- 
oped through associations of several senses, is proven by 
such facts as that when a blind person is suddenly given 
sight, the external world seems to touch the eye, i.e., is 
excentrically projected rather than externalized. That 
externalization is possible to the tactile sense or " mus- 
cular sense " is shown by hyperexcentric reference of 
sensations of double contact, as when the blind man 
seems to feel an object at the end of his cane, or the 
surgeon's sensation is transferred to the end of his probe. 
We may dismiss, as beyond our limits, the three sciences 
-optics, acoustics, haptics (the skin and muscular sensa- 
tions)-and there still remains a set of sensations which 
may be conveniently grouped as general sensations, 
270 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Emotions. 
Emotions. 
left," . . . "a cold and neutral state of intellectual 
perception is all that remains.'' "The more closely I 
scrutinize my states, the more persuaded I become that 
whatever moods, affections, and passions I have are in 
very truth constituted by, and made up of, those bodily 
changes which we ordinarily call their expression or con- 
sequence." These quotations serve at least to emphasize 
the importance of the corporeal element, however much 
they ignore the cognitive element. The natural and logi- 
cal criticism is that the effect on consciousness, which is 
all we get out of feeling, is wellnigh overlooked. 
Emotion consists (1) of general sensations of total, or- 
ganic, or irradiating varieties which have in common a 
lack of localization and, as a result of associational laws, 
are amalgamated more or less closely with the empirical 
ego ; (2) of more or less explicate or implicate cognitions 
(perceptions, intuitions) of the relation between the cause 
of the sensation and our well-being; (3) the emotion is 
more or less closely attached to various impulsive ex- 
pressions which tend in various ways to intensify the two 
preceding. More in detail: The sensations are produced 
in most cases by vaso-motor changes which, in turn, pro- 
duce " total sensations," usually entirely unlocalized and 
not necessarily distinguished apart from the feeling. 
Such sensations may be recognized, and to some extent 
analyzed, by practice. They precede the emotion proper 
and compose its sensational element. When one lies 
half asleep in the morning and a loud report startles him, 
the sudden surging of the blood to the periphery pro- 
duces a familiar but indescribable sensation, which may 
include tingling at the finger-tips, a curious twinge in 
the axials, a suffocating sensation in the chest, as more 
specific accompaniments. Then a flash of fancy depicts 
the burglar in the kitchen and a scene of bloodshed, 
danger to self, and the like ; now perhaps a strange 
" gone " feeling in the abdomen, and helpless atonic con- 
dition of muscles follow ; then impulse dominates, and 
the tendency to spring to the defensive arises ; all this be- 
fore judgment announced that the cook has slammed the 
range door. Granting that the illustration has served to 
indicate the meaning of the statement above, it need re- 
quire but brief experiment and self-observation to show 
that vaso-motor and organic changes always accompany 
and afford a sensational basis for feelings. A just analy- 
sis will not neglect the subjective processes in construing 
the physical. Stripped of the sensations above referred 
to, and the instincts and impulses associated with them, 
the residuum is still not to be passed over. " A feeling- 
less cognition that certain circumstances are deplorable," 
or otherwise, may be, and generally is, but the first step 
in a series of judgments or representations out of which 
spring the involuntary acts which are the really impor- 
tant results of emotion. The sensational element is that 
which represents the general, though subtle, bodily effect 
of the stimulus (be it physical or psychical), while it serves 
to awaken within us the empirical ego (the sum of our pure- 
ly subjective bodily reactions on consciousness), which 
gives point or poignancy to the following psychical pro- 
cesses and links self with phenomena, awakening the par- 
ticipation of the soul in the states of the body, or of 
other beings, which otherwise might concern us only as 
do phenomena in Mars. It is then no mere figure which 
localizes the emotions in the heart or bowels, but a state- 
ment of sober physiological truth. A heartless man is 
one whose intellectual appreciation of the results of an 
act does not awaken sympathetic thrills in his physical 
being adequate to quicken in him a participatory or sym- 
pathetic state. Such a condition may be acquired by 
habit or produced by heredity. Practically,*we are first 
interested to study the physical substrata conditioning 
the emotional temperament and its expressions. 
The sensational elements in emotion are, first, pains 
and sense gratifications ; second, obscure organic and total 
sensations which are not usually perceived as such, but 
are interpreted as part of the feeling ; third, reproduced 
pains or gratifications always followed or accompanied by 
total sensations ; fourth, representations which awaken 
by association either reproduced pains and gratifications 
which, in turn, give rise to total sensations, or the latter 
(SUPPLEMENT), 
without the former ; fifth, instincts, which obey laws of 
association whose rational explanation lies in the develop- 
ment or phylogenetic history. 
Pain and sense gratification are more difficult to con- 
strue, because more direct and simple than the others 
named. So long as pain, etc., were regarded as simply 
exaggerated forms of ordinary sensation the problem was 
insoluble. That this is not the case is suggested by the 
fact that they pursue other courses in the cord, and are as- 
sociated more closely with thermic sensations. If a small 
area of the skin is isolated it is found that tickling with a 
feather is interpreted as warmth, and a thrust with a 
needle cannot be distinguished from heat. In other 
words, if the local signs by which position is recognized 
are excluded, the differences break down. It may be 
noted that general changes in temperature states are 
closely connected with the general feelings, as witness a 
shudder or the cold chills of fear, and the glow of pleas- 
ure. Briefly stated, the peculiarity of pain and intense 
gratification of sense which adapt them to become sources 
of feeling, is their diffusive (irradiative) character. If the 
current suggestion that algesic stimuli pass by conduc- 
tion through the gray matter of the cord be substantiated, 
a much closer connection with the visceral centres than 
hitherto suggested may be postulated, and the thrill of 
pain can be readily interpreted as the sympathetic con- 
traction wave passing throughout the vascular system. 
The evidence for the existence of adequate vaso-motor 
causes of the sensational element in emotion is largely 
subjective, but those familiar with nervous diseases will 
not lack for evidence that variations in circulation are 
powerful factors in emotional disturbance. Shame is an 
emotion quite independent at times from any judgment 
of adequate occasion for chagrin. It is very closely con- 
nected with peripheral vascular changes. In anaemic or 
neurotic persons the flush may come without any exter- 
nal exciting cause, and yet frequently produces all the 
subjective effects of shame. Not very infrequently this 
symptom becomes intolerable and almost alone drives one 
from society. Still more frequently psychical reflexes 
become associated with it and enhance its power. Fear, 
which originates in a shock or contraction wave of the 
vascular system, bringing a whole series of visceral and 
secretory changes in its wake, illustrates the possibility 
of separating the sensational from the cognitive element. 
Dreams often afford instances of all the physical mani- 
festations of fear, with no adequate cognitive process. 
The writer has dreamed of being the actor in a play in 
which fear of impending danger entered, and, in his 
capacity as actor, felt fear (sensational) ; while in his 
capacity of critic he, at the same time, observed the entire 
inadequacy of the supposed occasions of fear. 
Lange says : " No one has ever thought of separating 
the emotion produced by an unusually loud sound from 
the true inward affections. No one hesitates to call it a 
sort of fright, and it shows the ordinary signs of fright. 
And yet it is by no means combined with the idea of 
danger, or in any way occasioned by associations, memo- 
ries, or other mental processes. The phenomena of 
fright follow the noise immediately, without a trace of 
spiritual fear. Many men can never grow used to stand- 
ing near a cannon when it is fired off, although they per- 
fectly know that there is danger neither for themselves 
nor for others-the bare sound is too much for them." 
One who has walked oyer a railroad trestle by night and 
narrowly escaped a fatal plunge by observing just in time 
the absence of a tie, will be able to recall the peculiar series 
of organic sensations involved. The thrill of vaso-motor 
disturbance pervading the body-the twitch of the radial 
artery-the pain in the sternal region-the suffocating 
sensation in the breast and lump in the throat-and, 
finally, the " gone " sensation in the abdomen somewhat 
resembling a sensation of cold, and due in all probability 
to vaso-constrictor reactions in the visceral vessels-these, 
and many more, illustrate the bodily effects which may 
wholly precede the apprehension of danger, and may be 
enhanced by a variety of imagination pictures, and may 
express themselves in impulsive gasps and gestures. It 
is not necessary to call attention to the fact that mental 
271 Emotions. 
Epidemiology. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
images may be almost equally effective with the actual 
external irritations in producing the sensational responses 
of emotions. Before passing from the direct sensational 
elements, however, it may be noticed that those senses 
which externalize their data (vision, hearing, etc.) have 
special powers over the emotions which may in part 
be explained by a sort of central (bulbar ?) irradiation. 
Simple colors and musical sounds produce a vague and 
feeble pleasure unworthy to be called emotional, but 
similar to the normal subjectivity of nervous action ; but 
a symphony or aurora plays on the sensitive organism 
like a harp. The writer, without musical tastes or edu- 
cation, confesses to the tumult of indescribable sensations 
produced by Wagner or Beethoven. Flushes of cold and 
heat ; tinglings and palpitations local and general ; gusts 
and torrents in the blood ; creeping, swelling, scintilla- 
tion of the skin ; giddiness and elation-these and inde- 
scribable " all-over " sensations are easily separable from 
intellectual appreciation, which may even be absent; and 
one may be a wondering spectator observing the irra- 
tional gyrations of his own sense to tintinnabulating stim- 
uli upon which judgment turns the cold shoulder. 
Another class afforded by the tickling and shuddering or 
irradiation sensations proper, further illustrate the neces- 
sity of diffusion in emotional sensation. The slight 
sensations of tickling, aided by subjective modifications, 
extend in most varied and irresistible sensations over the 
whole body. Its emotional character is almost wholly 
apart from the intellectual element. The shudder and 
chill which spring from a gritting sound or the velvety 
touch of a peach, imply in addition considerable instinc- 
tive elements. 
The effect of instinct is powerful in the emotions gen- 
erally. The faintness at sight of blood may be entirely 
apart from apprehension. The universal creepiness in- 
spired by the approach of a harmless snake or the prox- 
imity to a precipice, are illustrations of a form of sensa- 
tion obviously highly developed in animals (witness the 
rising hair of the new-born kitten at the odor of a dog). 
The sight of many small animals, pets, or children, pro- 
duces a marked thrill in most children, often accom- 
panied by curious sensations at the root of the teeth 
(analogous to the sensation sometimes felt with sur- 
charged bladder), and accompanied by strong impulse to 
squeeze or hug the animal, to contract the muscles of 
the jaws, arms, etc. 
These are often very powerful sensations, and product- 
ive of almost violent impulses. They are analogous to 
certain sexual instincts (perverted in gynophagia, etc.), 
but are quite distinct from them. 
The impulses of emotion have received careful study, 
and only too often have been identified as part of the 
feeling. If it were desired to analyze emotion as of 
threefold character, thus: sensation, cognition, impulse, 
there could be no serious objection, except that impulse 
does not always require consciousness of its occasion as 
emotion must. Strong evidence as to the nature of emo- 
tion is afforded by the fact that imitation of the expres- 
sions of emotion reflexly awaken the emotion, while vig- 
orous repression of these impulses quickly obliterate it. 
Distraction of the attention may check the tempest rising 
in a child's bosom which, once overflowing, could only 
find relief in exhaustion. 
Many persons who are not suspected of neurotic dis- 
ease, have a transitory mania which exhibits itself in 
paroxysms of fury as blind and unreasonable as those of 
a maniac, and which may be occasioned by trivial circum- 
stances. The fact that impulsive responses to emotional 
excitation have this reflex power is a significant one in 
the treatment of nervous disease Bucke's description 
of nervous dyspepsia may find a place here. " All phys- 
icians who have been much engaged in general practice 
have seen cases of dyspepsia in which constant low 
spirits and occasional attacks of terror rendered the 
patient's condition pitiable in the extreme. I have 
observed these cases often, and have watched them 
closely, and I have never seen greater suffering of any 
kind than I have witnessed during these attacks. . . . 
Thus a man is suffering from what we call nervous dys- 
pepsia. Some day, we will suppose in the middle of the 
afternoon, without any warning or visible cause, one of 
these attacks of terror comes on. The first thing the 
man feels is great, but vague, discomfort. Then he no- 
tices that his heart is beating much too violently. At 
the same time shocks or flashes, as of electrical dis- 
charges, so violent as to be almost painful, pass one after 
another through his body and limbs. Then in a few 
minutes he falls into a condition of the most intense 
fear. He is not afraid of anything ; he is simply afraid. 
His mind is perfectly clear. He looks for a cause of his 
wretched condition, but sees none. Presently his terror 
is such that he trembles violently and utters low moans, 
and at this stage there are no tears in his eyes, though 
his suffering is intense. When the climax of the attack 
is reached and passed, there is copious flow of tears, or 
else a mental condition in which the person weeps upon 
the least provocation. At this stage a large quantity of 
pale urine is passed. Then the heart's action again be- 
comes normal and the attack passes off." It is not the 
purpose of this article to suggest remedial or obviating 
procedure, but it is obvious that the vaso-motor condi- 
tions in hypochondria and nervous acme of all kinds 
acquire new significance in this connection. 
Another group of phenomena connected with emo- 
tional excitement has recently been adverted to. 
In a paper before the International Congress of Ex- 
perimental Physiology, session of 1892, Professor Hugo 
Miinsterberg details the results of experiments, showing 
that the emotional states react differently on the extensor 
and flexor systems of skeletal muscles. After having 
for some time practised moving an index on a scale ten 
or twenty centimetres centripetally and centrifugally, un- 
til the distance could be quite accurately estimated with 
closed eyes, he tried the same experiment while experi- 
encing pleasurable and painful emotions. The results 
are interesting. Purely physical variations, such as 
would be expected a priori, are seen in the under-estima- 
tion of the distance in dull or serious moods, and over- 
estimation when excited or amused. But psychical varia- 
tions appear when they would hardly have been expected. 
Thus in unpleasurable emotions the extensor motions are 
too small, while flexor motions are too large, and during 
pleasurable emotions the flexor motions are too small 
and the extensor motions too large. The author does 
not hesitate to found on this observation the theory, that 
it is not simply true that painful emotions produce flexor 
motions and pleasurable emotions extensor motions, but 
that the psycho-physical effect of the reflexly produced 
extension and flexion is precisely what we term pleasure 
or painful emotion. A farther generalization is that ex- 
tension must always, from the biological stand-point, 
occur with serviceable, and flexion with harmful, irrita- 
tions. 
Even the infusoria exhibit the same tendency. This 
lies at one extreme, while at the other the pleasurable 
emotion of assent is but an associated reproduction of 
earlier extensor motions, and vice versa. Pain and pleas- 
urable sensations acquire emotional value only through 
the aid of associated muscle sensations, i.e., such as form 
the foundation of our empirical ego. 
These suggestions are expressed in a somewhat differ- 
ent form in Tuke's well-known text-book. " By act- 
ing chiefly on the flexor muscles, fear causes the gen- 
eral bending or curving of the frame; while courage 
contracts the extensors, and produces expansion and 
height." 
"The opposite muscular states of contraction or ten- 
sion and relaxation, alike find illustration in the emo- 
tion of terror, for with the signs of the former already 
mentioned, and the stare of the eye, are combined the 
relaxation of the masseters, the sphincters, and the pro- 
cesses of organic life." "Calmness-a placid condition 
of the feelings generally-is marked by a gentle con- 
traction of the muscles, indicative of repose, but at the 
same time of latent power-by the countenance free 
from furrows, but not relaxed into weakness. Anger 
or rage contracts the masseters, inflates the nostrils, 
furrows the forehead, and exposes and rolls the eye- 
272 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Emotions. 
Epidemiology. 
balls, clenches the fist, and induces a violent action 
and more or less rigidity of the muscles generally." 
" As all movements have for their great end the pres- 
ervation as well as the enjoyment of the individual, and 
as contraction and relaxation take place primarily to at- 
tain this end, a general expansiveness of expression and 
gesture is allied with all the emotions which are excited 
by impressions (or generated by ideas) of a beneficent 
character ; while a general exclusiveness or contraction of 
features is allied with emotions excited by maleficent ex- 
pressions ; the object of one class of movements being to 
court and receive, and of the other to avoid and reject." 
" Pleasurable and painful sensations from without de- 
termine, then, the form which the muscles called into 
action assume ; the purpose being to protect the organs. 
Similar muscular changes arise from the emotions, ac- 
cording as they are pleasurable or painful, in conse- 
quence of the harmony between mental and bodily acts." 
The existence of impulses of the most recondite and 
adaptive sorts need not be denied, nor can it be doubted 
that these reflexly contribute to the emotional element. 
It must be urged, however, that emotion, strictly speak- 
ing, is subjective and must not be identified with its 
bodily occasions or results. The practical problem is to 
acquire control over the conditions. 
The transition from emotion to sentiment is impercep- 
tible. Joy and sorrow are sentiments growing out of 
pleasure and displeasure, and these have their counter- 
parts in sense gratification. Conjugal love is the senti- 
ment of which passion is the emotion, for which erotic 
excitement may afford one sensational basis. 
The rhythmical flux of the feelings is explained by 
physiological oscillations. In the morning, when the 
current of life is full, emotions are not easily awakened. 
A morning audience is not a responsive or emotional 
one. The processes of nutrition exert a powerful effect. 
Physiological acme, like puberty, and the climacteric, 
predispose to emotions. The early development of the 
sensational element of emotion and its preponderance in 
the lower animals has been thought to imply that feelings 
are prior to cognitions. A more just analysis recognizes 
the psychical element of emotion as essentially intellec- 
tual, and abandons the attempt to secure a serial relation 
of the " faculties." An interesting and important field 
is thus open to the practising physician in the minute 
study of the pathology and physiology of emotions. 
C. L. Herrick. 
EPIDEMIOLOGY is the science of epidemics. It is 
therefore chiefly concerned with the distribution of dis- 
ease, although it necessarily deals also largely with ques- 
tions of aetiology (c/. ^Etiology). The distinctive feat- 
ure of an epidemic is the sudden and temporary appear- 
ance of a disease in a considerable number of persons in 
a community at the same, or nearly the same, time. The 
epidemical diseases are naturally, therefore, chiefly, if 
not wholly, extrinsic or environmental diseases. We 
cannot well think of intrinsic disease appearing simul- 
taneously in large numbers of people. The explanation 
of epidemics was formerly simple, although really ob- 
scure. The commonest causes assigned were those de- 
scribed as " meteorologic" or " telluric." Exactly what 
these meant no one knew. " Emanations from the soil," 
"atmospheric conditions," and the like were the high- 
sounding paraphrases which have not yet wholly lost 
their force. 
It is only within the last half-century that a more 
comprehensible set of causes has been introduced, and 
that the scientific study of the distribution of disease has 
become a possibility. With the establishment of the 
doctrine of contagia viva the subject of epidemiology be- 
came a part of general biology, and the distribution of 
disease began to be studied as the distribution of plants 
and animals had long been studied. Contagion and in- 
fection became easily interchangeable terms, contagion 
being only one method of infection. 
At the present time we may safely assume the doctrine 
of a contagium vivum at the bottom of most epidemics, 
although in the last analysis it will be safer to assume 
the cause as toxic or toxicogenic. A poisoned well might 
easily produce an epidemic of arsenical poisoning. A 
car-load of trichinous pigs might as easily produce an 
epidemic of trichinosis in a community. An infected 
water-supply or milk-supply may produce an epidemic 
of typhoid fever. In all of these cases the ultimate as- 
sault upon the cells or the protoplasm of the body may 
be toxic in character, for while the trichinae are lodged 
in the muscle, and the bacillus of typhoid fever may mul- 
tiply in the intestine or in the blood or the tissues, the chief 
damage is done, in all probability, by substances pro- 
duced by the invader which are essentially toxic. It is a 
significant commentary upon the dependence of defini- 
tion upon knowledge and upon the value of a rational 
aetiology, that epidemics due to poisoning are seldom so 
called, being known rather as " cases," while epidemics 
whose origin is unknown, or not generally understood, 
are still called " epidemics," and popularly attributed to 
vague or supernatural causes. 
If we allow that what are thus called epidemics are, in 
reality, due to living organisms such as the spirillum of 
Asiatic cholera or the bacillus of typhoid fever (and at 
present the evidence of aetiology certainly lends very 
strong support to this view), then we have in epidemio- 
logy simply to inquire-How may the organisms of infec- 
tious or epidemic diseases be so disseminated as to attack 
simultaneously a number of persons and thus generate an 
epidemic ? Obviously food and drink afford convenient 
vehicles for the introduction into the alimentary canal of 
all kinds of particles, not excepting those which may act 
as the germs of disease. The atmosphere also may con- 
tain these minute particles, and, during the act of respira- 
tion, deposit them upon the pharyngeal or pulmonary 
mucous membranes. But even when so introduced into 
the alimentary or pulmonary passages the germs of dis- 
ease may conceivably do no damage. They may find 
their environment unfavorable, or they may be destroyed 
by the digestive juices, or having penetrated into the 
body proper they may be captured by phagocytes, or 
killed by the defensive substances of the tissues. As a 
matter of fact wTe find in all epidemics some striking ex- 
amples of apparent insusceptibility and exemption from 
attack, as well as cases affected in very different degrees, 
some lightly some severely. 
These facts are usually explained by the doctrine of 
" predisposition." A in an epidemic suffers severely ; B 
is entirely exempt, and C has only a " mild attack." It 
is usual to say that A was in a peculiarly " susceptible " 
condition, while B was not at all " susceptible," and C 
only slightly so. Theoretically this condition of things 
might easily have existed and each have received the 
same quantity of virus. Moreover, clinical experience 
strongly confirms this view, for in epidemics in general, 
and in those of typhoid fever in particular, it is the ob- 
viously weak or overburdened who most readily suc- 
cumb to infection. But there is another possibility to be 
kept in view. The amount of the dose may have some- 
thing to with the matter, and in this direction we are still 
very much in the dark. 
It is now generally admitted by epidemiologists that 
there must be an exciting cause acting upon a commu- 
nity before an epidemic can arise. Even Pettenkofer 
has referred to this cause, in his latest publication upon 
cholera (see The Lancet, 1892), as very likely an organism, 
but something properly designated as x. The individual 
condition of susceptibility or immunity he designates as 
2. Most epidemiologists of to-day regard these two fac- 
tors as sufficient to determine the question of the disease. 
But not so Pettenkofer, who adds to these an interme- 
diate requirement, viz., condition of locality, which he 
designates as y. While insisting upon this, Pettenkofer 
urges that those who omit his y are destitute of epidem- 
iological experience, and by virtue of their inexperience 
with epidemics easily become mere " contagionists." It 
is not easy to discover the evidence upon which Petten- 
kofer bases his claim for the importance of local condi- 
tions in the distribution of infectious disease. Those 
who are familiar with the works of Budd on typhoid 
fever will not readily accept the views of Pettenkofer, 
273 Epidemiology. 
Epileptics. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
and the doctrine of parsimony in logic will not allow us 
at present to require any other factors for disease than the 
fortuitous concurrence and combination of his x and his z. 
It is uncertain to what extent the air is a carrier of 
disease, but the tendency of recent inquiries is to di- 
minish rather than increase its importance. It is now 
generally held, upon the evidence of bacteriology, that 
the expired air is germ-free, so that this possible ave- 
nue, once regarded as important, and popularly still 
so regarded, is excluded. With pulmonary tuberculosis, 
diphtheria, and pneumonia, the sputum, when dried and 
pulverized, may act as the vehicle of disease driven by 
the air, but it is not yet accurately known to what extent 
the germs survive, or for how long, under natural condi- 
tions. With the exanthemata, particularly small pox, 
scarlet fever, measles, and the like, there is every reason 
to believe that the disease is often disseminated through 
the air by means of infected epidermal scales driven 
about. In the diarrhoeal diseases, on the other hand, it 
is apparently the bowel discharges (and only rarely the 
urine) which contain and convey the infection. Asiatic 
cholera and typhoid fever are apparently conveyed 
chiefly, if not exclusively, in this way. To provoke an 
epidemic of these diseases it is apparently only necessary 
to contaminate food or drink with (rather fresh) fecal 
material. Very numerous cases are on record of the dis- 
semination of typhoid fever by infected milk and infected 
drinking-water, and the same facts are probably true of 
cholera. Dr. Budd long ago proved that the former dis- 
ease is common among washerwomen, whose duty it is 
to wash infected linen soiled with the discharges of 
typhoid-fever patients, and there is an increasing quan- 
tity of evidence that milkmen and others suffering from 
incipient or walking typhoid may infect the milk which 
they sell by carelessness in cleaning their hands after 
defecation. One of the most instructive epidemics ever 
traced was that at Caterham, England, in February, 
1879, where a small quantity of the fecal discharges of 
one workman, apparently in the incipient stages of 
typhoid fever, contaminated an otherwise pure water- 
supply, and led to 352 cases and 21 deaths from this dis- 
ease. The low fatality may have been due to the enor- 
mous dilution of the virus. 
If by food we may understand broadly food and drink, 
then it is probably true that the principal vehicles for 
distribution of the seeds of disease are food and fingers. 
In the diarrhoeal diseases this is certainly true, and it 
will very likely be found hereafter to be equally true of 
other infectious diseases, although for diseases of the 
throat and lungs, such as diphtheria and tuberculosis, 
kissing may hereafter be found to be the most effective 
agent of distribution. Of contagion in the popular 
sense, namely, the " taking" of a disease directly, from 
mere contact or touching, there is probably no real ex- 
ample, except in kissing or venereal disease; but the hand 
must certainly be regarded as the ready carrier of the 
germs of disease to the mouth, so that " contagion " may 
readily result in infection. It ought to be more widely 
understood than it is that unclean hands may infect food, 
and that although contagion in the old sense plays a 
small part, the co-operation of fingers and food may make 
a very " short cut " for the distribution of disease. The 
author has seen epidemics of typhoid fever plainly due 
to secondary infection of this kind among unclean people, 
whose families prepare and serve their own food. These 
cases are more obscure, but not less instructive than 
those in which a public supply, such as water or milk, 
shared in common by many, has become infected. It 
must not be forgotten that if the modern views of the 
aetiology of contagious disease are correct, there can be 
no more real mystery in the genesis of epidemics and the 
distribution of disease than in the genesis of nations or 
forests and the distribution of plants and animals. 
William T. Sedgwick. 
EPILEPTICS, THE CARE OF. The care of epilep- 
tics really includes their medical treatment as well as all 
other kinds of help extended to them. But medical care 
has been given them, such as it is, for some thousands of 
(SUPPLEMENT.) 
years, and yet without adding much to the happiness of 
individuals under treatment, or accumulating much evi- 
dence of positive value concerning medication in epi- 
lepsy. Our results have been, indeed, almost valueless, 
for, with all our dosing with bromides, borax, belladonna, 
and so on through the alphabetical index of the Pharma- 
copoeia, it is extremely doubtful if in ordinary practice 
one per cent, of the cases of idiopathic epilepsy are cured. 
Besides the practical incurability and hopelessness of the 
disease, its victims have suffered untold sorrows in the 
way of negligence and ill-treatment at the hands of the 
communities in which they live. 
It is a peculiarity of this disease that the seizures may 
be momentary, or may last for a few minutes only, re- 
curring sometimes frequently, sometimes daily, and 
sometimes months apart, thus robbing the sufferers of 
their consciousness and faculties, for brief periods of 
time at long or short intervals. Between the attacks 
they may be as rational and as well qualified for all the 
vocations, duties, and social privileges of life as any other 
human being. 
These facts do not concern only a few members of a 
community. Epilepsy is a widespread disorder, and it 
has been calculated that one person in five hundred is thus 
afflicted. Thus there would be in the neighborhood of 
one hundred and thirty thousand such unfortunates in 
the United States alone, and over twelve thousand in the 
State of New York. Even supposing this percentage to 
be exaggerated to a very great extent, and that the actual 
ratio were one to one thousand, the number of epileptics 
would still be enormous, and would constitute a very 
large part of our defective classes. 
Outside of the efforts, thus far comparatively futile, of 
physicians to alleviate their purely physical infirmities, 
and to reduce the number and severity of the attacks, 
nothing has been done until late years to provide for 
their mental development and to meet the peculiar con- 
ditions of life which they are called upon to endure. 
Thus no general hospital will receive such cases for treat- 
ment, because of the incurable and unpleasant nature of 
their malady ; while much of the time thoroughly capa- 
ble of acquiring an education, they are debarred for 
obvious reasons from the schools; the churches are 
closed to them; very few care to employ epileptics in 
shops, stores, or offices, or are willing to teach them 
trades; few epileptics are at liberty to enjoy the com- 
panionship of their fellows, who rather are inclined to 
shun their unfortunate brethren. Thus every avenue 
for mental or moral development, for occupation, for as- 
sociation with the rest of mankind is closed to them. 
They are even burdensome to their families. It is little 
wonder, then, that many of them grow up dull and igno- 
rant, intellectually feeble, normally depraved, irritable in 
temper, with tendencies to retrogression and degeneration 
rather than to advance. A few of them become insane 
and are sent to insane asylums. Others, not insane, but 
ill adapted for existence under such miserable conditions, 
drift to the only homes offered them, the almshouses. 
The almshouse and the asylum are their only refuge 
when abandoned by their friends. In the State of New 
York, for instance, where there are twelve thousand epi- 
leptics, some four hundred or more are in insane asylums, 
and some six hundred in the county poorhouses. The 
rest of these are scattered throughout the State, in their 
own families, among the rich and the poor, in ratio to 
population and to the relative proportions of these classes. 
Many are so slightly affected that they are able in spite 
of their seizures to pursue some of the ordinary vocations 
of life. Thus I know personally of a doctor, clergyman, 
several bookkeepers, a bank president, a stock - broker, 
several clerks, some dressmakers, shoemakers, masons, 
and a telegraph operator who are epileptics, and yet able 
to carry on useful pursuits, albeit under adverse condi- 
tions. To all of us are familiar certain well-known his- 
torical or literary characters in whom epilepsy failed to 
restrict the development of their genius, such as Caesar, 
Napoleon, Moliere, Petrarch, Dostojewsky, and others. 
It would seem, therefore, from the above facts that, 
although there is such a thing as epileptic insanity, the 
274 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Epidemiology. 
Epileptics. 
(SUPPLEMENT.) 
to suggest the restraints and discomforts of large institu- 
tions. There was one small cottage set aside for such 
cases as should become mildly insane, but bad cases of 
actual insanity were sent to insane asylums. Everything 
had been thought out carefully for the perfect evolu- 
tion of this little social world, not only the multiplicity 
and details of occupations which would give each mem- 
ber of the community his choice of callings, but even 
the avocations, games, amusements, entertainments that 
might tend to divert his mind from the contemplation of 
his misfortunes. And since my visit the colony has con- 
tinued to expand, to develop new and valuable features, 
and to confer its blessings upon large numbers of per- 
sons afflicted with this disease. 
Taking Bielefeld as a model, nine other similar epileptic 
colonies have been established in Germany, one at Zurich, 
in Switzerland, and one in Holland. Most of these are 
not conducted by the state, but are under the jurisdiction 
of private or church charities. None of them are alto- 
gether self-supporting, but some of them approach very 
near it. 
It should be stated that before the founding of the 
Bethel colony at Bielefeld, a somewhat similar institu- 
tion, though on a much smaller scale, was begun in 
France, at a village called La Force, near Lyons. Over 
forty years ago a noble clergyman named John Bost 
established this institution, and it is in a flourishing state, 
doing a vast amount of good and redounding to the 
credit of his creative genius. 
It has been found in all of these colonies that no harm 
is done by bringing epileptics into contact with each 
other. They feel on an equality with their fellows in such 
a place, losing that sense of isolation and singularity 
which they cannot but observe in the ordinary world as 
separating them from the rest of mankind. They enjoy 
caring for each other and being kind and helpful to their 
fellow-sufferers. It has been noted, too, that the number 
of seizures almost always diminishes upon entering upon 
the new and more hopeful and encouraging life begotten 
in the busy community. 
Within two or three years interest has been awakened 
in other countries in the matter of provision for epilep- 
tics, notably so in America and England, where their 
peculiarly sad condition had never been noted nor con- 
sidered. In 1890 Ohio took steps toward the establish- 
ment of an institution for epileptics, a commission, 
consisting of Messrs. J. L. Vance, C. C. Waite, and one 
other having been appointed by Governor Campbell, pur- 
suant to an act of the Legislature, to select a site and pre- 
pare plans for the purpose. Of various sites examined, 
one at Gallipolis seemed best adapted for the project, 
and here a tract of one hundred acres was presented to 
the State by the citizens for the institution. To the 
writer, who was consulted upon the subject of site and 
plans, this seemed to be the best location offered, for, 
although an insufficient space for a large institution, there 
was plenty of land adjacent which could be subsequently 
added to the original tract. Contrary to the advice of 
the writer, the architect felt obliged, probably owing to 
the demand of the community of Gallipolis for an insti- 
tution of striking proportions, to group the buildings on 
a symmetrical plan, such as is frequently carried out in 
public establishments for the insane. The Ohio epilep- 
tic hospital is built on the pavilion or cottage plan, a 
large number of these being grouped about the centre or 
administration building. It will therefore not meet in 
this important particular the requirements of a colony 
for epileptics, although in respect to provisions for 
school-buildings, shops, and the like, an effort has been 
made to fit the institution for the particular kind of care 
needed by this class. The name of the institution for 
epileptics in Ohio is also unfortunately chosen, for it is 
called " The Asylum for Epileptics and Epileptic In- 
sane." The corner-stone was laid with appropriate cere- 
monies November 12, 1891, an interesting address and 
historical review being given by General Roeliff Brink- 
erhoff, President of the Ohio State Board of Charities. 
Three of the buildings were completed and made ready 
for occupancy in 1892, and nine additional cottages are 
proportion of insane epileptics to sane epileptics is really 
very small, much less than ten per cent, taken at the 
utmost, and that this ratio may be reduced by affording 
these unfortunates such opportunities for mental and 
moral development as are enjoyed by other and more 
happily situated citizens ; and not only may the percent- 
age of insanity be reduced, but the comfort and prosperity 
of all epileptics be increased by proper provision on the 
part of the State, or through private channels, of institu- 
tions of a peculiar character adapted to their peculiar 
wants. A large public hospital is very far from meeting 
their requirements, for, as has already been shown, me- 
dicinal treatment is uncertain and unpromising. Insane 
asylums should receive but very few, and almshouses 
none at all. What is demanded is an institution on the 
■community or village plan, where medical treatment 
(such as it is) may be given to every member, and where 
every sort of education, employment, and social privilege 
commensurate with his needs and conditions may be ex- 
tended to every beneficiary. 
The colony system only can attain this object. A 
colony for epileptics is not an impracticable scheme pro- 
posed by visionaries. It is already an accomplished 
fact. The Bethel Epileptic Colony, at Bielefeld, in the 
province of Westphalia, near Hanover, Germany, was 
founded by Pastor von Bodelschwingh, over twenty-five 
years ago. He purchased a small farm with one house, 
and with four epileptics as a beginning, established a 
charity which for nobility of conception and success in 
its results has nowhere an equal. It seemed to its benefi- 
cent founder feasible to create a refuge where these 
sufferers might be cured, if curable, might have a home 
if recovery were impossible, might learn trades, and the 
great majority become educated, useful, and industrious 
citizens. From that small beginning there has been a 
gradual evolution of his idea, until now there are over one 
thousand epileptics, resident in some sixty or more houses 
scattered irregularly but picturesquely over a large farm. 
Everyone who visits this unique colony is deeply im- 
pressed with the happiness, contentment, and prosperity 
everywhere apparent among the inhabitants of this little 
epileptic world. He sees that it is no longer an experi- 
ment, and the previously unanswerable objections to 
such aggregations are, by its success, answered and 
silenced. At the time of my visit to Bielefeld, in 1886, 
there were but eight hundred and twenty-five epileptic 
patients. The employments were numerous and varied. 
A school provided instruction for some one hundred and 
fifty pupils of both sexes. All branches were taught. 
The dairy and the farm and garden occupied the atten- 
tion of the greatest number of patients, especially as a 
large trade in vegetable and flower-seeds was carried on 
by the colony. 
Among the shops for epileptic workmen were those 
for carpenters, cabinet-makers, painters and varnishers, 
printers, bookbinders, blacksmiths and foundrymen, 
tailors, and shoemakers : and among the stores were a 
grocery, pharmacy, book-store, and a seed-store. The 
■carpenters aided in the building and furnishing of new 
houses. Plans and drawings for new buildings were 
made in the architects' room. Epileptics were employed 
in all the departments of industry relating to building. 
Books were printed and bound, and sold here, especially 
popular works for moral and religious instruction. The 
illumination of mottoes for hospital wards and school- 
rooms, and the coloring of picture-cards were features 
of the work performed; washing, cooking, knitting, 
sewing, and fancy-work employed many. A bureau 
had been established for the collection and sale of mu- 
seum objects, such as antiquities, articles of ethnographic 
and historic interest, autographs of distinguished people, 
coins, stamps, bronzes, gems, engravings, etc., and speci- 
mens from the animal, vegetable, and mineral kingdoms. 
For men alone there were over thirty different callings. 
The houses presented great diversity of architecture 
and position. They were well separated, generally in- 
closed in individual gardens, surrounded by fences or 
hedges and many trees, and altogether exhibited the 
home-likeness of a country village, with little or nothing 
275 Epileptics. 
Epileptics. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
now in course of construction, the last Legislature having 
made a liberal grant for the purpose. 
In California detached buildings are being erected 
upon the grounds of the California Home for Feeble- 
minded in Sonoma County, with the view of accommo- 
dating the epileptics dependent upon the State in pleas- 
ant quarters. 
Active measures are being carried out also in Massa- 
chusetts, Pennsylvania, Wisconsin, and Illinois, for the 
purpose of procuring State care and separate provision 
for the same class of unfortunates. 
Next to Ohio, the State of New York has manifested 
the most interest in her epileptic dependents, and in the 
winter session of 1891-92 a law was passed by the Legis- 
lature making the State Board of Charities a Commission 
to select a site and prepare plans for an institution for 
epileptics. The law was authoritative in requiring the 
tract of land secured for the purpose to be four hundred 
acres or more in extent, and the whole scheme of build- 
ings to be arranged on the colony or village plan. A 
committee of the State Board of Charities, consisting of 
Messrs. Oscar Craig, William P. Letchworth, and Peter 
Walrath, has been busy all of the past summer and 
autumn (1892) in examining a large number of localities 
which they were invited to inspect by the officers of va- 
rious counties. In their report made to the Legislature on 
Wednesday, January 11, 1893, the State Board of Chari- 
ties unanimously recommended for the proposed, colony 
a site in Livingston County, consisting of over eighteen 
hundred acres, the property of the " Shakers," now 
known as the Sonyea Society of United Christian Be- 
lievers. The Shakers have dwindled in numbers to such 
an extent that they decided to give up this colony and 
rejoin the mother colony near Watervliet, N. Y. The 
land is beautifully situated in the Genesee Valley, near 
the town of Mount Morris, and in one of the finest re- 
gions of the State. It is exactly fitted to meet the wants 
of a model colony for epileptics. It is traversed by two 
streams. One of these, the Cashauqua Creek, flows 
through the middle of the land in a deep gorge, with a 
fall of one hundred feet. This gorge and creek are of 
immense advantage for the complete separation of the 
sexes in free colony life. The supply of water is abun- 
dant, and the conditions for good sewerage perfect and 
adequate in every respect. The Western New York & 
Pennsylvania Railroad runs through the land, and two 
great trunk lines, the Erie Railway and the Delaware & 
Lackawanna Railroad, are within a mile of the proposed 
colony. The soil is exceedingly fertile and well adapted 
for all manner of agriculture, horticulture, the produc- 
tion of berries and fruits for canning industries, and the 
raising of garden produce and seeds of all kinds. It has 
some stone and brick clay, which will prove useful in 
the development of certain forms of out-of-door employ- 
ments. It already contains scattered buildings for the 
accommodation of three hundred patients. 
The law which has been introduced into the present 
session of the New York Legislature embodies provis- 
ions for the purchase of this tract of land, and also for 
the methods of management, government, and admission 
of patients to the colony. As some of these may be use- 
ful to those interested in the establishment of similar in- 
stitutions, a few of the chief points will be mentioned here 
and the entire law given below. 
The name of the institution is " The Sonyea Colony." 
Thus any direct reference to its object is avoided in the 
title. The word " Sonyea" is an old Indian word, mean- 
ing sunshine, and is historical in that this point was once 
the site of an ancient Indian village of the same name. For 
the present all insane epileptics are to be excluded, but 
probably ultimately there will be some building for the 
insane, especially for such as become mentally deranged 
temporarily while residents of the colony, since their 
removal from the happy influences of the community 
system to an asylum for the insane would be very de- 
pressing and tend to retard rather than promote their 
recovery. 
There are to be nine managers appointed by the Gov- 
ernor, two of whom are to be women and two to be 
(SUPPLEMENT.) 
physicians. They are to represent the eight judicial dis- 
tricts of the State of New York, an additional member 
to represent the City of New York. 
The colony is to have a medical superintendent, stew- 
ard, matron, and such teachers and other assistants as 
are necessary. 
The main object of the colony is to provide for the in- 
digent epileptics of the State, but private patients will 
also be admitted to an extent to be determined by the 
Board of Managers. Epileptics of all ages are to be re- 
ceived and cared for ; minors are detained by authority 
delegated by the parents or guardians ; adults are free to 
go or remain, as they choose, there being no deprivation 
of liberty of any kind by methods of legal commitment, 
such as are necessary in asylums for the insane. The 
charge for maintenance of indigent patients is to be borne 
by the State, and a limit of $250 per annum per capita 
is established by the law. But it is expected that the 
colony will eventually become, to a very great extent, 
self-supporting. 
Patients that become insane are to be sent to asylums 
in the districts from which they come, in accordance 
with the lunacy statutes. 
A special pathologist to reside in the community and 
devote his sole attention to the discovery of the causes 
and cure of epilepsy is one of the features ultimately 
contemplated in connection with this great institution. 
An Act to Establish an Epileptic Colony.-Sec- 
tion 1. Sonyea Colony. There shall be established in 
Livingston County, in this State, a colony for epileptics, 
to be known as the Sonyea Colony. 
Sec. 2. Objects of such Colony. The objects of such 
colony shall be to secure the humane, curative, scientific, 
and economical treatment and care of epileptics, exclusive 
of insane epileptics ; to fulfil which design there shall 
be provided, among other things, a tract of fertile and 
productive land, in a healthful situation, with an abun- 
dant supply of wholesome water, sufficient means for 
drainage and disposal of sewage, and sanitary conditions ; 
and there shall be furnished, among other necessary 
structures, cottages for dormitory and domiciliary uses, 
buildings for an infirmary, a school-house, and a chapel, 
workshops for the proper teaching and productive pros- 
ecution of trades and industries ; all of which structures 
shall be substantial and attractive, but plain and moderate 
in cost, and arranged on the colony or village plan. 
Sec. 3. Managers of the Colony. There shall be a 
board of nine managers of the Sonyea Colony, seven of 
whom shall be men, and two of whom shall be women, 
appointed by the Governor, by and with the advice and 
consent of the Senate. Two of said managers shall be 
well-educated physicians ; and all of them shall be citi- 
zens of the State, and residents respectively as follows : 
one in each of the eight judicial districts of the State, 
with one additional manager for the city and county of 
New York ; but no manager shall reside in the town 
where said colony is located, or in Livingston County. 
The full term of office of each appointed manager shall 
be eight years, after the first appointments ; and the 
term of office of one of such managers shall expire an- 
nually. To effect such order of expiration of terms 
of managers, the first appointments shall be made for 
the respective terms of eight, seven, six, five, four, 
three, two, and one years. Appointments of successors, 
and of persons to fill vacancies occurring by death, re- 
signation, or failure in attendance at meetings shall be 
made without unnecessary delay. Failure of any mana- 
ger to attend in each year the whole of two stated meet- 
ings of the board, shall cause a vacancy in his office. 
The managers shall receive no compensation for their 
services, but shall be allowed their reasonable travelling 
and official expenses, when duly*verified and approved 
by an auditing committee of the board, and duly pre- 
sented to the Treasurer of the colony for payment. 
Sec. 4. Land. The Board of Managers, within sixty 
days from their appointment, shall submit to the Attorney- 
General the land contract with option in the State, re- 
ported to the Legislature by the State Board of Charities 
at this session, and an official search and abstract of the 
276 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Epileptics. 
Epileptics. 
(SUPPLEMENT.) 
and papers may be attested by the secretary, with, or 
without a seal ; and when attested under seal shall be 
received in evidence as if duly acknowledged before an 
officer authorized to take acknowledgments of deeds. 
The managers shall establish such by-laws as they may 
deem necessary or expedient for regulating the appoint- 
ments, powers, and duties of officers, teachers, attendants, 
and assistants, for fixing the conditions of admission, 
treatment, education, support, and discharge of patients, 
and for conducting in a proper manner the business of 
the colony ; and they shall ordain and enforce a suitable 
system of rules and regulations, for the internal govern- 
ment, discipline, and management of the colony. 
The managers shall maintain an effective inspection of 
the affairs and management of the colony, for which 
purpose they shall meet at the institution at least twice in 
each year, at such times as the by-laws shall prescribe, 
provided that their annual meeting shall be held on the 
fifteenth day of October. 
A committee of three managers, to be appointed by the 
Board at the annual meeting thereof, shall visit the colony 
once in every month, and perform such other duties and 
exercise such other powers as shall be prescribed in the 
by-laws or directed by the Board. 
The Board shall keep in a bound book to be provided 
for the purpose a fair and full record of all its doings, 
which shall be open at all times to the inspection of its 
members, the members and officers of the State Board of 
Charities, and all persons whom the Governor or either 
house of the Legislature may appoint to examine the 
same. 
Sec. 9. Officers of the Colony. The Board of Man- 
agers shall appoint, outside its members, two officers, 
namely : a superintendent of the colony, who shall be a 
well-educated physician and a graduate of a legally char- 
tered medical college, with an experience of at least five 
years in the practice of his profession ; and a treasurer, 
who shall reside in the county of Livingston, and shall 
give an undertaking to the people of the State, for the 
faithful performance of his trust, in such penal sum and 
form and with such sureties as the Comptroller shall ap- 
prove. 
Said officers and each of them may be discharged or 
suspended at any time by the said Board in its discretion. 
The superintendent shall appoint a steward and a 
matron, who, with the superintendent, shall constantly 
reside in the colony, and he shall employ an experienced 
and competent bookkeeper, and such teachers, attend- 
ants, and assistants as he may think necessary or proper 
economically and efficiently to carry into effect the de- 
sign of the colony ; and he shall prescribe their several 
duties and places and fix their compensation ; and he 
may, at any time in his discretion, suspend or discharge 
any of them. 
The Board shall determine the annual salaries and 
allowances of the superintendent, steward, and matron, 
not exceeding, in addition to maintenance supplies, the 
following sums for salaries : Four thousand dollars to 
the superintendent ; fifteen hundred dollars to the 
steward ; fifteen hundred dollars to the matron, and the 
Board shall determine the annual salary of the treas- 
urer of the colony, not exceeding two thousand dol- 
lars. 
Such salaries and allowances shall be paid quarterly 
on the first days of October, January, April, and July, 
each year, by the treasurer of the colony, on presentation 
of the bills therefor, audited, allowed, and certified as 
prescribed in the by-laws. 
Sec. 10. Duties of Superintendent. The superinten- 
dent shall be the chief executive officer of the colony, 
and, subject to the supervision and control of the Board 
of Managers, he shall discharge the following among 
other duties : 
1. Oversee and secure the individual treatment and 
personal care of each and every patient of the colony 
while resident therein, and the proper oversight of all the 
inhabitants thereof. 
2. Have the general superintendence of the buildings, 
grounds, and farm, with their furniture, fixtures, and 
title of the tract of land described in said contract, con- 
taining eighteen hundred acres, more or less, lately oc- 
cupied and owned by the United Society of Christian 
Believers, situated in Livingston County ; and if such 
title be approved by the Attorney-General, and certified 
by him to be good and free from incumbrance, the Board 
of Managers shall, within thirty days thereafter, accept 
a good and sufficient deed of conveyance of said tract of 
land to the State, to be approved by the Attorney-Gen- 
eral ; and thereupon the Treasurer of the State, on the 
warrant of the Comptroller, shall pay therefor, as herein- 
after provided, the consideration of $125,000, with pro- 
portionate reduction for deficiency, if any, in the quan- 
tity of land, which is assumed in said contract to be at 
least eighteen hundred acres for said purchase price. 
Provided, that if such title shall not be approved, or 
such deed with a good title free from incumbrance cannot 
be secured, the Board of Managers shall, so soon as prac- 
ticable, report the facts to the Legislature. 
Sec. 5. Buildings and Improvements. Upon securing 
the conveyance of said tract of land to the State, with 
the approval of the Attorney-General as aforesaid, the 
Board of Managers shall immediately put the premises 
thus conveyed into proper condition for reception of 
patients ; and shall receive them gradually and as rapidly 
as practicable ; and for such uses and purposes shall 
utilize the present buildings and improvements upon said 
premises, and adopt a general design including the same, 
and the recommendations of the State Board of Charities 
in its said report, and subsequently from the beginning 
to the end, make all buildings and improvements sub- 
serve such design and recommendations and true econ- 
omy. 
Sec. 6. Donations in Trust. The managers may take, 
and hold in trust for the State, any grant or devise of 
land, or any gift or bequest of money7 or other personal 
property, or any donation, to be applied, principal or in- 
come or both, to the maintenance and education of epi- 
leptics, and the general uses of the colony. 
Sec. 7. State Board of Charities. The Board of 
Managers of the Sonyea Colony shall annually, on or 
before the first day of November, for the preceding fis- 
cal year ending September 30th, report to the State 
Board of Charities the affairs and conditions of the 
colony, with full and detailed estimates of the next 
appropriation required for maintenance and ordinary 
uses and repairs; and of special appropriations, if 
any, needed for extraordinary repairs, renewals, exten- 
sions, improvements, betterments, or other necessary7 ob- 
jects ; as also for the erection of additional buildings 
needed by reason of over-crowding, and in order to pre- 
vent the same, or to meet the need of sufficient accommo- 
dations for patients seeking admission to the colony, and 
the State Board of Charities shall, in its annual report to 
the Legislature, certify what appropriations are, in its 
opinion, necessary or proper. 
The said colony shall be subject to the visitation and 
supervision and to the general powers of the State Board 
of Charities. 
Sec. 8. Powers and Duties of Managers. Five mem- 
bers of the Board of Managers shall constitute a quorum 
for the transaction of business. The Board shall have 
the government of the patients, officers, employees, in- 
mates, and inhabitants of the colony, and the general di- 
rection and control of all the persons, property, and con- 
cerns of the colony, not otherwise provided for by7 law ; 
including the purchase of supplies and of raw materials 
for the trades and industries of the colony, and the sale 
and disposal of the manufactured products and the prod- 
uce of the land, through its officers or agents, and the 
supply of necessary7 assistance to educate and profitably 
employ the labor of the patients ; and shall take charge 
of the general interests of the colony, and see that its 
general design is carried into effect, and everything done 
faithfully and according to the requirements of the Legis- 
lature and the by-laws, rules, and regulations of the col- 
ony. 
The managers shall elect from their number a presi- 
dent and a secretary, and may secure a seal. Documents 
277 Epileptics. 
Epileptics. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
stock, and the direction and control of all persons em- 
ployed in and about the same. 
3. Give, from time to time, such orders and instruc- 
tions as he may deem best calculated to induce good 
conduct, fidelity, and economy in any department of 
labor, or of education or treatment of patients. 
4. Maintain salutary discipline among all employees, 
patients, and inhabitants of the colony, and enforce 
strict compliance with his instructions and uniform 
obedience to all the rules and regulations of the colony. 
5. Cause full and fair accounts and records of the en- 
tire business and operations of the colony, with the condi- 
tion and prospects of the patients, to be kept regularly, 
from day to day, in books provided for that purpose. 
6. See that such accounts and records shall be fully 
made up to the first days of April and October in each 
year, and that the principal facts and results, with his 
report thereon, be presented to the Board at its semi- 
annual meetings. 
7. Conduct the official correspondence of the colony 
and keep a record or copy of all letters by himself and 
by his clerks and agents, and files of all letters received 
by him or them. 
8. Prepare and present to the board at its semi-an- 
nual meetings a true and perfect inventory of all the 
personal property and effects belonging to the colony, 
and account, when required by the Board, for the careful 
keeping and economical use of all furniture, stores, and 
other articles furnished for the colony. 
9. Keep a record of all applications for admission of 
patients, and enter in a book, to be provided and kept 
for that purpose, at the time of the admission of each 
patient to the colony, a minute, with the date, name, res- 
idence of the patient, and of the persons on whose appli- 
cation he is received, with a copy of the application, 
statement, certificate, and all other papers received re- 
lating to such epileptic patient, the originals of which he 
shall file and carefully preserve, and certified copies 
whereof he shall forthwith transmit to the State Board 
of Charities. 
Sec. 11. Duties of Treasurer. The treasurer, among 
his other duties, shall perform the following : 
1. Have the custody of all moneys, notes, mortgages, 
and other securities and obligations belonging to the 
colony. 
2. Keep a full and accurate account of all receipts and 
payments in such form as directed in the by-laws, and 
such other accounts as shall be required of him by the 
managers. 
3. Balance all the accounts on his books on the first 
day of each October and make a statement thereof, and 
an abstract of all the receipts and payments of the past 
year ; and, within three days thereafter, deliver the same 
to the auditing committee of the managers, who shall 
compare the same with his books and vouchers and ver- 
ify the same by a further comparison with the books of 
the superintendent, and certify the correctness thereof to 
the managers at their annual meeting. 
4. Render a quarterly statement of his receipts and 
payments to such auditing committee, who shall, in like 
manner as above, compare, verify, report, and certify 
the result thereof to the managers at their annual meet- 
ing, who shall cause the same to be recorded in one of 
the books of the colony. 
5. Render a further account of the state of his books 
and of the funds and other property in his custody 
whenever required by the managers. 
6. Receive for the use of the colony any and all sums 
of money which may be due upon any obligations or 
securities in his hands belonging to the colony, and any 
and all sums charged and due to the asylum for the sup- 
port of any patient therein, or for actual disbursements 
made in his behalf for necessary clothing and travelling 
expenses, and any and all sums of money due to the 
colony. 
7. Prosecute an action in the name of the people of the 
State to recover any sum of money that may be due or 
owing to the colony from all sources, including the 
bringing of suit for breach of contract between private 
patients or their guardians and the managers of the col- 
ony. 
8. Execute a release and satisfaction of a mortgage, 
judgment, or other lien in favor of the colony when paid, 
so that the same may he discharged from record. 
9. Pay the salaries of the superintendent, treasurer, 
the matron, and the steward of the colony, and of em- 
ployees duly appointed as aforesaid, and the disburse- 
ments of the officers and members of the board as afore- 
said. 
The treasurer shall have power to employ counsel, 
subject to the approval of the Board of Managers. 
Sec. 12. Designation and Admission of Patients. 
There shall be received and gratuitously supported in 
the colony, epileptics residing in each judicial district, 
who, if of age, are unable, or, if under age, whose parents 
or guardians are unable to provide for their support 
therein, and who shall be designated as State patients. 
Such additional number of epileptics, whether of age or 
under age, as can be conveniently accommodated, shall 
be received into the colony by the managers on such 
terms as shall be just, and shall be designated as private 
patients. 
Epileptic children shall be received into the colony 
only upon the written request of the persons desiring to 
send them, stating the age, place of nativity, if known, 
Christian and surname, the town, city, or county in which 
such children respectively reside, and the ability of 
their respective parents or guardians or others to provide 
for their support, in whole or in part, and if in part only, 
stating what part; and stating also the degree of rela- 
tionship or other circumstances of connection between 
the patients and the persons requesting their admission, 
which statements, in all cases of State patients, must be 
verified by the affidavits of the petitioners and of two dis- 
interested persons, and accompanied by the opinion of a 
qualified physician, all residents of the same county with 
the epileptic patient, and acquainted with the facts and 
circumstances stated, and who must be certified to be 
credible by the County Judge or Surrogate of the county, 
and such judge or Surrogate must also certify, in each 
case, that such State patient is an eligible and proper 
candidate for admission to the colony. 
State patients, whether of age or under age, may also 
be received into the colony upon the official application 
of a County Superintendent of the Poor, or of the Com- 
missioners of Charity or Overseers of the Poor of cities or 
towns having such officers. 
It shall be the duty of the Superintendent of the Poor 
in every county, and of the Overseer, Commissioner, or 
Board of Commissioners of every city having supervision 
of the poor, to furnish annually to the State Board of 
Charities a list of all epileptics in their respective juris- 
dictions, so far as the same can be ascertained, with such 
particulars as to the condition of each epileptic as shall 
be prescribed by the said State Board. 
Whenever an epileptic shall become a charge for his 
or her maintenance on any of the towns, cities, or coun- 
ties of this State, it shall be the duty of all Overseers or 
Charity Commissioners, or other officers of the poor of 
such city, and of the County Superintendent of the Poor, 
and of the Supervisors of such county, to place such epi- 
leptic in the said colony. 
Any parent, guardian, or friend of an epileptic child 
within this State may make application to the Overseer or 
Charity Commissioner, or Board of Commissioners or 
other officers having charge of the poor of any city or 
town, or the Superintendent of the Poor of any county, 
or the Board of Supervisors or any Supervisor of such 
county where such child maybe, showing by satisfactory 
affidavit, or other proof that the health, morals, comfort, 
or welfare of such child may be endangered or not prop- 
erly cared for if not placed in such colony ; and there- 
upon it shall be the duty of such Overseer, Charity Com- 
missioner, Poor Officer, Superintendent of the Poor, or 
Supervisor or Board of Supervisors, to whom such appli- 
cation may be made, to place such child in the said col- 
ony, provided that in all cases not properly coming un- 
der section thirteen relating to the support of State 
278 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Epileptics. 
Epileptics. 
patients, the Board of Supervisors shall provide for the 
support of such cases, and may recover the same from 
the parents or guardians of such children. 
In the admission of patients, preference shall always 
be given to poor or indigent epileptics or the epileptic 
children of poor or indigent persons, over all others ; 
and preference shall always be given to such as are able 
to support themselves only in part, or who have parents 
able to support them only in part, over those who are 
able, or who have parents who are able wholly to furnish 
such support. 
Sec. 13. Support of State Patients. Each indigent 
patient and each patient who is the child of indigent 
parents received into the colony as aforesaid, shall be pro- 
vided with proper board, lodging, medical treatment, 
care, and tuition ; and shall be denominated State patient; 
and the managers of the colony shall receive for each of 
such patients so provided for, the sum necessary for such 
provision and purpose, not to exceed the sum of two 
hundred and fifty dollars per annum, the intent of this 
act being that the colony shall be self-supporting so far 
as practicable ; which payments, if any, shall be made 
by the Treasurer of the State, on the warrant of the 
Comptroller, to the treasurer of the said colony, on his 
presenting the bill of the actual time and number of 
patients in the colony, signed and verified, by the super- 
intendent and treasurer of the colony, and by the presi- 
dent and secretary of its Board of Managers. 
The Supervisors of any county, from which such State 
patients may have been received into the colony, shall 
cause to be raised annually, while such patients remain 
in the institution, the sum of thirty dollars, for the pur- 
pose of furnishing suitable clothing for each of such 
State patients ; and the same shall be paid to the treas- 
urer of the colony, on or before the first day of April of 
each year. 
Sec. 14. The Support of Private Patients. The super- 
intendent of the colony may agree with any epileptic who 
may be of age, or his committee or guardian, or with the 
parents, guardian, or committee of any epileptic child, or 
with any person, for the entire or partial support, main- 
tenance, clothing, tuition, training, care, and treatment of 
such epileptic in the colony, on such terms and conditions 
as may be prescribed in the By-laws, or approved by the 
managers. Every parent, guardian, committee, or other 
person applying for the admission into the colony of an 
epileptic who is, or whose parents or guardians are, of suf- 
ficient ability to provide for his support and maintenance 
therein, shall, at the time of his admission, deliver to the 
superintendent an obligation, with one or more sureties, to 
be approved by the superintendent and treasurer, in such 
manner and penalty as the managers shall prescribe, to 
the effect that the obligors will pay to the treasurer of 
the colony all sums of money at such time or times as 
shall be so agreed upon, and remove such epileptic from 
the colony, free of expense to the managers, within 
twenty days after the service of the notice hereinafter 
provided for. If such epileptic, his parents or guardian 
are of sufficient ability to pay only a part of the expenses 
of supporting and maintaining him at the institution, such 
undertaking shall be only for such partial support and 
maintenance and for removal from the institution as 
above mentioned ; and the superintendent may take 
security by such obligation, or in his discretion by note 
or other written agreement, with or without sureties as he 
may deem proper, for such part of such expenses as the 
epileptic, his parents or guardians are able to pay ; but 
such exercise of discretion shall be subject to the ap- 
proval of the treasurer and a committee of the managers, 
in the manner that shall be prescribed in the By-laws. 
Notice to remove a patient shall be in writing, signed by 
the superintendent and directed to the epileptic, his 
parents, guardians, committee or other person upon whose 
request the patient was received at the colony, at the 
place of residence mentioned in such request, and de- 
posited in the post-office at Sonyea, or any post-office in 
Livingston County, with the'postage prepaid. 
Sec. 15. Discharge of Patients. The superintendent of 
the colony, with the approval of the managers or of its 
committee duly empowered, shall have power to dis- 
charge patients ; provided that no epileptic patient shall 
be returned to any poorhouse directly through a super- 
intendent of the poor, or otherwise. 
In case a patient, not an epileptic, shall be sent to the 
colony, through mistaken diagnosis of his disease, or 
other cause, and there received, such patient shall be 
returned to, and the travelling expenses of such return 
shall be paid by the person who sent him or her to the 
colony. 
Should an epileptic patient become insane, and be so 
certified, as prescribed by the statute, such patient, if a 
State patient, shall be sent to the State Hospital of the 
district of which he was a resident just prior to his admis- 
sion to the colony, or, if a resident of New York to the 
asylum of that county, of if a resident of Kings to the 
asylum of that county. Said State patient shall be sent 
to said State Hospital, or County Asylum, in a manner 
prescribed by the President of the State Commission in 
Lunacy, at the expense of the State, and any State Hos- 
pital or County Asylum to which said patient is to be sent 
may be required, by and under the regulations made by 
said President, to send a trained attendant to bring the 
patient to the hospital or asylum. 
In all cases there shall be provided a female attendant 
for every female patient. 
The bills for the reasonable expenses incurred in the 
transportation of State patients to the State Hospitals, or 
Asylums of New York and Kings Counties, after they 
have been approved in writing by the State Commission 
in Lunacy, shall be paid by the Treasurer of the State on 
the warrant of the Comptroller from the funds provided 
for the support of the State Hospitals. 
In case any insane person, his relatives, guardians, or 
friends desire that he may become an inmate of any 
State Hospital situated beyond the limits of the district 
of which he was formerly a resident, or outside of New 
York and Kings, if a resident of either of those coun- 
ties, and there be sufficient accommodation there to 
receive him, he shall be received there upon the same 
grounds and terms, and the same in all respects as are or 
may be at any time provided by law, respecting transfers 
of other insane persons. 
Private patients, who may become insane, and are so 
certified, as prescribed by law, shall be committed, sub- 
ject to the regulations of the State Commission in Lunacy 
to such institution for the insane as may be designated 
by such patient, his or her relatives, guardians, or friends, 
all travelling and other expenses of removal to be paid by 
them. 
After any patient has been delivered to the managers or 
officers of any of said hospitals or asylums, the care and 
custody of the managers of the colony over such insane 
person shall cease ; and after any patient shall, as afore- 
said, be so certified to be insane as prescribed by law, 
such patient shall come under the supervision of the 
State Commission in Lunacy. 
Sec. 16. Apportionment of State Patients. Whenever 
applications are made at one time for admission of more 
State patients than can be properly accommodated in the 
colony, the managers shall so apportion the number re- 
ceived that each county may be represented in a ratio of 
its dependent epileptic population to the dependent epi- 
leptic population of the State as shown by statistics fur- 
nished by the State Board of Charities. 
Sec. 17. Notice of Opening of Colony. So soon as the 
colony shall be ready for the reception of patients, it 
shall be the duty of the Board of Managers officially to 
notify the County Clerks and the Clerks of the Boards of 
Supervisors of the respective counties of the State, and 
the Secretary of the State Board of Charities ; and to 
furnish said clerks of the counties and of the Boards of 
Supervisors with the suitable blanks for admission and 
entrustments of epileptics to such colony. 
Sec. 18. Appropriations. The sum of one hundred 
and fifty thousand dollars, or so much thereof as may be 
necessary, is hereby appropriated for the purposes of this 
act, out of any moneys in the treasury not otherwise ap- 
propriated. The Treasurer of the State shall, on the 
279 Epileptic*. 
Eugenol. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
warrant of the Comptroller, pay to the treasurer of the 
Board of Managers of said colony, such sums as may 
from time to time be required for the purchase of land, 
improvements, and betterments, erection of buildings and 
furnishing the same, heating, lighting, and ventilating the 
same, and putting the lands and buildings into proper con- 
dition for the reception of patients, not to exceed one hun- 
dred and twenty-five thousand dollars for the purchase 
of the land as hereinbefore provided, and not to exceed 
twenty-five thousand dollars for such other purposes; 
provided that such purposes and all requirements upon 
which such payments shall be made shall be certified to 
the Comptroller by said Board of Managers, in writing, 
specifying the items, the purposes for which the said 
sums are required, and be verified by the affidavit of the 
superintendent and treasurer of the colony, and of the 
president and secretary and majority of the said Board of 
Managers. 
Sec. 19. This act shall take effect immediately. 
While these measures have been in progress in the 
United States, a similar movement has been inaugurated 
in England. The Countess Meath has established at 
Godaiming a small home for epileptics, in which instruc- 
tion and occupation are among the principal features 
aimed at. There has been organized in Great Britain 
also a National Society for the Employment of Epilep- 
tics which numbers among its members many medical 
men of eminence and many citizens of wealth and influ- 
ence. This society proposes to acquire a tract of land in 
England for the purpose of colonizing epileptics, accord- 
ing to the system herein advocated. 
The care of the epileptic population is then to be sum- 
marized as follows: 
All are to be treated in accordance with the usual 
regulations as to diet, hydrotherapy, and medicinal agen- 
cies, with the hope that in this way between one and six 
per cent, of them may be cured, and the disorder in a 
larger percentage ameliorated. 
Out-of-door employment in agriculture and kindred 
pursuits is to be provided in abundance. All manner of 
trades and occupations are to be carried on in an epi- 
leptic community, organized on the village plan. Facili- 
ties for education are to be afforded to almost every 
extent. 
Amusqment and entertainment and the enjoyment of 
social intercourse are to be privileges from which no 
epileptic will hereafter lie debarred. 
In this way the happiness of a large number of these 
miserable creatures will be materially increased, in spite 
of the distressing disease which they are called upon to 
suffer, usually for the whole of their lives ; and though 
remedial agents applied to their malady may prove in- 
efficient, their fate can never lie as wretched or hopeless 
as it has been throughout the world heretofore. 
Although it is not given to every epileptic to describe 
his own sufferings as Dostojewsky does in his novel 
" The Idiot," or to delight the world with music as did 
the epileptic Handel, or with comedy as did Moliere, or 
with poetry as did Petrarch, or with military exploits as 
did Caesar and Napoleon, or with religion as did Ma- 
homet and St. Paul, still it is a consolation to those 
afflicted with this malady to know that epilepsy and 
genius may coexist, and that the possession of the disease 
does not necessarily lead to mental and moral degenera- 
tion. The patient may not reach the highest position 
among mankind, but under the new dispensation he will 
not be withheld from any attainment in education, nor 
prevented from exercising all of his capabilities for his 
own support and for his own welfare and happiness. 
Literature. 
Peterson, Frederick, M.D. : The Bielefeld Epileptic Colony, New York 
Medical Record. April 23. 1887. 
Peterson, Frederick, M.D. : The Colonization of Epileptics, Journal of 
Nervous and Mental Disease, December. 1889. 
Peterson, Frederick. M.D. : A Plea for the Epileptic, State Charities 
Record, June, 189'). 
Vance, J. L., Waite. C. C. (Commissioners), ami J. W. Yost (Archi- 
tect) : Report of Commission to Select Site and Prepare Plans tor the 
(SUPPLEMENT.) 
Accommodation of the Epileptic and Epileptic Insane to the Governor 
of the State of Ohio, December 31, 1890. 
Peterson. Frederick, M.D. : State Provision for Epileptics, Address of 
Chairman of Health Department, American Social Science Association, 
at Saratoga me. ting, September, 1891 
Peterson, Frederick, M.D. : State Care for Epileptics, New York Sun, 
January 11, 1891. 
Peterson, Dr. F., and Jacoby, Dr. Gi W. : The Care of the Epileptic, 
Report of Sub-Committee of State Charities Aid Association, State 
Charities Record, February, 1891. 
Stryker, Rev. Peter: A Much-needed Philanthropy, Illustrated Christian 
Weekly, January 31, 1891. 
Brinkerhoff, Gen. R. : Address on Laying Cornerstone of the Asylum 
for Epileptics at Gallipolis, O., Ohio State Journal, November 13, 
1891. 
Ewart. Dr. Theodore C. : Colonization of Epileptics, Journal of Mental 
Science. June, 1892. 
Peterson, Frederick, M.D. : Outline of a Plan for an Epileptic Colony, 
New York Medical Journal, July 23, 1892. 
Peterson. Frederick, M.D. : The Care and Colonization of Epileptics, 
Journal of Nervous and Mental Disease, Aueust. 1892. 
Taylor, Dr. Madison J. : The Care of Epileptics, University Medical 
Magazine, 1891-92. 
Drs. Henry R. Stedman. W. N. Bullard, and L. W. Raker, in this 
country, have also contributed to the movement for better care for epi- 
leptics, especially in their State of Massachusetts. 
Frederick Peterson. 
ETHYL CHLORIDE. This has recently been intro- 
duced as a local anaesthetic, and promises to prove of de- 
cided value. It is obtained by saturating an artificially 
cooled alcoholic solution of chloride of zinc with hydro- 
chloric-acid gas. It is also obtained as a by-product in 
the manufacture of chloral. Its chemical formula is 
C2H5CI4. At ordinary temperatures it is a gas, but is 
easily compressed into a colorless liquid with a pleasant 
ethereal odor. Below 50° F. it remains a fluid, but at 
that temperature it is volatilized and becomes a light and 
very inflammable gas. 
Advantage has been taken of its rapid evaporation 
to utilize the intense cold produced, as a local anaes- 
thetic, in dental and minor surgical practice, and for the 
relief of the pain of superficial neuralgia. It has been 
used with satisfaction for the extraction of teeth, open- 
ing of abscesses, removing ingrowing toe-nails, and 
similar painful operations, and has been found to give in- 
stantaneous relief in facial neuralgia, intercostal neural- 
gia, and sciatica. 
The method of utilizing this property has been made 
simple and easy by M. Monnet, of Lyons, who sug- 
gested the storing of the compressed fluid in small cap- 
sules and tubes, by which means it may be preserved 
without alteration for a great length of time. When the 
drug is required for use the point of the capillary tube is 
broken off, and the opening directed downward on the 
part to be anaesthetized. The heat of the hand is suf- 
ficient to raise the temperature of the fluid above its 
boiling point, and a stream of the rapidly volatilizing 
fluid issues as a spray, and may be applied to any part. 
The stream may be made weaker or arrested by simply 
closing the opening with the finger, or made stronger by 
grasping a larger portion of the tube and raising the tem- 
perature of its contents. It is considered best to hold 
the tube from six to ten inches away from the surface, to 
avoid excessive and useless cold. Each tube contains 
about two and a half drachms, which is sufficient to an- 
nul the sensibility of the skin and the parts immediately 
beneath, over a surface and to a depth sufficient for 
small operations. For the removal of teeth the spray is 
to be directed on the mucous membrane of the gum. 
The membrane is first dried and then rubbed with 
glycerine or oil, and the spray applied until the part 
becomes white. The sound teeth, as well as the mucous 
membrane of the mouth, must be protected by a napkin, 
and the patient directed to breathe only through the nos- 
trils. It is said that the teeth may be extracted with- 
out pain by directing the spray against the cheek, over 
the inferior maxillary nerve for the lower jaw, and at the 
exit of the trigeminal nerve, in front of the ear, for the 
upper jaw. 
It is simple in application and requires no apparatus, 
which gives it a decided advantage over methyl chloride, 
CHgCl, which has also been used for the same purpose. 
The low boiling-point of this older anaesthetic(- 1.4° F.) 
280 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Epileptic*. 
Eugenol. 
requires a careful management to control its action and 
avoid excessive freezing and destruction of tissue. 
Methyl chloride also at times affects the system, causing 
more or less disturbance of the brain and mental facul- 
ties. Ethyl chloride in no way produces any effect be- 
yond its local action. Its one objectionable feature is its 
great inflammability, which must be guarded against by 
performing the operation at a distance from a flame. 
Drs. H. C. Wood and Cerna report in the Therapeutic 
Gazette, August, 1892, a series of experiments upon the 
anaesthetic properties of ethyl chloride when administered 
by inhalation. Anaesthesia was produced in the animal 
when the fluid was poured into a closed cone, almost im- 
pervious to air, and held closely to the nostrils. The 
anaesthesia was rapid and of short duration, ten 
grammes producing insensibility for only two minutes. 
It also caused the desired effect when injected into the 
veins, but failed to do so when the vapor was forced 
into the lungs through a tube inserted into the trachea. 
As a result of their experiments they conclude : (1) 
That the chloride of ethyl is capable of acting as an 
anaesthetic, but that it is eliminated with extraordinary 
rapidity, and that its action is extremely fugacious ; (2) 
that the anaesthesia which it produces is always accom- 
panied by a fall of the blood-pressure, which is probably, 
at least in part, due to a direct depressing effect of the 
drug upon the heart ; (3) that the action of the drug upon 
the circulation is in no way dependent upon its influence 
upon the respiration, although it is not certain that the 
pronounced depression of the blood-pressure is not a 
factor in influencing respiratory movement ; (4) that, at 
least in the dog, chloride of ethyl produces at first an 
increase of the respiratory movement, either in rate or 
amount, or more commonly in each respect, but that 
finally respiration becomes slow, and at last stops ab- 
ruptly ; (5) that usually, if not always, the cessation of 
heart-beat and the arrest of respiratory movement occur 
as nearly simultaneously as may be. They think that 
the fugacious action and its depressing effects will pre- 
vent its becoming used as a safe anaesthetic, but are sat- 
isfied that the small amount that may be inhaled during 
its local use for dental purposes, has practically no effect 
on the system, as it is very rapidly eliminated. 
Beaumont Small. 
ETHYLENE BROMIDE. This organic compound has 
been introduced into therapeutics as a convenient means 
of supplying bromine in cases where its use is indicated 
for a prolonged period. The advantage claimed for it is, 
that it is not combined with potassium, sodium, or any 
basylous radicle, and its use does not disturb the diges- 
tion, the skin, or the mucous membranes, or produce any 
of the unpleasant effects that the older salts are liable 
to cause. 
It is the di-brom derivative of ethane, in which each 
bromine atom is attached to a separate carbon atom ; its 
chemical formula is C2H4Br2. It is a colorless or faintly 
brown liquid, containing 90.9 per cent, of bromine. The 
odor is agreeable and taste sweetish. Its specific gravity 
is 2.163 at 69.8° F. Below 48° F. it becomes a solid, 
forming crystals. It is insoluble in water, soluble 1 in 4 
of rectified spirit, and miscible in all proportions with 
absolute alcohol and oils. 
The employment of ethylene bromide in epilepsy has 
been recommended by Dr. J. Donath.1 He used it in a 
great number of cases, and reports the details of ten cases 
in which he was able to watch its effects carefully. As 
a substitute for the bromides he found it very satisfac- 
tory, and the results he considers were much better. The 
cases were all of long standing and had been subjected to 
many forms of treatment Under its use the attacks be- 
came milder, shorter, and fewer in number, and in many 
instances assumed the character of petit mal. In three 
of the cases the convulsions were replaced by simple 
muscular twitchings without loss of consciousness. 
The dose administered was six to twelve drops three 
times a day. It may be given in capsules with oil or in 
solution. The following preparations are recommended : 
(1) Ethylene bromide, 75 grains ; oil of almonds, emulsion, 
(SUPPLEMENT.) 
1,500 grains ; oil of peppermint, 2 drops ; dose, thirty drops 
three times a day, in a third of a glass of milk. (2) Ethyl- 
ene bromide, 75 grains ; rectified spirits, 75 grains; oil of 
peppermint, 2 drops ; dose, live to ten drops three times a 
day. In preparing these mixtures the high specific gravity 
must not be forgotten, it being nearly two and a half 
times as heavy as water. Before using the drug Donath 
tested its action on himself, and found that in ordinary 
doses it did not produce any disturbing effects ; but in 
large doses it was sometimes followed by nausea. 
This drug must not be mistaken for ethyl bromide, 
which it resembles both in name and appearance. A 
case is reported2 in which such a mistake was made with 
fatal consequences. A written order for the anaesthetic, 
ethyl bromide, was sent to a druggist, who supplied 
ethylene bromide. Ten drachms were inhaled without 
producing any insensibility or anaesthesia. The admin- 
istration was followed by suppression of urine and un- 
controllable vomiting, which continued until the patient 
died, upon the following day. At the post-mortem exam- 
ination there was found an hyperaemia of the meninges 
of the brain, also of the lungs, spleen, and kidneys. The 
liver was much enlarged, of a dirty-yellow color, and the 
cells were affected by a granular degeneration. 
Beaumont Small. 
1 British Medical Journal, July 11, 1891. 
2 The London Lancet, January 10,1891. 
ETRETAT. One of the most frequented seaside 
resorts on the Channel coast. Etretat is in the Depart- 
ment of Seine-Inferieure, France. It is situated between 
two cliffs, over 250 feet high, and is famous for its pict- 
uresque appearance. It was formerly a mere fishing 
village, but is now very fashionable, so that at the height 
of the season, in July and August, it is often impos- 
sible to secure proper accommodation. Baughan, in the 
" Northern Watering Places of France," gives the follow- 
ing description of the bathing peculiarities : 
The beach of Etretat is lower than the sea at the high 
tides, from which it is protected by a dyke of bowlders, 
which, however, is constantly being removed by the 
waves, which lash the shore with great violence at cer- 
tain seasons of the year; so much so that it is the custom 
at Etretat every year at the/efe of Ascension Day for the 
priests to go down to the shore to pronounce a benedic- 
tion on the sea, and to exhort, it to respect its limits. 
Picturesque and charming as Etretat is, the bathing is 
not so pleasant as in other places along the coast, for 
apart from the fact that the bowlders are not such a 
pleasant footing as sand, the bathing is dependent on 
the state of the tide, and, therefore, hours of meals, oc- 
cupations, and even the amusements of the place, seem 
to depend on the tide. Edmund C. Wendt. 
EUGENOL, EUGENIC ACID, is formed from the oil 
of cloves by oxidation ; it may also be obtained from 
other essential oils, as cinnamon, bay, pimento, sassafras. 
Its chemical composition is Cells. C31I6(OH) (OCTI3). It 
is an aromatic, oily liquid, colorless, with a strong clove 
odor. On exposure to the air it turns brown. It is read- 
ily soluble in alcohol but only very sparingly so in water. 
It forms compounds of a definite character with caustic 
alkalies. It possesses powerful antiseptic properties 
which are said to be superior to those of phenol. It has 
also been recommended as a febrifuge, but is inferior to 
salicylic acid, quinine, antipyrine, etc. Eugenol, which 
is somewhat analogous to guaiacol, has become of some 
importance on account of its being suggested for ad- 
ministration in tubercular diseases by Dr. Koch. He 
recommends its administration during the tuberculine 
treatment. The dose is forty-five minims during the 
day, dissolved in spirit and diluted with water. Ap- 
plied locally, eugenol has a mild local anaesthetic action. 
It is useful for toothache and for painful affections of 
the skin ; in the latter class of cases it is applied as an 
ointment with lanoline. 
Two derivatives of eugenol-benzoyl-eugenol and cin- 
namyl-eugenol-have lately been introduced, and are be- 
281 Eugenol. 
Exalgine 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
ing used in the treatment of tubercular affections. Their 
dose and action are as yet uncertain. 
Benzoyl-Eugenol, the benzoate of eugenol, occurs in 
neutral acicular crystals, free from color and odor, but 
having a faint bitter taste, very slightly soluble in water, 
but freely in alcohol, chloroform, and ether, With con- 
centrated sulphuric acid it gives a purple-red color, which 
is characteristic of eugenol ; this reaction distinguishes it 
from benzosol, a compound of benzoyl and guaiacol (the 
latter gives a pale yellow color). Its melting-point is 
158° F. 
Cinnamyl-Eugenol also is formed in colorless, neutral 
crystals, free from odor and taste. Its solubility is the 
same as the benzoyl salt. With sulphuric acid it gives 
the same reaction as its fellow salt, but may be distin- 
guished by its melting-point, 194° to 198° F. 
Beaumont Small. 
EUPHORBIA PILULIFERA. A plant of the order 
Euphorbiacese, which has been recommended as a remedy 
for spasmodic affections and neuroses of the respiratory 
tract. It is indigenous to Australia, Brazil, and other 
southern tropical countries. It derives its specific name 
from the seeds, which are held in capsules in the axils of 
the leaf, and when ripe are brown and hard. It is com- 
monly known as the pill-bearing spurge. It is a very 
common annual herbaceous plant, and has a local reputa- 
tion as a curative agent in all pulmonary troubles. Dr. 
Mattheson, of Queensland, was the first to call attention 
to its value in asthma, paroxysmal dyspnoea, whooping- 
cough, and other spasmodic affections. Later it was 
studied by Dr. Marsset, under the direction of Dujardin- 
Beaumetz, and the result of his researches was published 
in the Therapeutic Gazette, February, 1885. Its action 
is directed to the respiratory and cardiac centres, and 
causes a retardation of the respiration and pulse, and 
when death has been produced it arises from a paralysis 
of these organs. It does not influence any of the other 
organs of the body, but when administered it produces 
an irritant action on the gastric mucous membrane. 
Its active principle is an acrid resin, which is soluble 
in water and dilute alcohol. Experiments on animals 
show that one part of the resin to one hundred of the 
animal, by weight, will produce a fatal result. 
It has proved of service in all spasmodic affections of 
the bronchial tubes and lungs, in the dyspnoea of em- 
physema of the lungs, and in that due to cardiac affec- 
tions. Dujardin-Beaumetz recommends it to be used in 
all cases in which iodide of potassium is used to relieve 
dyspnoea. It has also been used to relieve the spasms 
and distress of angina pectoris, and in hay asthma and 
coryza. In the latter diseases it rapidly checked the 
sneezing and other troublesome symptoms. 
The dried plant is used and its virtues are said to be 
best extracted by water. A decoction may be made by 
steeping half an ounce of the plant in two quarts of water, 
the dose to be three or four wineglassfuls during the 
day. A tincture may be made of one part to five of 
proof spirit: dose, ten to fifteen minims, three times a 
day. It is advisable always to begin with small doses 
and gradually increase the amount, watching its effect, 
as its action is sometimes violent. The administration 
cannot be continued for a great length of time owing to 
its irritant action on the stomach. 
Beaumont Small. 
EUPHORIN (Phenyl-urethan. Carbonate of ethyl and 
phenyl). Its formula is C8 H5 NHCOOCa Hs. This is a 
compound derived from aniline and is somewhat allied 
to acetanilide. It occurs as a white crystalline powder, 
with a faint aromatic odor and slight taste, almost insol- 
uble in water, but freely soluble in weak alcohol and 
wines. It was introduced in 1890 by Dr. Sansoni to re- 
place antipyrine, antifebrine, and other drugs of the same 
class. It was said to possess all their medicinal properties 
and to be devoid of their many objectionable effects. 
In a large number of cases of fever due to various 
causes in which it had been used as an antipyretic the 
(SUPPLEMENT) 
temperature fell quickly within one hour. The fall 
reached its maximum in about three hours, and lasted for 
five or seven hours. The subsequent rise of temperature 
was usually rapid. Its action was found to vary in dif- 
ferent individuals. It is advised to commence with a 
dose of three grains, which may be increased until 
fifteen or thirty grains are given daily. In acute rheu- 
matism fifteen grains daily caused disappearance of the 
swelling and pain in the joints and lowered the tempera- 
ture. In chronic cases the results were not so satisfac- 
tory. Subsequent observers have also found it of bene- 
fit in sciatica, migraine, neuralgia, and in some cases of 
muscular rheumatism. As an external application its 
antiseptic properties have been made use of as an appli- 
cation to wounds, ulcers, burns, etc. Dusted on the sur- 
face it has acted very beneficially ; the parts are rapidly 
rendered clean and healthy, the secretion is diminished, 
and cicatrization promoted. It does not cause pain or in 
any way prove irritating. It may also be used as an 
ointment. For internal administration it should be 
given in wafers, or in solution in weak alcohol or with 
wines. It must never be combined with antipyrine, as 
chemical decomposition takes place and a fluid results. 
Beaumont Small. 
EUROPHEN. This is one of the many compounds 
containing iodine and devoid of any disagreeable odor, 
that have been introduced as substitutes for iodoform. 
Chemically it is di-isobutylortho-cresol iodide, its formula 
being ^jj^'^CeHsO^HI. Its relation to cresol and 
iodine is much the same as that of aristol to thymol and 
iodine. It is prepared by adding isobutyl alcohol to 
ortho-cresol with zinc chloride, at a high temperature, 
which forms isobutyl ortho-cresol. This is dissolved in 
a dilute alkaline solution and then mixed with a solution 
of iodine in iodide of potassium, which yields a copious 
precipitate of the above compound. This is collected, 
washed, and dried in the dark. 
It is an extremely light amorphous yellow powder, 
with an aromatic odor resembling saffron. It contains 
27.6 per cent, of iodine. It is insoluble in water and 
glycerine, soluble in alcohol up to thirty per cent., and 
in ether, chloroform, collodion, and fatty oils up to 
twenty-five per cent. It must be excluded from light 
and heat, as it is readily decomposed. In contact with 
water it is slowly decomposed, yielding free iodine. 
Alcoholic and ethereal solutions also evolve iodine if 
kept for a long time. 
Starch or starchy preparations should never be pre- 
scribed with europhen, as the reaction between the two 
is rapid, particularly when water is added to the mixt- 
ure, or when the fluid secretions cause the powder to 
evolve the iodine freely. The metallic salts, especially 
zinc and mercury, so freely used in dermatology, should 
never be combined, on account of the well-known in- 
compatibility of these metals. The most durable mixt- 
ures are those prepared with oil or lard, vaseline or 
lanoline. The latter is to be preferred, as it allows of a 
greater amount of absorption of the fluids, and con- 
sequently a more thorough action of the application. 
Europhen is, however, a dry antiseptic, and is most 
effective when applied as a powder directly to the part. 
Its action is due to the continuous liberation of free 
iodine, which commences as soon as the drug comes in 
contact with moisture. This gradual escape of iodine, 
together with the well-known antiseptic properties of 
the cresol also present, has a very decided effect 
in checking the growth of bacteria, and also prevents 
the reducing power of bacteria having an anaerobic 
growth. • It, however, is devoid of bactericidal action, 
and in no way destroys bacteria or spores. Over iodo- 
form it possesses certain advantages. It is free from 
the powerful penetrating odor that is so objectionable ; 
its toxic properties are only evident after very large doses, 
and for internal use it may be administered without fear- 
ing any dangerous symptoms. As much as twenty-two 
grainshave been taken daily, for three weeks, without the 
slightest discomfort. It is extremely light, being about 
282 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Eugenol. 
Exalgine. 
five times as bulky as iodoform, and readily adheres to 
the skin or mucous membrane. 
The use of europhen is indicated in all cases where 
iodoform is employed in wounds and ulcers and ulcer- 
ated surfaces, and in diseased conditions of the nasal and 
pharyngeal cavities, of the vagina and uterus, and all 
mucous surfaces. In various forms of skin disease it has 
proved beneficial, especially the acute and chronic ecze- 
mas. It lias also been found useful as an application in 
erysipelas. An alcoholic or ethereal solution, of the 
strength of ten per cent, of the powder, has been said to 
act remarkably well when applied to syphilitic ulcers and 
to the initial sores. It is also administered internally in 
all stages of syphilitic disease, but is most recommended 
as being very active in the third stage, and is thought to 
replace the iodide of potassium as a specific. The dose 
to commence with should be one-quarter of a grain, 
gradually increased to one or two grains. If it is admin- 
istered too rapidly there is a danger of iodism manifest- 
ing itself. The same amount may be used hypodermi- 
cally, a ten per cent, solution in oil being prepared for 
this purpose. For external use as an ointment the fol- 
lowing has been selected as an excellent combination : 
Europhen, 3 parts ; olive-oil, 7 parts ; vaseline, 60 parts ; 
lanoline, 30 parts. Beaumont Small. 
EVIAN-LES-BAINS. A watering-place and climatic 
resort on the Lake of Geneva, France. 
Location.-Evian is a little town, having a population 
of 2,600, situated on the southern or Savoy side of the 
Lake of Geneva. It is built close to the edge of the wa- 
ter, and lies directly opposite the city of Lausanne. It 
is pleasantly located, with charming views in all direc- 
tions, and, apart from the popularity of its mineral 
springs, is known for the genial mildness and equability 
of its climate. 
Access.-By rail or steamer from Geneva, also by rail 
from Aix-les-Bains. 
Analysis.-There are six principal springs, all having 
about the same composition, and all very faintly mineral- 
ized. The temperature of the water is about 54° F. It 
is colorless, faintly alkaline, and so pure and agreeable 
to the taste that it is largely used as a mere table-water. 
The Source Bonnevie, according to an analysis of the 
Ecole des Mines, contains in 1,000 grammes : 
Grammes. 
Bicarbonate of lime 0.2210 
Bicarbonate of magnesia 0.0150 
Bicarbonate of soda 0.0200 
Bicarbonate of potash 0.0070 
Phosphate of soda 0.0017 
Carbonic acid, free 0.0970 
0.3017 
Traces of alkaline chlorides. 
Indications.-A course of Evian waters is frequently 
prescribed to supplement the rigorous cure at Aix-les- 
Bains. According to Dr. Vintras ("Medical Guide to 
the Mineral Waters of France"), " the Evian waters are 
drunk, and used for baths and douches. As shown by 
the analysis, nothing in their chemical composition indi- 
cates their well-known therapeutical value. They agree 
perfectly with the stomach, and act as an excellent diu- 
retic in cases of gravel, enlargements of the prostate, and 
catarrhal affections of the bladder and kidneys, by the 
species of irrigation which they produce in the interior 
of these organs. If there is irritability of the urinary 
passages, caused by the presence of a calculus, or after 
lithotritic operations, they are to be preferred to those of 
Vichy, Vittel, or Contrexeville, which in such cases 
would be much too exciting. 
" Chronic affections of the digestive organs, such as 
dyspepsia, gastralgia accompanied by acid eructations, 
pyrosis, chronic irritation of the intestines, chronic diar- 
rhoea, obstinate constipation, hemorrhoids, etc., are all 
treated with benefit at Evian. Patients suffering from 
the irritability which accompanies most forms of chronic 
neuralgia have been relieved from it, after using the wa- 
(SUPPLEMENT.) 
ters for some days. It is supposed to have a calmative 
influence in all kinds of hypersensitive conditions." 
The amount of water taken varies from two glasses to 
twenty-five per day. The baths are soothing and seda- 
tive, and patients generally sip several glasses of mineral 
water while in the tub. 
Accommodation.-There are good hotels like the 
Grand Hotel des Bains, a Casino, and two thermal estab- 
lishments with modern comforts and hydrotherapeutic 
appliances. Life is gay during the season, there being 
plenty of amusements. Edmund C. Wendt. 
EXALGINE. This is the trade name of methylacetan- 
ilide. Its chemical formula is CeHsNCHgCsHsO ; it is 
formed by the addition of the methyl group, CH3, to 
acetanilide, C8HsNHCaH3O, replacing one atom of hy- 
drogen. It occurs as beautiful needle-shaped crystals, 
colorless, with a faintly aromatic odor and slightly pun- 
gent taste. It is almost insoluble in cold water, slightly 
soluble in hot, and very soluble in dilute alcohol. From 
sixteen to twenty grains may be dissolved in half a 
drachm of rectified spirit and this solution diluted with 
two or three ounces of water without producing any 
precipitation. Its melting-point is 212° F., and it may 
be heated to its boiling-point, 240° or 250° F., without 
causing decomposition. By the addition of soda it is 
decomposed and partially converted into methylaniline. 
Hydrochloric acid causes the same decomposition. The 
presence of methylaniline and other compounds of the 
same base may be detected by the irritating fumes pro- 
duced when the impure salt is heated with alcoholic 
solution of potash and chloroform. Its purity may be 
further tested by dissolving in nitric acid, which forms 
a colorless solution ; when heated this becomes of a 
bright yellow color, and evolves irritating fumes. 
Exalgine may be distinguished from acetanilide, phen- 
acetine, and methacetine by treating two grains of the 
suspected salt with twenty minims of hydrochloric acid. 
Phenacetine remains undissolved ; acetanilide dissolves 
but separates again in crystals; methacetine also dis- 
solves and gradually colors the solution reddish-brown 
on the addition of one drop of nitric acid. Another test 
for the presence of phenacctine or acetanilide is to treat 
a chloroform solution with ten volumes of petroleum 
ether; if either of these substances is present a turbid 
mixture is formed. 
Methylacetanilide was discovered in 1874 by A. W. 
von Hofman. Its therapeutic properties were studied to 
a certain extent by Kahn and Hepp during their re- 
searches upon acetanilide and other antipyretics, but it 
was not until March, 1889, that Dujardin-Beaumetz and 
Bardet made known its value as an analgesic, in a com- 
munication to the French Academy. A very careful 
series of experiments, both physiological and clinical, 
enabled them to indicate its therapeutic qualities with a 
marked degree of accuracy. With the other members 
of the aromatic series it was found to possess antisep- 
tic, antipyretic, and analgesic properties, and they also 
pointed out that its action on the nervous system should 
make it of value in the treatment of many functional 
diseases. It was as an analgesic that they particularly 
advocated its use ; the addition of the methyl atom to 
acetanilide had intensified this action without affecting its 
antipyretic properties, but it was found that a dose large 
enough to produce antipyresis, was accompanied by such 
alarming toxic symptoms that this use could not be con- 
sidered. They advocated its employment in headache, 
migraine, neuralgia, neuroses of the viscera, the pains of 
locomotor ataxia, and in all non-febrile affections accom- 
panied by pain. It was thought to be the most serviceable 
organic compound yet obtai ned for this purpose. It proved 
quite as active and certain as antipyrine, and yet never 
produced any disturbance of the digestive organs, never 
gave rise to any rash, nor had they found it accompanied 
by any distressing symptoms in the cases in which they 
had used it to relieve pain. It was found to relieve pain 
by producing insensibility without in any way affecting 
tactile sensibility or causing any other noticeable change 
in the condition of the patient The dose they advised 
283 Exalgine. 
Examiner, Medical. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
was from four to six grains (0.25 to 0.40 gramme) in a 
single dose, or from six to eleven and a half grains (0.40 
to 0.75 gramme) in the twenty-four hours. 
Following this highly laudatory introduction, the use 
of the drug became very general, and the reports that 
followed were chiefly in accord with the statements of 
Dujardin-Beaumetz and Bardet; but it was also found 
that toxic symptoms frequently followed its use and that 
its employment was not without danger. 
In Great Britain the notice of the profession was par- 
ticularly directed to the value of this remedy by Pro- 
fessor Fraser, of Edinburgh,1 who gave the results of his 
experience with it in the Royal Infirmary. The remark- 
able point in Professor Fraser's paper was the smallness 
of the dose and the success that followed its use in such 
quantities. The usual dose was half a grain in spiritu- 
ous solution, repeated three or four times a day, accord- 
ing to the return of the pain. In some cases it was in- 
creased to one and two grains, and in a few instances 
four grains were given ; the largest quantity given was 
fourteen grains during the twenty-four hours. In the 
cases of neuralgia and angina half-grain doses would 
relieve the pain in ten or fifteen minutes, and in one hour 
there would be perfect ease, which lasted from three to 
nine or ten hours, and in many instances a complete cure 
was obtained. In sciatica and locomotor ataxia one and 
two grains secured the same freedom from suffering. In 
cancerous disease and in the pain accompanying an an- 
eurism the success was less marked, and it was in these 
cases that the larger doses were given. Dr. Fraser con- 
siders that the smaller dose is the proper method of ad- 
ministering the drug, and that all its virtues may be as 
readily secured as with the larger doses. When given in 
this way, there is not the slightest danger of any un- 
favorable symptoms, as in none of his cases did any such 
occur. He considers methylacetanilide to be an anal- 
gesic of much value, not so powerful as opium, but 
devoid of any of the latter's disturbing influence on the 
system and free from any danger. The following table, 
arranged by Dr. Fraser, shows at a glance the diseases in 
which he used this remedy and the successes and failures 
in each class of cases : 
neuralgia of the epidemic of influenza, but in such cases 
it was inferior to the other new antipyretics, antipyrine 
and acetanilide. 
The small doses recommended by Dr. Fraser, how- 
ever, were not accepted generally. On the continent 
the doses of four to six grains were more frequently 
given ; in England it was often found necessary to in- 
crease the dose to this amount, and many from its first 
use had adopted the larger doses of Dujardin-Beaumetz. 
Many reports of its complete failure were also made, 
but it has been very generally accepted as having useful 
analgesic properties, and promises to remain as a per- 
manent addition to our armamentarium. 
Exalgine has been used with equally favorable results 
in infantile troubles. Dr. Moncorvo 5 publishes his ex- 
perience of its use in twenty-one cases of children rang- 
ing from one to twelve years of age, in which it was 
given for the relief of pain. He considers it a very use- 
ful agent. It was well borne in every case, no unfavor- 
able symptoms being ever noticed. The dose com- 
menced with was three-fourths of a grain, increased in 
some cases to five grains. In one case choreic symp- 
toms were present and were improved. 
Its use in chorea has been reported upon by Dr. Hugo 
Lowenthal.6 Thirty-five cases were treated with doses 
of three grains, usually three times a day, never exceed- 
ing fifteen grains in the twenty-four hours. The effects 
were very satisfactory. The mild cases were cured 
quickly, but the more severe ones were less influenced 
and required more time. The beneficial effects of the 
treatment were most marked in the cases in which it was 
given early in the course of the disease, in two cases a 
cure being effected in eight days. A favorable influence 
over the mental state was also noticed ; the fear and ner- 
vousness were lessened and the intelligence brightened. 
In some of the cases in which it was administered for a 
prolonged period, nausea, vertigo, headache, and other 
distressing symptoms were noticed. 
Unfortunately the occurrence of toxic symptoms are 
not infrequent. No fatal termination has yet been re- 
ported, but the condition of the patient becomes very 
alarming both to the friends and to the physician. The 
toxic disturbances, however, are far in advance of its 
fatal dose. Experiments on animals have shown that the 
lethal quantity is seven and a half grains for each two 
pounds of the weight of the animal, and three grains, it 
lias been found, will give rise to severe symptoms. The 
poisoning arises from the action of the drug on the ner- 
vous centres as well as from the alteration that occurs in 
the condition of the blood. The changes in the blood are 
the same as are produced by all aniline compounds, by 
which the haemoglobin is altered into methaemoglobin 
and the function of oxidation interfered with. The 
approach of the toxic action is noticed by a sense of ful- 
ness in the head, a constriction and oppression of the 
chest, dyspnoea, vertigo, dizziness, numbness, disturb- 
ances of vision. This is followed by a rapid pulse, shal- 
low respiration, and all the sensations of death with symp- 
toms of asphyxia and collapse. Unconsciousness is 
common in the severe cases of poisoning ; convulsions do 
not so frequently occur. Generally, very large quanti- 
ties are given before any ill effects are noticed. In one 
instance 1 the drug was continued for seventeen clays, in 
gradually increasing doses, and during the last seven days 
eighteen grains were administered daily. In another 
case 8 thirty-six grains were given within nine hours, and 
in another,9 twenty-four grains within two hours. The 
ill effects of the drug generally follow the prolonged 
use of the drug, or the administration of large doses, but 
in some instances very small doses have produced very 
alarming effects. An instance 10 is reported in which 
two doses of three grains caused ali the serious symp- 
toms of poisoning, and another instance in which two 
doses of five grains were given with the same effect. A 
remarkable 11 case is reported in which, in an adult, two 
doses of one and two grains, respectively, produced most 
profound prostration. The symptoms came on about an 
hour after the last dose, while the patient was sitting at 
a table engaged in a game of cards. He first complained 
Disease. 
Number 
of obser- 
vations. 
Success- 
ful. 
Unsuc- 
cessful 
or doubt- 
ful. 
Facial neuralgia 
8 
8 
Sciatica 
10 
9 
i 
Herpetic neuralgia 
10 
9 
1 
Neuralgia of arm, in hemiplegia 
11 
11 
Locomotor ataxia, first case 
2 
2 
Locomotor ataxia, second case 
1 
1 
Toothache, first case 
2 
2 
Toothache, second case 
2 
2 
Toothache, third case 
2 
2 
Too'hache, fourth case 
2 
2 
Cardiac angina 
2 
2 
Pleuritic pain, first case 
1 
i 
Pleuritic pain, second case 
4 
4 
Rheumatic synovitis 
4 
4 
Blennorrhagic rheumatism 
2 
1 
i 
Gastric pain, cancer 
Gastric pain, catarrh and cicatrized 
* 
2 
ulcer 
4 
2 
2 
Cancer in abdomen 
10 
ti 
4 
Oarcinoma of liver 
2 
2 
Aneurism of aorta 
4 
4 
Lumbar abscess 
3 
3 
Following Dr. Fraser's paper came a number of re- 
ports of successful results with half- and one-grain doses, 
by Drs. Herschell,2 Farrar,2 Holden,3 Maloney,* and 
many others. In these cases there was the usual success 
in pains of a purely neurotic character, and less favor- 
able effects where it was due to organic disease or me- 
chanical causes. It was found to be of greatest service 
in spare persons of a nervous temperament, and those 
subject to neurotic derangements. Contrary to the views 
of Dujardin-Beaumetz, it proved to be of much service 
in certain febrile troubles, particularly the headache and 
284 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Exaijiine. 
Examiner, Medical. 
of a fulness in the head and suddenly fell prostrate, un- 
able to speak or move, and gasping for breath. A second 
attack took place in about an hour, and the oppression 
and dyspnoea continued for several hours. Very differ- 
ent to these cases are those in which very large quantities 
have been given without evil consequences. Dr. Chur- 
ton 12 reports two such cases. In the refilling of a bottle 
of medicine a mistake was made by which a solution 
was prepared of one grain to a drachm, instead of one 
grain to the ounce. The medicine was given as usual, 
four grains instead of half a grain being contained in 
each dose. This was continued for several days, and 
during the last twenty-four hours before the mistake was 
detected the patient was given forty grains. The pulse 
and respiration were rapid, and the patient complained of 
a burning sensation in the stomach, but no other effects 
were noticed. The second patient was given twenty-four 
grains from the same preparation without producing any 
other effect than slight vertigo and a sense of being 
"dazed," which caused her to walk unsteadily. The 
quality of the drug is vouched for, as it was given to a 
number of patients with satisfactory results, and small 
doses were again given to the first patient, and its anal- 
gesic action secured. 
The quality of the drug undoubtedly affects its action, 
and in many instances explains the varying results that 
follow its use, but certain conditions of the system must 
exercise a decided influence, probably by promoting the 
decomposition of the drug and the formation of more toxic 
compounds. Mr. Bokenham7 dwells upon this point 
in his remarks upon two cases of poisoning and suggests 
that some condition of the blood preceding menstruation 
may assist this reaction. The activity of the action is 
also influenced by the time of its ingestion. Professor 
Fraser and others, who find benefit in the small doses, al- 
ways recommend that it should be given on an empty 
stomach, while those who use the larger doses advise it 
to be given after meals, and others still have remarked 
that the toxic symptoms arise when it has been given be- 
fore meals. In the majority of cases the toxic symptoms 
pass away without requiring any assistance, but when the 
depression and dyspnoea are severe, stimulating remedies 
must be used. Alcohol has been resorted to in most of the 
cases of poisoning with apparent benefit, and hypodermic 
injections of ether have also been employed. In the cases 
reported by Dr. Jones7 marked relief was secured by 
the use of strychnine in addition to the stimulants. Two 
minims of the liquor strychnias were given hypoder- 
mically and ten minims of tincture of digitalis by the 
mouth. In these cases the inhalation of nitrite of amyl 
and Ti<y-grain doses of nitro-glycerine increased the cya- 
nosis, showing that the arterial as well as the venous blood 
was altered. 
The following conclusions have been arrived at by 
Marandon de Montyel13 from clinical observations on 
patients in whom its use had been pushed to its physio- 
logical limits :-It has no influence on digestion. If the 
stomach is empty it causes an increased flow of saliva, a 
bitter taste, and a sense of tightness about the epigas- 
trium. The pulse, respiration, and temperature are les- 
sened in patients without convulsive tendencies. Ver- 
tigo, flashes of light and ringing in the ears are frequent. 
A local or general cyanotic surface, sensations of cold, 
numbness, and formication, are prominent symptoms. 
Its action is prompt and recovered from promptly, the 
brain being the first organ affected and the first to re- 
cover. When administered after meals its physiological 
action is less marked. Beaumont Small. 
EXAMINER, MEDICAL. The medical examiner sys- 
tem of Massachusetts, enacted in place of the coroner's 
inquest system which was abolished in 1877, has now 
(1893) been in successful operation for nearly sixteen 
years, and it is safe to say that no return to the coroner 
system will ever be made in Massachusetts. The law is 
quoted in full, and its advantages are fully stated in the 
second volume of this work. 
The following statistics relative to the operation of 
this law are quoted from the registration reports of Mas- 
sachusetts, for the years 1885 to 1891 inclusive : 
Total Deaths, and Deaths by Sexes, Investigated Under the 
Medical Examiner Laws in Massachusetts, 1885-1891. 
Totals 
1885 
1886 
1887 
1888 
1889 
1890 
1891 
M 
5 
8,370 
973 
1,027 
1,191 
1.261 
1,253 
1,303 
1,362 
Males. 
pt 
to 
76.1 
74.5 
76.5 
76.4 
75.8 
73.5 
74.0 
Per cent. 
to 
c? 
to 
286 
319 
350 
373 
388 
449 
457 
Females. 
M 
23.6 
22.4 
23.2 
22.5 
22.6 
23.4 
25.3 
24.8 
Per cent. 
881 
19 
32 
15 
17 
13 
21 
21 
■Unspeci- 
fied. 
io 
1.5 
2.3 
0.8 
1.2 
1.2 
Per cent. 
o 
1,278 
1,378 
1.556 
1,651 
1.654 
1.773 
1,840 
Totals. 
In the following table the same deaths are classified 
by the modes of death : 
Recapitulation. 
Totals 
h- a go -I cs tn 
Yeabs. 
ri 
O CO or or or 
Number. 
Homicide. 
3.07 
3.52 
3.41 
8.34 
3.15 
3.08 
1.97 
3.26 
Per cent. 
63 
s 
181 
157 
173 
190 
199 
196 
187 
Number. 
Suicide. 
11.53 
14.17 
11.38 
11.12 
11.51 
12.03 
11.05 
10.16 
Per cent. 
, 5,298 
567 
678 
748 
785 
792 
S62 
866 
Number. 
Accident ok 
09'Lt 
44.87 
49.17 
48.07 
47.55 
47.89 
48.62 
47.07 
Per cent. 
NEGLIGENCE. 
4,207 
485 
496 
583 
<524 
612 
680 
727 
Number. 
Natural and 
UNKNOWN 
CAUSES, IN- 
CLUDING AL- 
COHOLISM. 
37. SO 
37.94 
36.00 
37.47 
37.79 
37.00 
38.36 
39.51 
Per cent. 
oefn 
1,278 
1.378 
1,556 
1.651 
1,654 
1,773 
1,840 
Totals. 
Iii the following table are presented the number of 
autopsies, the total expenses incurred in each year, and 
the average cost of investigation of each case, so far as 
the medical examinations were concerned. The ex- 
penses of 1891 had not been made up at the time of writ- 
co co co co co co 
z r r f j 
C ?D co *5 c: Oi 
Year. 
1,278 
1,378 
1.550 
1,651 
1,654 
1,773 
Total number 
of cases ex- 
amined. 
165 
202 
188 
219 
216 
206 
Autopsies. 
$16,322.54 
18,024.22 
18,626.26 
19,611.53 
19,489.69 
20,710.63 
Total expen- 
ses. 
$12.77 
13.08 
11.97 
11.88 
11.78 
11.68 
Average ex- 
pense of 
each caw. 
1 British Medical Journal, February 17, 1890. 
3 Ibid., July 19, 1890. 
3 Ibid., September 27, 1890. 
4 Ibid., October 18, 1890. 
6 Bull. Gen. de Therap , May 30, 1891. 
6 Berlin klin. Wochen., March, 1892. 
7 British Medical Journal, February 8, 1892. 
8 Medical Press and Circular, March 16, 1892. 
9 The Therapeutic Gazette, February. 1892. 
10 British Medical Journal, July 12, 1890. 
11 Ibid.. May 3. 1890. 
13 The London Lancet, May 28. 189'. 
13 La Tribune Medicale, June, 1892. 
ing, but it is safe to say that the average expense of each 
case was still further reduced as compared with that of 
previous years. 
After the system was inaugurated, and had been in 
successful operation for three years, a careful inquiry of 
285 Examiner, Medical. 
Eye Diseases. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
the expenses under the old coroner laws, and also under 
the present system showed a decided lessening in the ex- 
penses, the two chief causes of the reduction being the 
abolition of the useless coroner's jury, and the diminu- 
tion in the number of inquests. 
It is a sufficient comment upon this law that more than 
eighteen thousand cases of sudden, suspicious, and vio- 
lent deaths have been investigated under its authority, 
and in a far more satisfactory, intelligent, and economi- 
cal manner than could have been possible under the old 
regime. Samuel IF. Abbott. 
EXMOUTH. A popular sea-bathing resort in Devon- 
shire, England. Exmouth is ten miles from Exeter and 
occupies a fine situation on the Devon coast. The beach 
is remarkably good. The climate is moderately warm 
and equable, although the place is not so well sheltered 
from winds as Budleigh Salton, some five miles distant. 
There are fine coast and inland views, and the usual 
facilities for seaside enjoyments. Season, June to Sep- 
tember. The place, though foggy, is healthy. 
Edmund C. Wendt. 
EXPECTORANTS. The well-known action of oil of 
turpentine upon the bronchial mucous membrane seems 
to be possessed by its derivatives, terpin hydrate, tere- 
bene, and terpinol. Terpin hydrate was recommended 
in 1885 as a very efficient agent in chronic bronchial 
catarrh, and preferable to oil of turpentine on account of 
the absence of unpleasant physical properties. Since 
then it has been employed by a large number of clini- 
cians, and has been found to be a reliable remedy in 
bronchitis and whooping-cough. 
Terpin Hydrate, Ci0H163H2O, is a hydrate of oil of 
turpentine that often forms when the oil is in contact 
with a small quantity of water for some time. On a 
large scale it is obtained by mixing oil of turpentine with 
alcohol and nitric acid. It is in the form of large color- 
less crystals, having no odor and only a very slight 
aromatic taste. It dissolves in 250 parts of water at 15° 
C., in 32 parts of boiling water, and in 10 parts of 
alcohol. 
Terpin hydrate was introduced by R. Lepine, of Lyon, 
as an effective remedy for chronic bronchitis. He had 
used it in several hundred cases, and had observed that 
doses of 0.2 to 0.6 (three to nine grains) daily rendered 
the sputa less tenacious and more copious, and facilitated 
expectoration. In cases of bronchorrhoea larger doses, 
1.5 daily (twenty-two grains), lessened the quantity of 
sputum. Such doses also increased the action of the 
kidneys, but, when these organs were normal, never 
caused albuminuria or haematuria. 
The observations of Lepine have been corroborated by 
a number of clinicians in large hospitals. Thus Germain 
See found terpin hydrate very effective in catarrhal affec- 
tions of the respiratory mucous membrane, the morbid 
secretion gradually diminishing under its prolonged use. 
In catarrhal forms of phthisis, he observed that the muco- 
purulent secretion lessened and often entirely ceased. 
He employed it also to arrest the haemoptysis of, the early 
stage of phthisis, and held it to act more rapidly than 
ergotin. 
Dr. Lazarus, of Berlin, employed terpin hydrate in a 
large number of cases of bronchitis with good results. 
Marked effects, however, occurred only when he used 
large doses, from twenty to thirty grains daily. To 
avoid unpleasant effects on the digestive organs, the 
medicine was given in pills and taken during meals. He 
regards as the special indication for terpin hydrate great 
irritability of the bronchial mucous membrane with very 
scanty or very tenacious secretion. The effect observed 
was an increase of the sputum, which became more fluid 
and was easily expectorated. Usually the catarrhal 
symptoms vanished in from eight to fourteen days. 
Dr. Manasse, of Berlin, used terpin hydrate for several 
years in a large number of cases of bronchitis. When 
small doses were given no very striking effects resulted ; 
but large doses, from thirty to forty-five grains daily, 
proved decidedly efficient in chronic bronchial catarrh. 
(SUPPLEMENT.) 
In no case, although hundreds were treated, did any un- 
pleasant incidental effects occur. He found terpin hy- 
drate very useful also in whooping cough, of which he 
treated forty-one cases, varying in age from nine months 
to twelve years. Every case was carefully observed, the 
frequency and severity of the paroxysms being noted 
daily. To children under one year of age he sometimes 
gave as much as 1.5 (twenty-two grains) daily, and never 
observed any injurious action on the digestive or urinary 
apparatus. And in no case, when 2.5 to 3.0 daily were 
given to older children, did the urine become albuminous 
or bloody. As a rule, in four or five days the paroxysms 
were less numerous and always less severe. The bron- 
chial catarrh, which was present in most cases, dimin- 
ished more rapidly than usual, and finally disappeared 
entirely. All the cases treated with terpin hydrate recov- 
ered. The medicine was given in the form of powder: 
Terpini hydrati 5.0-10.0 
Div. in part, sequal. No. x. S.: One powder three 
times daily. 
The following formulae have been recommended : 
R. Terpini hydrat 3.0 
Sacch. alb., 
Mucil. acaciae „ S3 q. s. 
M. ft. pil. No. 30. S.: One to four pills three times 
daily. 
5. Terpin hydrat 2.0 
Spiritus, 
Aq. dest., 
Syr. menthae pip aS 50.0 
M.S.: One tablespoonful from three to six times 
daily. 
Codeine.-Codeine has recently come into use as a 
means of allaying cough. According to numerous re- 
ports, it is generally as effectual as morphine or the prep- 
arations of opium. Often it has been observed that the 
cough of mild forms of bronchitis ceased in a few days. 
But its principal advantage is that it does not depress 
the functions of the alimentary canal. The use of mor- 
phine is usually followed by a diminution of appetite, 
and often by constipation. Codeine, while it allays the 
cough, does not interfere with the appetite, or with the 
normal action of the bowels. This has been especially 
observed in phthisis, in which codeine was found to 
mitigate the cough without lessening the desire for food. 
When, to test the difference in action, Dover's powder 
was given to patients that had been taking codeine, the 
appetite, which had improved under the use of codeine, 
diminished again, showing the decided superiority of 
codeine. It has been found to be very useful in the 
bronchitis of children, and, in appropriate doses, has been 
given to infants, without any unpleasant effects. 
Codeine should, therefore, be preferred to morphine 
in all cases of severe cough in which it is necessary to 
maintain a good appetite, as in bronchial catarrhs com- 
plicating chronic wasting diseases, in children, and in 
persons subject to constipation. Especially, should 
codeine be preferred to morphine to relieve the cough 
of phthisis ; for if the means used to mitigate this tor- 
menting symptom interfere with digestion and nutrition, 
little hope of saving life can be entertained. 
The salts of codeine commonly used are the sulphate, 
phosphate, and hydrochloride. They all readily dissolve 
in water, and are usually prescribed in aqueous solution 
with a small quantity of syrup, or together with sugar, 
in the form of powder. The dose for adults is one- 
fourth to three fourths of a grain ; for infants, one-six- 
tieth of a grain ; and for children three or four years of 
age, one-fifteenth to one-tenth of a grain, from three to 
five times daily. Samuel Nickles. 
EYE DISEASES. NOMENCLATURE AND STATIS- 
TICS OF. No successful effort has been recently made 
to decide upon a complete and scientific nomenclature of 
eye diseases, and in the present state of ophthalmology 
it would be difficult, if not impossible, to do so. When 
286 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Examiner, Medical. 
Eye Diseases. 
'SUPPLEMENT. 
Total num- 
ber of 
cases. 
Number of 
cases of such 
disease in 
1.000 cases 
of eye dis- 
ease in gen- 
eral. 
Brought forward 
I. Affections of the Lids (Con- 
tinued) :- 
Tumors (Continued):- 
26,209 
- 
Enchondroma 
1 
Epithelioma 
236 
1 
Fibroma 
152 
Hordeolum 
1,999 
7 
Horny growth 
23 
Lipoma 
13 
Lupus 
5 
Millium 
22 
Molluscum contagiosum 
100 
Papilloma 
19 
Syphiloma 
11 
Verruca 
238 
1 
Ulcer 
79 
" syphilitic 
7 
Wound 
590 
2 
Xanthelasma 
78 
Total 
29,782 
Equal to 
nearly 10 
per cent, of 
all eye 
cases. 
such action is taken, it must be by some representative 
scientific body, as the American Ophthalmological So- 
ciety, not by an individual. The nomenclature pre- 
sented below is, strictly speaking, neither complete nor 
scientific, but practical ; for it covers and enables us to 
study the statistics-to us the most important side of the 
question-of upward of three hundred thousand eye 
patients, as reported in the leading eye hospitals in this 
country. It was prepared from the lists of diseases as 
they appeared in the twenty-four annual reports of the 
ten different eye hospitals enumerated at the close of this 
article. Each disease was recorded, and when the list 
was complete, it was placed under its proper heading 
for final use. 
The statistical portion is based upon a study of the 
301,744 cases of eye disease embodied in the reports 
above referred to. 
The tables explain themselves. Each disease is credited 
in the first column with the number of cases of such 
affection found in the grand total of 301,744 recorded 
cases, while the second column shows the relative fre- 
quency of each such affection, this frequency being ex- 
pressed in numbers which indicate how often the dis- 
ease is encountered in 1,000 of the cases which form the 
basis of this inquiry. When the proportion is materially 
less than one in a thousand, no entry whatever is made 
in the second column ; and, furthermore, these entries are 
made only in round numbers. 
I. Affections of the Lids : 
Total num- 
b er of 
cases. 
Number of 
cases of such 
d i s e a se in 
1,000 cases 
of eye dis- 
ease in gen- 
eral. 
Abscess 
1,180 
42 
4 
Anchyloblepharon 
Blepharitis 
11,899 
1,747 
14 
40 
Blepharoconjunctivitis 
Blepharo-phimosis 
6 
Blepharospasm 
390 
1 
Burn 
306 
1 
Canities 
2 
Cellulitis 
22 
Coloboma 
Cretaceous deposits 
10 
10 
Distichiasis 
89 
Ecchymosis 
348 
1 
Ectropion 
573 
2 
Eczema 
1,289 
3 
4 
Elephantiasis 
Emphysema 
37 
Entropion 
545 
2 
Epicanthus 
70 
Erysipelas 
32 
Erythema 
24 
Favus 
15 
Foreign body 
164 
Herpes 
67 
" zoster ophthalmicus 
47 
Lagophthalmos 
84 
Madarosis 
6 
Malignant disease 
45 
Nictitation 
114 
(Edema 
698 
109 
2 
Phtheiriasis 
Poison 
23 
Ptosis 
391 
1 
Trichiasis 
1,091 
378 
4 
Tumors 
1 
Angioma 
112 
Chalazion 1 
4,183 
50 
14 
Cystoma f 
Dermatoma 
Carried forward 
26,209 
II. Affections of the Conjunc- 
tiva : 
Abscess 
Total num- 
ber of 
cases. 
Number of 
cases of such 
di se a se in 
1,000 cases 
of eye dis- 
ease in gen- 
eral. 
25 
Argyria 
20 
Atrophy 
16 
Burn 
1,084 
4 
Caruncle, abscess of 
4 
" inflammation of 
13 
" hypertrophy of 
9 
" tumor of 
5 
Chancre 
1 
Ch emosis 
81 
Conjunctivitis 
" blennorrhmal 
324 
1 
274 
1 
catarrhal 
44,705 
149 
" .chronic 
8,091 
27 
" croupous 
194 
1 
diphtheritic 
79 
" follicular 
91 
" gonorrhoeal 
196 
1 
" granular 
7,685 
26 
" haemorrhagic.. 
9 
" lachrymal 
810 
3 
" neonatorum 
1,223 
4 
" phlyctenular 
9,632 
32 
" purulent 
. 1,416 
5 
" rheumatic 
20 
" scrofulous 
47 
" traumatic 
1.682 
6 
" vernal .... 
52 
Ecchymosis 
688 
2 
" subconjunctival 
1,064 
4 
Foreign body 
1,679 
6 
Hyperaemia 
774 
3 
Hypertrophy 
71 
Carried forward 
82,064 
- 
287 Eye Diseases. 
Eye Diseases. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT. 
Total num- 
ber of 
cases. 
Number of 
cases of such 
disease i n 
1.0G0 cases 
of eye dis- 
ease in gen- 
eral. 
Brought forward 
II. Affections of the Conjunc- 
tiva (Continued):- 
82,064 
- 
Irritation 
13 
Lithiasis 
2 
Lymphangiectasis 
8 
(Edema 
99 
Pemphigus 
3 
Pterygium 
1,689 
6 
Symblepharon 
293 
1 
Tumor 
66 
Angioma 
3 
Carcinoma 
24 
Cystoma 
80 
Dermatoma 
17 
Fibro-lipoma 
3 
Granuloma 
8 
Gumma 
2 
Melano-sarcoma 
2 
Pinguecula 
268 
1 
Polypus 
136 
Ulcer 
112 
Wound 
540 
2 
Xerosis 
24 
Total 
85,456 
Equal to 
about 28 
per cent, of 
all eye 
cases. 
Total num- 
ber of 
cases. 
Number of 
cases of such 
disease i n 
1,000 cases 
of eye dis- 
ease in gen- 
eral. 
Brought forward 
III. Affections of the Cornea 
{Continued):- 
37,714 
- 
Keratitis, traumatic 
1,274 
1,523 
116 
4 
" ulcerative 
" vascular 
5 
Kerato-conjunctivitis 
" conus 
" cyclitis 
489 
115 
10 
2 
" iritis 
Kerato-irido-cyclitis 
" scleritis 
1,272 
6 
7 
1,553 
584 
49 
20 
73 
4 
Leucoma 
5 
" adherent 
" total 
Metallic incrustation 
Necrosis 
2 
Opacity 
5,540 
18 
Pannus 
935 
3 
Staphyloma 
Tumor : 
Cyst 
Dermoid 
Epithelioma 
610 
4 
2 
3 
12 
2 
Ulcer 
8,518 
28 
" perforating 
" rodent 
" serpiginous . 
" syphilitic 
224 
3 
IM 
1 
" traumatic 
239 
1 
" with prolapse of iris 
290 
1 
Wound 
1,976 
7 
" abrasion 
'4 penetrating 
" rupture 
" with prolapse of iris 
411 
92 
133 
34 
1 
T otal 
63,936 
Equal to 
about 21 
per cent, of 
all eye 
cases. 
III. Affections of the Cornea : 
Abscess 
Anaesthesia 
Burn 
Calcareous deposits 
Fistula 
Foreign body 
" " in cornea and ante- 
rior chamber 
Herpes 
Keratitis 
" bullosa (pemphigus).... 
" dendritic 
" diffuse 
" fascicular 
" hypopyon 
" interstitial 
" malarial 
" marginal 
" neuro-paralytic 
" phlyctenular 
" punctate (descemitis, see 
serous iritis) 
" pustular 
" serpens 
Total nuin- 
b e r of 
cases. 
Number of 
cases of such 
disease 
1,000 
of eye 
ease in 
eral. 
i n 
Hases 
dis- 
gen- 
297 
1 
465 
9 
3 
20,251 
12 
32 
6,560 
9 
1 
38 
277 
181 
965 
35 
103 
6 
8,403 
62 
4 
1 
2 
67 
22 
1 
3 
28 
Carried forward 
37,714 
• 
Total num- 
ber of 
cases. 
Number of 
cases of such 
disease i n 
1.C00 cases 
of eye dis- 
ease in gen- 
eral. 
IV. Affections of Sclera. 
Burn 
4 
Episcleritis 
596 
2 
Foreign body 
46 
Gumma 
8 
Scleritis 
259 
1 
Sclero-choroiditis, anterior 
13 
Sclero-keratitis 
49 
Staphyloma 
99 
Tumor 
1 
Wound 
154 
" contusion 
1 
" of sclera and cornea 
31 
Total 
1,261 
Equal to not 
quite one per 
cent, of all 
eye cases. 
288 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Eye Disease*. 
Eye Diseases. 
Total num- 
ber of 
cases. 
Number of 
cases of such 
disease i n 
1.000 cases 
of eye dis- 
ease in gen- 
eral. 
Brought forward 
VI. Affections of the Lens 
{Continued) :- 
1,276 
- 
Cataract diabetic 
3 
" hard 
7,401 
24 
" incipient 
2,188 
7 
inflammatory 
116 
" lamellar 
112 
' * morgagnian 
15 
" nuclear 
28 
" polar 
" " anterior 
27 
130 
" " posterior 
79 
" secondary 
232 
1 
" soft 
449 
1 
" traumatic 
1,289 
4 
Dislocation of lens 
473 
1 
" " congenital.... 
4 
" " traumatic 
16 
Foreign body in lens 
14 
Sclerosis of lens 
5 
Total 
13,857 
Equal to a lit- 
tle over four 
and one-half 
per cent, of 
all eye cases. 
V. Affections of Iris and Cil- 
iary Body. 
Aniridia 
Total num- 
ber o f 
cases. 
Number of 
cases of such 
disease i n 
1,000 cases 
of eye dis- 
ease in gen- 
eral. 
10 
99 
3 
19 
81 
7 
7 
2 
22 
8 
30 
565 
237 
7 
108 
119 
3,501 
o 
2 
664 
9 
43 
118 
196 
7 
895 
478 
482 
227 
19 
18 
31 
404 
7 
597 
1,167 
10 
5 
1 
41 
1 
8 
166 
80 
30 
2 
1 
12 ' 
2 
1 
3 
2 
1 
1 
2 
4 
Atrophy of iris 
Coloboma of iris 
" of iris and ciliary body 
" of iris and ciliary body 
and choroid 
Cyclitis 
Displacement of iris, traumatic.. 
" of pupil 
Exclusion of pupil 
Foreign body in iris 
Hetero-chromia iridis 
Hyperaemia of iris 
I rido-choroiditis 
" cyclitis 
" cyclo-choroiditis 
dialysis 
" donesis 
Iritis 
" exudative 
" hemorrhagic 
" plastic 
" purulent 
" recurrent 
" rheumatic 
" serous (uveitis serosa, desce- 
metitis, etc.) 
" spongy 
" syphilitic 
" traumatic 
Mydriasis 
medicinal 
paralytic 
traumatic 
Myosis 
Occlusion of pupil 
Persistent pupillary membrane... 
Synechiae, anterior 
' ' posterior 
Tumor of iris 
cyst 
granuloma 
gumma 
melano-sarcoma 
in ciliary region 
Wound of iris 
" with prolapse of iris 
" with rupture of iris .... 
Total 
10,530 
Equal to 
about three 
and one-half 
per cent, of 
all eye cases. 
Number of 
cases of such 
Total num- 
disease i n 
b e r of 
1.000 cases 
cases. 
of eye dis- 
VII. Affections of the Choroid 
ease in gen- 
and the Vitreous. 
Albinism 
32 
Atrophy of choroid 
888 
3 
Cholesterin crystals in vitreous... 
11 
Choroiditis 
918 
3 
" atrophic 
6 
" circumscripta 
1 
" disseminata 
193 
" exudative 
114 
" metastatic 
5 
" plastic 
66 
" sclero-posterior 
450 
1 
" serous 
5 
" suppurative 
2 
Choroido-retinitis 
352 
1 
" " central 
43 
" -scleritis 
14 
Coloboma of choroid 
21 
Colloid excrescences in choroid .. 
1 
Cysticercus in vitreous 
1 
Detachment of vitreous 
2 
Foreign body in vitreous 
79 
Growths and opacities in vitreous. 
510 
2 
Hemorrhage into vitreous 
202 
1 
" in choroid 
25 
Hernia of choroid 
5 
Hyalitis 
82 
" diffuse 
5 
Hyperaemia of choroid 
4 
Persistent hyaloid artery 
11 
Rupture of choroid 
65 
Synchesis scintillans 
10 
Tubercles in choroid 
1 
Tumor of choroid 
Total 
28 
4,172 
Equal to a lit- 
tie over one 
per cent, of 
all eye cases. 
Number of 
cases of such 
Total num- 
disease i n 
ber o f 
1,000 cases 
VI. Affections of the Lens. 
Aphakia 
cases. 
of eye dis- 
ease in gen- 
eral. 
190 
Capsulitis 
2 
Cataract 
74 
" calcitic 
44 
' ' capsular 
556 
2 
" congenital 
366 
1 
" cortical 
44 
Carried forward 
1,276 
- 
289 Eye Diseases. 
Eye Diseases. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.; 
X. Amblyopia and Amaerosis : 
Amaurosis 
' ' cerebral 
" congenital 
" fugax 
Amblyopia 
* ' cerebral 
" congenital 
" hysterical 
" from insolation 
" toxic: 
alcohol 
alcohol and tobacco.. 
quinine 
tobacco 
uraemia 
Chromatopsia 
Hemeralopia 
Hemianopsia 
Nyctalopia 
Scotoma 
" scintillans 
Total num- 
ber of 
cases. 
Number of 
cases of such 
disease 
1,000 
of eye 
ease in 
eral. 
i n 
'ases 
dis- 
gen- 
7 
2 
5 
2 
608 
7 
50 
21 
1 
366 
5 
30 
1 
188 
2 
96 
29 
3 
36 
1 
2 
1 
Total 
1,497 
Equal to 
nearly one- 
half of one 
per cent, of 
all eye cases. 
VIII. Affections of the Retina : 
Atrophy 
Cysticercus 
Total num- 
ber of 
cases. 
Number of 
cases of such 
disease 
1,000 
of eye 
ease in 
eral. 
i n 
cases 
dis- 
gen- 
21 
o 
Detachment 
Embolism of central artery 
Epilepsy 
Glioma 
Hemorrhage 
" at macula lutea. 
Hy perse mia 
Hyperesthesia 
(Edema 
Opaque nerve-fibres 
Perivasculitis 
800 
54 
3 
79 
167 
15 
108 
43 
8 
45 
1 
2 
Retinitis 
" alba .. .. 
" albuminuric 
" diabetic 
" exudative 
" hemorrhagic 
" leucocythemic 
" macular 
289 
2 
177 
7 
19 
192 
13 
1 
" pigmentosa 
" proliferous 
" serous 
" syphilitic 
" traumatic 
Retino-choroiditis 
Rupture 
Thrombus of retinal vein 
Tumor 
213 
24 
14 
4 
50 
2 
2 
1 
1 
Total 
2,365 
Equal 
t 0 
about three- 
quarters of 
one per cent, 
of all eye 
cases. 
XI. Glaucoma : 
Glaucoma 
Total num- 
ber of 
cases. 
Number of 
cases of such 
disease in 
1,000 cases 
of eye dis- 
ease m gen- 
eral. 
317 
83 
126 
474 
13 
64 
57 
13 
90 
1 
1 
" absolute 
" acute 
" chronic 
" hemorrhagic 
" secondary 
" simple 
" subacute 
Glaucomatous degeneration 
Total 
1,237 
Equal to 
nearly one- 
half of one 
per cent, of 
all eye cases. 
Total num- 
b e r of 
cases. 
Number of 
cases of such 
disease i n 
1.000 cases 
of eye' dis- 
ease in gen- 
eral. 
IX. Affections of Optic Nerve : 
Atrophy 
2,352 
10 
8 
" congenital 
" incipient 
55 
Concussion 
1 
Hemorrhage on disk 
2 
Hypersemia of disk 
12 
Neuritis 
564 
35 
18 
2 
Papillitis 
Retro-ocular neuritis 
Neuro-retinitis 
679 
2 
(Edema of disk 
2 
Persistent nerve-sheath 
3 
Total 
3,733 
E q u a 1 to a 
little over 
one per cent, 
of all eye 
cases. 
XII. Errors of Accommodation 
and Refraction : 
Anisometropia 
Total num- 
ber of 
cases. 
Number of 
cases of such 
disease i n 
1,000 cases 
of ej'e dis- 
ease in gen- 
eral. 
279 
1 
Asthenopia 
715 
2 
" accommodative 
779 
2 
" muscular 
116 
Astigmatism 
5,139 
154 
17 
" compound 
" " hyperopic. 
4,228 
14 
Carried forward 
11,410 
290 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Eye Diseases. 
Eye Diseases. 
(SUPPLEMENT.) 
Total num- 
ber of 
cases. 
Number of 
cases of such 
disease i n 
1.000 cases 
of eye dis- 
ease in gen- 
eral. 
Brought forward 
XIII. Affections of the Nerves 
and Muscles of the Globe 
{Continued) :- 
2,382 
- 
Strabismus: convergent 
" deorsum vergens 
7,384 
5 
24 
" divergent 
" periodic 
" sursum vergens 
1,098 
64 
15 
3 
Totals 
10,948 
Equal to 
a little over 
one-third of 
one per cent, 
of all eye 
cases. 
Total num- 
ber of 
cases. 
Number of 
cases of such 
disease i n 
1,000 cases 
of eye dis- 
ease in gen- 
eral. 
Brought forward 
XII. Errors of Accommodation 
and Refraction {Continued)-.- 
Astigmatism compound myopic .. 
' ' irregular 
" hypermetropic 
" mixed 
" myopic 
ifypermetropia 
Myopia .... 
11,410 
760 
41 
3,477 
642 
1,538 
23,467 
8,334 
189 
3 
4 
9,638 
153 
2 
11 
2 
5 
78 
27 
Paralysis of accommodation.... 
" " " trau- 
matic 
Paralysis of accommodation, post 
diphtheritic 
Presbyopia 
Spasm of accommodation 
32 
Total 
59,656 
Equal to 
nearly 20 per 
cent, of all 
eye cases. 
XIV. Affections of the Globe : 
Anophthalmos 
Burn 
Total num- 
b e r of 
cases. 
N umber of 
cases of such 
disease i n 
1,000 cases 
of eye dis- 
ease in gen- 
eral. 
97 
22 
16 
2 
30 
163 
15 
84 
317 
319 
61 
23 
31 
40 
1 
182 
2,217 
36 
116 
376 
376 
109 
32 
19 
41 
67 
201 
4,993 
1 
1 
7 
1 
1 
Equal to 
about one 
and one-half 
per cent, of 
all eye cases. 
Malformation (congenital) 
Dislocation 
Exophthalmic goitre 
Exophthalmos 
Foreign body in anterior cham- 
ber 
Foreign body in globe 
Hyphaemia 
Hypopyon 
Intra-ocular hemorrhage 
' ' tumor 
Megalophthalmos 
Microphthalmos 
Neuroma optic nerve 
Panophthalmitis 
Phthisis 
Sympathetic irritation 
" inflammation 
Wound: 
Contused 
In ciliary region 
Corneo-scleral 
Gunpowder explosion 
Gun-shot 
Perforating 
Rupture 
Total 
Number of 
cases of such 
Total num- 
disease i n 
b e r of 
1,0011 cases 
cases. 
of eye dis- 
XIII. Affections of the Nerves 
ease in gen- 
and Muscles of the Globe : 
Diplopia 
189 
Esophoria 
88 
Exophoria 
476 
1 
Hyperphoria 
34 
Hyperesophoria 
3 
Hyperexophoria 
4 
Nystagmus. 
475 
1 
" horizontal 
15 
" monocular 
1 
' ' rotatory 
12 
" vertical 
1 
Ophthalmoplegia externa 
10 
Paralysis of external rectus 
393 
1 
" of inferior rectus 
19 
" of inferior oblique .... 
5 
" of internal rectus 
65 
" of superior oblique.... 
52 
" of superior rectus 
30 
" of 3d nerve 
354 
1 
" of 3d nerve, partial.... 
67 
" of 2d, 3d, 4th, 5th, and 
Gth nerves 
1 
Paralysis of 2d, 3d, 4th, and 6th 
nerves 
1 
Paralysis of 3d, 4th, 6th, and 7th 
nerves 
3 
Paralysis of 3d and 4th nerves... 
4 
" of 3d, 4th, and 6th nerves 
7 
" of 4th, 5th, 6th, and 7th 
nerves 
43 
Rupture of external rectus (trau- 
matic) 
1 
Rupture of inferior rectus (trau- 
matic) 
2 
Rupture of internal rectus (trau- 
matic) 
1 
Strabismus : 
alternating 
26 
Carried forward 
2,382 
- 
XV. Affections of the Lachry- 
mal Apparatus: 
Abscess of caruncle 
Total num- 
ber of 
cases. 
Number of 
cases of such 
disease i n 
1.000 cases 
of eye dis- 
ease in gen- 
eral. 
1 
1 
875 
2 
" of lachrymal gland 
" of " sac 
Carried forward 
877 
- 
291 Eye Diseases. 
Eye Symptoms. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Total num- 
ber of 
cases. 
Number of 
cases of such 
disease i n 
1.000 cases 
of eye dis- 
ease in gen- 
eral. 
Brought forward 
877 
- 
XV. Affections of the Lachry- 
mal Apparatus {Continued):- 
Cancer lachrymal gland 
" " sac 
2 
19 
Closure of puncta. 
4 
Cyst over lachrymal sac 
33 
Dacryoadenitis 
12 
Dacryocystitis 
1,879 
6 
" acute 
89 
" blennorrhoeal 
182 
" catarrhal 
1,004 
3 
" chronic 
99 
" phlegmonous 
55 
Dacryolith 
2 
Epiphora 
1,790 
6 
Fistula, lachrymal 
154 
Foreign body in canaliculus 
3 
Hypertrophy of lachrymal gland. 
15 
Malposition of puncta 
51 
Obstruction of canaliculi 
54 
" of lachrymal duct 
(stricture) 
1,522 
5 
Stillicidium 
15 
Supernumerary lachrymal gland. 
1 
Tumor over lachrymal sac 
11 
Wound over lachrymal sac 
9 
Total 
7,881 
Equal to 
about one- 
quarter o f 
one per cent, 
of all eye 
cases. 
Wills Eye Hospital, Philadelphia, Pa., 1888, 1890. and 1893. 
Presbyterian Eye, Ear, and Throat Charity Hospital, Baltimore,Md.,'91. 
New York Ophthalmic and Aural Institute, New York City, 1885, 1886, 
and 1891. 
Massachusetts Charitable Eye and Ear Infirmary, Boston, Mass., 1889, 
1890. and 1891. 
Newark Charitable Eye and Ear Infirmary, Newark, N. J., 1888, 1889, 
1890, and 1891. 
Maine Eye and Ear Infirmary, Portland, Me., 1892. 
Buffalo Eye and Ear Infirmary, Buffalo, N. Y., 1887. 
James Lancelot Minor. 
EYE SYMPTOMS, DIAGNOSTIC SIGNIFICANCE 
OF; AND ETIOLOGY OF EYE DISEASES. The study 
of the causes of eye affections is not only important with 
reference to the treatment of these diseases, but often 
proves of service in the practice of clinical medicine in 
general. The eyes are so often involved in consequence 
of derangements of other organs that ocular symptoms are 
not rarely the earliest signs of internal diseases. Thus, 
kidney disease and diabetes are sometimes recognized by 
the oculist before the necessity for the family physician 
has been felt. Syphilis, acquired or congenital, may 
reveal itself for a time in the eye only, and various dis- 
eases of the central nervous system are first seen in their 
incipiency by the ophthalmic specialist or require his 
methods for their correct localization. In order, there- 
fore, that this article shall be of full value to the general 
reader, it must involve the diagnostic significance of 
mere symptoms as well as the etiology of ocular lesions. 
Affections of the eyes, like diseases in general, may be 
classified etiologically as either primary diseases, in which 
the derangement is directly due to some cause from the 
outer world, or secondary affections, which result from a 
pre-existing anomaly in some other part of the system. 
While this distinction must be kept in view for the pur- 
pose of research, our knowledge is not yet sufficiently 
complete in every instance to maintain it in practice. In 
the case of the eye, perhaps more than in the case of any 
other organ, there occur, moreover, affections which may 
be termed intermediate between primary and secondary 
diseases. For there are many eye troubles which are pri- 
mary in the sense that they are caused by infection, an 
occurrence originating in the outer world, but secondary 
inasmuch as such infection -will take place only if the 
germs have previously gained a foothold in some other 
part of the economy. 
The frequent occurrence of eye symptoms and lesions 
in consequence of other diseases depends on the excep- 
tionally intimate connection between the visual organ and 
other parts of the economy, as well as on the complicated 
and hence delicate histological structure of the eye. 
Through the general circulation germs and poisons can 
reach the eye, while the nutrition of the ocular tissues 
reacts readily to changes in the blood or the walls of the 
vessels. Infections gain access through the extensive 
lymphatic connections, through fissures in the walls of 
the orbit, or along the channel of the tear-duct. The 
nutritive integrity of the optic nerve is influenced by 
morbid processes in many parts of the brain or even spinal 
cord, and derangements in the co-ordination of the ex- 
trinsic and intrinsic muscles of the eye indicate in the 
most sensitive manner any disease in the large central 
area from which their nerves originate. 
The etiological dependence of any eye affection on a 
given anomaly in some other part of the body may be 
proven in various ways. It is suggested by the coin- 
cidence or sequence of the two disturbances, and the 
probability of a relationship increases with the frequency 
of the observations. As some forms of eye trouble may 
have different modes of origin in different cases, the oc- 
casional occurrence of an eye disease in the course of 
other disturbances, but which may also be seen at times 
without the coexistence of the latter, does not exclude a 
relationship. But if a characteristic ocular lesion is seen 
only in connection with certain internal diseases, as the 
"albuminuric" form of retinitis in kidney diseases, the 
relationship is clearly established. 
The etiological proof is also furnished whenever a 
morbid process can be watched clinically or traced patho- 
logically in its encroachment from some adjacent struct- 
XVI. Affections of the Orbit : 
Abscess 
Total nuni- 
ber of 
cases. 
Number of 
cases of such 
disease i n 
1,000 cases 
of eye dis- 
ease in gen- 
eral. 
39 
19 
98 
5 
1 
3 
9 
56 
1 
51 
97 
1 
8 
38 
20 
4 
1 
11 
87 
Caries 
Cellulitis 
Contusion 
Emphysema 
Foreign body 
Fracture 
Necrosis 
" from phosphorus 
Periostitis 
Tumor 
Aneurism 
Carcinoma 
Cyst 
Exostosis 
Haematoma 
Osteoma 
Sarcoma ... 
Wound 
Total 
549 
Equal to 
about one- 
sixth of one 
per cent, of 
all eye cases. 
Hospital Reports Referred to. 
Brooklyn Eye and Ear Hospital, Brooklyn, N. Y., 1892. 
New York Eye and Ear Infirmary, New York City, 1882, 1885, 1890, and 
1891. 
Manhattan Eye and Ear Hospital, New York City, 1888, 1890, and 1891. 
292 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Eye Diseases. 
Eye Symptoms. 
(SUPPLEMENT.) 
ure into the orbit. In other instances the dependence of 
ocular disturbances upon pre-existing other anomalies 
may be shown by the influence exerted upon them by the 
treatment of the suspected condition. Unless such in- 
fluence, however, is very striking, and the prognosis of 
the eye-trouble is fully known, this mode of reasoning is 
liable to errors. The most satisfactory proof of the re- 
lation of any morbid occurrence to any eye anomaly is 
only furnished by the experimental production of the 
latter. But this method has been as yet but little pursued. 
For reasons of convenience the plan of this article will 
be to detail the etiological significance of the various eye 
affections from the standpoint of the oculist, while a 
survey of the eye symptoms and lesions to which any 
specified internal disease may give rise can be obtained 
from the classified index.* 
I. Lachrymal Apparatus. 
1. The lachrymal gland-very rarely the seat of dis- 
ease-may undergo chronic inflammatory enlargement in 
acquired syphilis. A few observations are on record of 
swelling of the gland during an attack of mumps, and a 
similar subacute inflammation has also been interpreted 
as a vicarious form of mumps, the diagnosis being based 
on the existence of mumps in others in the same dwell- 
ing. In leucocythcemia the tumefaction characteristic of 
that disease may also, though rarely, occur in the lachry- 
mal gland. 
2. Lachrymation, or the overflow of tears, indicates 
over-activity of the gland, but not necessarily impaired 
drainage of tears, as is shown by ordinary crying. It oc- 
curs during the course of all irritating forms of disease of 
the anterior parts of the eye. It may also result, though 
less frequently, from eye-strain. In some instances it 
depends on irritability of the mucous lining of the nose, 
due to sharp crests on the nasal septum or to enlarged 
turbinated bodies. 
Obstruction of the tear-passages is not necessarily ac- 
companied by steady lachrymation, but if in this condi- 
tion a flow of tears is started by eye-strain or irritation by 
wind and dust, the tears can only escape by running over 
the lower lid. In about one-half the cases of lachrymal 
stricture the disease of the tear-passage seems to be by it- 
self the cause of continuous overaction of the tear-gland. 
3. Obstruction of the lachrymal canaliculi may result 
from extension of conjunctival inflammations. Strictures 
just above or in the lachrymal sac and suppurative in- 
flammation of the sac, dacryocystitis, are usually, if not 
always, of nasal origin. The suppuration of the sac in 
the latter form is, of course, the direct result of the action 
of pus microbes. It is not merely the more serious forms 
of nasal disease, like syphilitic ulceration, lupus, and 
polypi which lead to disease of the lachrymal duct, but 
more frequently even transient acute catarrh, especially 
in connection with stenosis of one or both sides of the 
nose. Quite often a one-sided lachrymal disease corre- 
sponds to the narrower side of the nose. In a large pro- 
portion of cases of lachrymal obstruction permanent 
anomalies can be found in the nose, such as enlargement 
of the inferior turbinated body and malformation of or 
crests on the septum. The extension of infection from 
the sac to the skin covering it (phlegmonous dacryo- 
cystitis) and the subsequent formation of a lachrymal 
fistula can sometimes be traced to the influence of an 
acute nasal catarrh. 
Dacryocystitis is an occasional occurrence during 
small-pox. 
II. Lids. 
1. The various forms of diseases of the skin of the lids, 
eczema, lichen, acne rosacea, and favus, are, as a rule 
but an extension of the same affection on adjacent parts 
of the facial skin, and their causes, so far as they are 
known, are also the same. Herpes, more common in the 
vicinity than on the lid itself, may, however, also involve 
the lids, or even be limited to them (herpes zoster ophthal- 
micus). The accompanying neuralgia and local anaes- 
thesia show that it is due to disease of the fifth nerve. 
Globules attached to the cilia like beads on a string 
are the eggs of lice. Direct infection leads occasionally 
to a vaccinia pustule on the lid. Chancre of the lid ha's 
also been observed. Of secondary syphilitic eruptions 
condylomata are more common than ulcerating papules. 
Ulceration may be due to lupus vulgaris, lupus erythe- 
matosus, epithelioma, or rodent ulcer. 
Multiple tumors of the lids have been seen in leucocy- 
thamia. 
Ecchymoses, most commonly of traumatic origin, oc- 
cur without trauma in scurvy and in purpura hamor- 
rhagica. 
2. Oedema of the lids, if bilateral, is an early sign of re- 
nal disease and of arsenical poisoning. Mere puffiness, not 
pitting on pressure, has not this significance. It is not 
uncommon in irritative nasal disease, especially hay fever, 
and it may also occur with some slight forms of con- 
junctivitis, or as the result of any inflammatory action in 
cornea, sclera, or iris. Irritation of a hypersensitive nasal 
membrane causes at times a sudden transient, one-sided, 
or bilateral oedema of the skin of the lids, sometimes 
resembling urticaria, sometimes more like erysipelas. 
Frequent repetition of such attacks leaves the lids either 
dusky or permanently puffy. Genuine erysipelas, i.e., 
the infection by the streptococcus, differs from these 
pseudo-erysipelatous attacks by its accompanying fever 
and its progressive tendency. A condition which a 
hasty observer can mistake for erysipelas is the inflam- 
matory oedema of the lower lid induced by the extension 
of phlegmonous infection from the lachrymal sac to the 
surrounding skin. 
3. The only disease of the tarsus known etiologically is 
the chronic inflammatory hypertrophy of (late) syphilis. 
In some instances of a similar disease, however, syphilis 
is not present. 
4. Chalazion, the inflammatory enlargement of a Meibo- 
mian gland, is perhaps in some, probably rare, instances 
of tubercular origin, as Tangl1 has found the bacillus 
tuberculosis, and Koenigshoefer and Maschke2 have ob- 
served the tuberculin reaction, in such cases. In the 
majority of cases this harmless tumor is not tubercular, 
according to clinical experiences as well as bacteriological 
tests by Weiss,3 and Deutschmann.4 
5. Blepharitis, inflammation of the edge of the lid, ap- 
pears in the squamous, interstitial, and ulcerative forms. 
In the latter the ulceration is due to pus microbes, but 
whether the other forms depend on parasites is unknown. 
There are, however, four conditions, one or more of which 
often maintain the blepharitis, or cause it to relapse after 
the cessation of local treatment. These are, (a) eye-strain 
(hypermetropia or astigmatism); (6) insufficient length of 
the skin of the upper lid 5 causing gaping of the lids 
during sleep ; (c) obstruction of the tear-passages, and (d) 
nasal disease, sometimes in the form of stenosis, some- 
times in that of atrophic rhinitis. Some of the alleged 
factors stated in the books as causes of blepharitis, viz., 
scrofula and unhealthy surroundings, are not confirmed 
by experience in actual practice. 
' Blepharitis is a very common sequence of measles. 
6. Of the distortion of the lids, ectropion is mostly due 
to cicatricial shrinkage of the skin after burns or lupus, 
sometimes also to hypertrophic swelling of the conjunc- 
tiva from long-standing irritation by the tears in conse- 
quence of lachrymal obstruction, especially in elderly 
people. A characteristic form of ectropion is that due 
to cicatricial adhesion of the skin to the margin of the 
orbit from caries of the orbital rim in scrofulous chil- 
dren. Entropion is most commonly the result of con- 
junctival shrinkage after trachoma. Inversion of the cilia 
-trichiasis-is generally due to the same cause ; some- 
times to long-continued interstitial blepharitis. Partial 
turning in of the lashes-distichiasis-may occur congen- 
* The writer has not aimed at absolute completeness in the present 
place, and will therefore not include the etiological bearing of rare eye 
diseases based on very exceptional occurrences or on deductions sup- 
ported by insufficient evidence. On the other hand, it would be super- 
fluous to merely tabulate those eye-affections the etiology of which is not 
known. As there is a reference at the end of the article to the general 
literature of the subject, the quotations in the text are limited to the 
more important or recent researches, or such as are not included in the 
references appended. 
293 Eye Symptoms. 
Eye Symptoms. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
itally. In old people with relaxed skin the puffiness 
engendered by tears under an eye-bandage (after opera- 
tions), or accompanying irritative diseases of the eye, may 
cause transient spasmodic entropion. 
7. Anomalies of the muscles of the eyelids are always 
of nervous not of muscular origin. Spasm of the orbi- 
cularis muscle is either tonic or clonic. The former 
accompanies to a variable degree all irritative diseases of 
the anterior part of the eyeball which cause photophobia ; 
it may be due also to foreign bodies in the conjunctival 
sac. The most distressing form of tonic blepharospasm 
is the spasm sometimes persisting in neurotic patients 
after the original ocular disease itself has disappeared. 
In some instances its continuance depends on the exist- 
ence of tender spots (neuritis ?) in the distribution of 
sensory nerves of the face around the orbit. This is at 
any rate the interpretation of the curative results ob- 
tained by Von Graefe and others by neurotomy of the 
supra-orbital and other nerves. 
Clonic blepharospasm appears in various forms. Mere 
fibrillary twitching of a transient character occurs from 
eye strain and a variety of influences, like overwork, in- 
sufficient sleep, etc. Fibrillary twitching of the orbicu- 
laris, as well as the adjoining facial muscles, generally 
one-sided, the tic convulsif of neurologists, is a serious 
and often incurable disease of the facial nerve. Its 
pathology is generally not known ; in certain not com- 
mon instances it is a reflex which may start from eye. 
strain 6 or conjunctival irritation (personal observation), 
from nasal anomalies,1 or from defective teeth. 
Spasmodic winking of the lids is but a localized form 
of chorea and quite often the movements, at first limited 
to the lids, extend later on to other facial muscles. The 
subjects usually have a neurotic disposition, revealed by 
the family history or their own neurotic antecedents or 
subsequent history. 
Often a reflex origin can be detected, either eye strain 
(H. or As.) or follicular hypertrophy of the conjunctiva 
or nasal anomalies, and the correction of these defects 
may prove the reflex character. It must not be over- 
looked that the disposition to such exaggerated reflexes 
is augmented by all influences which lower the resisting 
power of the organism, as close confinement, overwork, 
disturbances of digestion, anaemia, etc. 
Lagophthalmos, the inability to close the eyelids, is the 
result of paralysis of the facial nerve and may depend on 
a peripheral facial neuritis (sometimes from disease of 
the ear or the temporal bone) or on an affection of the 
central nucleus of tlie facial nerve. 
Ptosis, the (partial or complete) inability to open the 
lids, is either due to excessive thickness of the lids (after 
trachoma or from subcutaneous tumor) or to lesion of 
the third nerve. A slight form is not rarely congenital, 
probably from ante-natal nuclear disease (often involving 
the recti muscles as well). The significance of recent 
paralysis of the motor oeuli can be treated to better ad- 
vantage in connection with paralysis of the ocular mus- 
cles. 
The lid aperture is of more than average width (but 
without muscular weakness) in high myopia and in ex- 
ophthalmus, especially in exophthalmic goitre. Charac- 
teristic of the latter trouble is Von Graefe's sign. On 
looking downward the upper lid normally follows the 
movement of the eyeball, while in exophthalmic goitre the 
upper lid lags behind, and with extreme downward ver- 
sion of the eye more than the usual amount of the ocu- 
lar surface is exposed. 
III. Conjunctiva. 
1. Conjunctival hemorrhages occur in purpura, but 
also from violent cough, especially whooping-cough, and 
other violent exertion, as in epileptic attacks or from 
slight trauma. They have been considered diagnostic of 
death from asphyxia. If they occur without sufficient 
provocation in elderly people they indicate vascular dis- 
ease and danger of apoplexy. The conjunctiva of the 
eyeball presents the best conditions for the observation of 
jaundice. 
(SUPPLEMENT.) 
Sudden chemosis of the conjunctiva indicates in some 
instances that a purulent inflammation of the cerebral 
meninges is encroaching upon the orbital contents. 
2. Chronic conjunctival hyperaemia (often associated 
with blepharitis) is indicative of eye-strain, lachrymal ob- 
struction, or nasal stenosis. Chronic catarrh is often a 
secondary infection of a conjunctiva habitually congested. 
It may depend in other cases on skin diseases, as eczema of 
the lid, or of parts adjoining it, or it may be the remnant of 
a former acute conjunctivitis. Acute follicular conjunc- 
tivitis leaves in some persons a permanent enlargement of 
the adenoid tissue which at times becomes complicated 
with catarrhal inflammation, but without it, too, may con- 
stitute an easily overlooked source of irritation. It is also 
stated (Foerster) that a chronic catarrhal conjunctivitis 
of very tedious course may be kept up by masturbation. 
3. Acute conjunctivitis is probably always an infection, 
excepting the form due to the influence of the ultra-violet 
rays of the electric arc light.8 The severe but transient 
form, which when epidemic is popularly known as 
" pink-eye," has been traced by Weeks9 to the invasion 
by a characteristic small bacillus. There are probably 
various micro-organisms capable of causing contagious 
conjunctivitis. Other forms are apparently due to com- 
mon saprophytic bacteria, which are frequently found in 
the conjunctiva and always on the skin. Whenever the 
conjunctiva is wounded or chemically irritated, catarrhal 
infection commonly follows. Contagious, and hence 
clearly of parasitic origin, is the form of acute conjunc- 
tivitis which in many of the persons affected causes fol- 
licular enlargement and may even resemble trachoma 
(although different in its course). 
A rather rebellious form of conjunctivitis, usually not 
severe, but sometimes leading to considerable hyper- 
trophy, is at times observed in connection with purulent 
rhinitis. Transient conjunctivitis is also a regular symp- 
tom of measles during the initial period. Conjunctivitis 
w'ith hemorrhages has been observed in attacks of in- 
fluenza. 
The most violent conjunctivitis is that caused by the 
gonorrhoeal virus, usually transferred by tow'els, hands, 
etc. The gonococcus is likewise the cause of all cases 
of characteristic conjunctivitis neonatorum. The infec- 
tion occurs in the vagina and leads to visible inflamma- 
tion on the third day after birth. If the conjunctivitis 
appears before this date the case was one of protracted 
birth w'ith early rupture of the membranes. The proof 
of the origin of this scourge of infants is furnished both 
by the regular presence of the gonococcus in the secre- 
tion as well as by its absolute prevention by means of 
nitrate of silver (two per cent.) dropped into the con- 
junctival sac at birth (Credo's method). The insignifi- 
cant conjunctivitis of babies, of irregular occurrence and 
of a duration of but a few days, is usually not caused by 
the gonococcus. Whether this parasite ever occurs in a 
form of diminished virulence after long existence in the 
maternal passages is not unlikely on the strength of 
clinical evidence, but not yet proven. An entirely differ- 
ent, mild, not dangerous, but persistent form of con- 
junctivitis, not due to the local action of the gonorrhoeal 
virus, but occurring during the course of gonorrhoea, has 
been described by Haltenhoff. Diphtheritic conjunc- 
tivitis is caused by the bacillus characteristic of diphtheria, 
but the conditions necessary for its invasion usually es- 
cape analysis, as the patients are generally free from diph- 
theria in other parts of the system. It has been, how- 
ever, produced by the coughing of diphtheritic patients 
hurling the virus into the eye of the attendant. Whether 
croupous conjunctivitis is due to the same parasite is not 
yet known. 
Trachoma or granular conjunctivitis is a disease so 
unmistakably contagious that there can be no doubt as 
to its parasitic origin. Yet none of the attempts made 
by Sattler, Michel, and various others to identify the 
virus (as a micrococcus) have led to satisfactory or con- 
vincing results. The disease has often occurred in an 
epidemic form in former times in armies, schools, and 
other institutions. Cleanliness and isolation have within 
recent years diminished the frequency of such epidemics. 
294 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Eye Symptoms. 
Eye Symptoms. 
In its non-epidemic form the disease is not apt to spread 
to others as long as care is taken in the use of towels, 
handkerchiefs, etc. Hence it is evident that unsanitary 
surroundings and poverty favor its spreading. A factor, 
which the writer believes has not received due attention, 
seems to account for the variable contagiousness. Ob- 
servation shows that the disease is, or at least can be, 
transferred by means of the conjunctival secretion. 
Sporadic cases, however, of pure trachoma are often not 
accompanied by any secretion whatsoever, or show pus 
only during periods of aggravation. Epidemic tracho- 
ma, on the other hand, furnishes copious conjunctival 
pus. It seems, therefore, not unlikely that the more 
virulent and contagious forms of granular lids represent 
a mixed infection by the trachoma virus, associated with 
some microbe causing catarrhal inflammation. 
Burnett has pointed out that the negro has nearly ab- 
solute immunity against trachoma. Chibret has likewise 
credited the Celtic races of Europe with being less prone 
to take the disease,10 a statement which is not confirmed 
by the distribution of the disease in this country. Chi- 
bret has also called attention to the comparative immu- 
nity of localities of an altitude over two hundred metres, 
from which rule numerous exceptions, however, have 
been pointed out by others. Occasionally trachoma is 
limited to one eye. Whether the disease in these instances 
is etiologically different from ordinary bilateral trachoma 
is not known. The writer has observed the frequent co- 
incidence of one-sided trachoma with one-sided nasal ob- 
structive lesions. 
Goldzieher 11 has described a disease resembling tra- 
choma, but due to syphilis and curable by antisyphilitic 
treatment. 
4. Xerosis, an inflammation with the occurrence of char- 
acteristic white, fatty-appearing spots on the conjunctiva, 
and often leading to corneal ulceration, or even necrosis, 
is a disease indicative of grave danger to life, and is ob- 
served mainly in ill-nourished infants. The disease is 
often accompanied by hemeralopia. Von Graefe origi- 
nally described it as coincident with encephalitis, but 
Jastrowitz 12 has since shown that the lesions found in 
the brain, viz., fat-granules in the neuroglia cells, do not 
signify inflammatory, but simply degenerative change. 
Indeed, xerosis has been seen in the course of various 
exhausting diseases-typhus, small-pox, etc. 
Jewezki13 has seen the disease remarkably often 
among workmen in a glass furnace. In the xerotic 
patches Kuschbert and Neisser have found a pure cult- 
ure of a characteristic bacillus. But while the existence 
of this bacillus has been confirmed, it has been shown 
by Fick, Weeks, and others, that it is but a common 
parasite of the normal conjunctival surface, and not pe- 
culiar to or causative of xerosis. 
5. Tuberculosis of the conjunctiva may either result 
from extension of the same disease in the nasal cavity or 
from metastasis of tuberculosis of internal organs. 
6. Pemphigus of the conjunctiva has been seen in 
connection with pemphigus of the skin. It may lead to 
partial or complete obliteration of the conjunctival sac 
by adhesion of the lids to the eyeball. 
IV. Sclera. 
Episcleritis occurs in some instances in persons of rheu- 
matic or of gouty history and is often influenced by cor- 
responding remedies (salicylates and antipyrin) in such a 
decisive manner that a rheumatic or-as the case may 
be-gouty origin is strongly suggested. In other in- 
stances, however, no such relationship can be demon- 
strated. 
V. Cornea. 
1. The superficial opacity of the cornea with new for- 
mation of vessels known as pannus is the result either of 
irritation by inverted eyelashes or of trachomatous dis- 
ease of the lids. A circumscribed surface opacity with 
vascular connection is sometimes caused by a relatively 
bland foreign body (especially grain-husks) embedded in 
the cornea. Another form of superficial vascular kera- 
titis beginning with circumscribed corneal exudations 
near the limbus, and of very persistent course, the writer 
has found associated with hypertrophic rhinitis. 
2. Herpes vesicles limited to the cornea have been de- 
scribed by Horner as a not infrequent occurrence (to- 
gether with herpes labialis) during the course of or after 
inflammatory disease of the respiratory passages. 
3. Phlyctenular keratitis, usually considered indica- 
tive of infantile scrofula, is so often associated with, or 
preceded by, subacute suppurative rhinitis that a causa- 
tive relation of the latter is strongly suggested. This 
form of rhinitis and consecutively corneal phlyctenulae 
frequently follow measles. Attention has also been called 
to the frequent coincidence of head-lice and phlyctenulae 
(rare in this country). On the other hand, both clinical 
sequence as well as therapeutic results show that eczema 
of or around the lids and ulcerative blepharitis may in- 
duce phlyctenular disease as well as even deeper corneal 
infiltration. The attempts to identify the alleged micro- 
organism of phlyctenular keratitis (Burchardt) cannot be 
called satisfactory. 
4. A superficial form of linear corneal infiltration 
(with loss of epithelium) assuming an arborescent shape 
has been referred by Kipp 14 to malarial influence, on ac- 
count of the patient's history and the influence of quinine 
on this disease. But a similar form has been met with 
by Emmert in non-malarial cases, and termed by him kera- 
titis dendritica. It has been seen more often following 
influenza during the recent epidemics. Another form of 
corneal disease, characterized by its name keratitis punc- 
tata superficialis, has also been described but very re- 
cently, and has been known to follow in the wake of in- 
fluenza, Superficial corneal infiltrations, often leading 
to ulceration, depend often upon disease of the conjunc- 
tiva, especially trachoma, but also, though less fre- 
quently, on chronic catarrhal conjunctivitis with hyper- 
trophy of the fold of the fornix. Another source of 
similar corneal disease is ulcerative blepharitis. 
5. Inflammation of the substance proper of the cornea 
often occurs without assignable cause. A variety has 
been ascribed by Arlt to rheumatic influence, and is said 
to be characterized by the ground-glass appearance of 
the cornea, by epithelial abrasions, which sometimes 
lead to shallow ulceration, and by the indolent course. 
Recent observations (Berger) confirm the view as to the 
rheumatic origin of this form by the marked influence 
upon it of antipyrin and salicylates. A similar form of 
keratitis the writer has seen following herpes frontalis. 
The existence of a gouty keratitis in the form of small 
circumscribed interstitial opacities has been confirmed by 
Chevallereau by the chemical detection of uric acid in the 
opaque spot. 
The most characteristic form of deep keratitis of ex- 
tremely indolent course, usually affecting one eye ahead 
of the other and followed regularly by the formation of 
a very delicate but persistent net-work of vessels in, and 
not merely on the surface of, the cornea,16 occurs in chil- 
dren or young persons with hereditary syphilis. Most 
observers agree that this disease is by itself diagnostic of 
inherited syphilis. 
It has also been asserted that some forms of interstitial 
keratitis depend on carious teeth and yield only to the 
extraction of the latter (Galezowski). 
A central interstitial keratitis, often with iritis, has 
been found by Chibret associated with neuralgia of the 
fifth nerve and apparently secondary to the latter trouble. 
6. What is commonly called keratitis punctata, or kera- 
titis postica, is not a disease of the cornea itself, but a 
deposit of clusters of cells on the posterior surface of 
Descemet's membrane in connection with the serous (or, 
much more rarely, the plastic) form of iritis, and also in 
certain acute attacks of circumscribed chorio-retinitis.16 
7. Corneal ulceration is the result of local infection, 
and in those instances of spreading ulcer (ulcus serpens) 
which have been examined bacteriologically the pus- 
forming staphylococci and streptococci were found. As 
these micro-organisms are widely disseminated, they can 
easily gain access to any wound, or even scratch, by for- 
eign bodies. The most virulent infection results from 
the presence of the pus of dacryocystitis. Where such 
295 Eye Symptoms. 
Eye Symptoms. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
virulent pus is not present, it evidently requires special 
conditions, but imperfectly understood, for the occur- 
rence of progressive infection. Some of these condi- 
tions are pre-existing disease of the conjunctiva, espe- 
cially trachoma, lacerated wounds of the cornea, for in- 
stance, by sawdust blown into the eye, and an enfeebled 
state of the system, as on recovery from typhoid fever 
and other exhaustive diseases. Variola may cause cor- 
neal ulcers either by the extension of pustules localized 
on the cornea or by infiltration occurring at a later stage, 
which subsequently breaks down. Ulcers also occur, 
though not commonly, in diabetic patients. In scrofu- 
lous children some ulcers, of a very persistent character, 
give the characteristic reaction to tuberculin injections 
and heal under its use so promptly as to raise a suspicion 
as to their tubercular origin. But the presence of the 
tubercle bacillus has not yet been demonstrated. 
8. Necrosis of the cornea-complete or partial-has 
been observed in consequence of invasion by mould fun- 
gus (aspergillus glaucus, Leber). The cornea turns yel- 
low and the disease is accompanied by pus in the ante- 
rior chamber. Necrosis of the cornea is also a rare 
complication of facial erysipelas. After experimental 
division or destructive disease of the fifth nerve, corneal 
necrosis is common, unless the lids are kept closed. It 
is not yet definitely known whether this accident results 
only from trauma and desiccation of the exposed and 
anaesthetic cornea, or whether the trigeminus exerts an 
influence on its nutrition. 
9. A neurosis of the cornea, characterized by intense 
pain and photophobia, but with scarcely any injection 
of the pericorneal vessels, is sometimes seen weeks or 
months after minute injuries to the cornea. Careful in- 
spection shows that it is due to an inflammatory condi- 
tion of the minute cicatrix left by the injury. 
VI. Iris. 
1. Unequal intensity of color of the iris of the two eyes 
has been found by Fere11 sixty-two times in the examina- 
tion of seventy-six cases of hysteria, and is considered by 
him as a characteristic hysterical stigma. Discoloration 
of an iris (especially a blue iris) may, however, remain as 
well after iritis. The existence of a past iritis is revealed 
by deposits on the anterior capsule of the lens, which are 
rarely absent when the dilated pupil is examined (unless 
the iritis was treated early and thoroughly by atropia). 
2. Plastic iritis may depend on various well-known 
causes. A localized inflammation of the iris results from 
the pressure of a swelling lens undergoing cataractous 
change, even where no infection exists. Severe contu- 
sion of the eyeball is often followed by iritis, probably due 
to secondary infection. Ulcers of the cornea frequently 
lead to the same result, and iritic complication is not rare 
in parenchymatous keratitis, whatever be its cause. The 
most frequent cause of non-traumatic iritis is syphilis. 
Syphilitic iritis is an early manifestation, and usually bi- 
lateral. In the later stages of syphilis a (one-sided) iritis 
is sometimes seen with gummatous tumors in the iris. It 
must not be overlooked that in a person who has once 
acquired syphilis, iritis may also occur from other causes, 
in which case anti syphilitic treatment has no influence 
upon it. Another known cause of iritis is rheumatism. 
While the origin is often suggested by the patient's pre- 
vious or present rheumatic history, it can be but rarely 
proven by any specific influence of recognized anti-rheu- 
matic remedies. Very often the name " rheumatic " iritis 
hides our ignorance of its causation. Iritis may also 
accompany gonorrhoeal rheumatism, and is indeed some- 
times observed as the only manifestation of this disease. 
Whether gout can provoke iritis is still a matter of doubt. 
Similar doubts exist as to the origin of iritis from kidney 
disease. Diabetes leads occasionally to a rebellious iritis, 
which improves when the systemic condition is con- 
trolled. Influenza has been followed rather frequently 
by iritis during the recent epidemics. In leucocythoemia 
characteristic infiltration with diffuse inflammation has 
been observed in the iris. Tumors in the iris, with sub- 
sequent diffuse iritis, can be referred etiologically either 
to this disease, viz., leucocythamia (rare), to tuberculosis, 
or most commonly to syphilis (gummata). 
A cause of iritis which has as yet received but insuffi- 
cient attention is nasal suppuration. Ziem has pointed 
out the possible connection between rebellious iritis and 
suppuration of the accessory sinuses (especially the maxil- 
lary antrum). The writer's experience has also included 
cases of recurrent iritis which were regularly preceded 
by acute coryza. 
Iritis is usually one of the manifestations of sympa- 
thetic ophthalmia, the inflammation of an eye due to 
chronic inflammation of the ciliary region of the other 
eye, generally dependent on the presence of a foreign 
body. Such iritis is, however, associated with inflamma- 
tion of the ciliary body, and often also of the deeper 
parts of the eye. 
Unlike the plastic form of inflammation, serous iritis 
is a local disease of which we know no etiological con- 
nection with other disturbances. 
VII. Pupil. 
1. The pupil is smaller during the first few weeks of 
life, and also during the senile period, than during youth 
and middle age. It is also narrower in hypermetropia 
than in the short-sighted eye under the same illumina- 
tion. The absolute width varies inversely with the in- 
tensity of the light. 
2. The pupil is contracted in iritis as well as in severe 
inflammation of the cornea or conjunctiva, or even in in- 
tense irritation by the presence of foreign bodies. It is 
characteristically wide and immobile in glaucoma, even 
if attended by inflammatory symptoms. It enlarges in 
all diseases of the eye or optic nerve in which the sensi- 
bility to light (not merely the distinctness to sight) is re- 
duced, and attains a medium width in one-sided absolute 
blindness. If the pupil is normal in size and reaction in 
an eye said to be blind, the condition is either hysteria or 
simulation. The pupil is still wider in bilateral blind- 
ness, as the perception of light by one eye influences the 
pupil of the other. The pupil of a blind eye, therefore, 
still responds to the illumination of the other (sensitive) 
eye. If in double sided blindness the pupils react to 
light, the lesion must be situated in the brain above the 
pupillary centre in the corpora quadrigemina, i.e., in the 
cortex or white substance of the occipital lobes. Such 
instances have been observed after cerebro-spinal menin- 
gitis. 
3. A wide and absolutely immobile (i.e., not sensitive 
to illumination) pupil indicates paralysis of the motor 
oculi nerve, be it by the effect of drugs on its termina- 
tion, by disease of the trunk, or of the central origin of 
the nerve. The pupil, if wide from inactivity of the 
third nerve, is enlarged still further by the local effect of 
atropin. 
Dilatation of the pupil is also caused by activity of the 
cervical sympathetic nerve, either experimentally or as 
the result of irritating lesions in acute disease of its ori- 
gin in the cervical spinal, cord. Under these circum- 
stances the reaction to light is not impaired. The influ- 
ence of the sympathetic upon the pupil is also manifested 
in a reflex manner whenever painful impressions are 
made upon the skin. This dilatation, very slight ordi- 
narily, is more easily observed in so-called "nervous" 
subjects, but particularly during incomplete ether or 
chloroform narcosis. Indeed, during surgical anaesthesia 
the pupil is an index of the sensibility. 
Contraction of the pupil indicates activity of the third 
nerve or paralysis of the sympathetic. In paralysis of 
the cervical sympathetic in man, from disease or injuries, 
the resulting contraction is only moderate and not always 
permanent. 
4. The pupil is contracted during natural sleep and 
during narcosis, but dilates whenever pain is felt and 
whenever asphyxia occurs. The narrowness of the pupil 
during opium stupor serves to distinguish this condition 
from coma, in which the pupil is wide. 
5. Pupillary disturbances are very common in diseases 
of the nervous system, but they are generally not charac- 
296 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
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Eye Symptoms. 
Eye Symptoms. 
teristic symptoms. In meningitis narrowness is usually 
seen, while dilatation in this disease indicates brain press- 
ure from effusion or hemorrhage. All localized destruc- 
tive lesions in the brain dilate the pupil when they in- 
volve the nucleus or the trunk of the third nerve-for 
instance, syphilitic meningitis, apoplexy, and embolic in- 
farctions. In general paresis pupillary symptoms have 
been found in one-third to two-thirds of all cases. They 
consist rather in equality of the two pupils than in marked 
dilatation or contraction in either eye. In fact, inequality 
of the two pupils, if not explicable by an intra-ocular or 
peripheral nerve lesion, may be considered a grave symp- 
tom, even during apparent health, indicative of cerebral 
changes. It is a very common precursor of various 
forms of insanity. 
6. Pupillary inequality occurs in at least one-third of 
tabetic patients, usually early. Less common in this dis- 
ease is the "Argyll-Robertson pupil"-a marked con- 
traction without reaction to light, but with slight 
increase in the contraction during efforts at accommoda- 
tion (usually bilateral). The same form of pupil occurs 
also in other forms of disease of the cervical spinal cord. 
In Pott's disease of the cervical region the pupil is occa- 
sionally disturbed, sometimes dilated, more often con- 
tracted'. Epileptics often show a permanently wide pupil. 
The same may result (by reflex stimulation of the sym- 
pathetic ?) from pelvic or intestinal irritation (worms). 
Various transient pupillary changes are not uncommon 
in hysteria. 
Enlarged glands, tumors, and aneurisms pressing upon 
the cervical sympathetic nerve cause pupillary contraction. 
7. Pupillary dilatation and immobility, with paralysis 
of the accommodation, is a characteristic symptom of 
ptomaine poisoning from tainted meats, sausages, or fish. 
The same paralysis of the third nerve occurs in belladonna 
poisoning. Whenever this condition comes on suddenly, 
either in one eye or in both, without other nervous symp- 
toms, the first suspicion should be that of local atropin or 
belladonna action. 
VIII. Accommodation. 
1. Enfeeblement of the accommodation reveals itself 
by inability to read or to see distinctly at a proximity at 
which the patient could formerly see distinctly. As the 
accommodative power diminishes normally from youth 
until about the fifty-fifth to sixtieth year, when it is prac- 
tically lost, the age of the patient must be taken into ac- 
count in all consideration of the faculty of adjustment. 
Likewise the refraction of the eye must be known before 
the accommodation can be measured. Of intra-ocular 
conditions the prodromal stage of glaucoma manifests 
itself by rapid diminution of accommodation. 
2. The accommodative power is further reduced in 
many conditions which derange nutrition or lower the 
general vigor, as neurasthenia, kidney disease, diabetes, 
derangements of the liver, after hemorrhages, and during 
recovery from exhausting fevers. More characteristic is 
the influence of carious teeth, in consequence of which 
Schmidt18 saw the accommodation enfeebled 73 times in 
92 instances, and sometimes only on the side of the de- 
fective teeth. This observation does not seem to have 
been confirmed by others. 
3. Absolute paralysis of the accommodation without 
pupillary change follows diphtheria very frequently in 
the course of two to four weeks. It is indeed charac- 
teristic of the after-effect of the diphtheritic poison. 
Whether the same paralysis can follow scarlatina and 
mumps, or whether an error had not been committed in 
the diagnosis of these affections in the instances observed 
is an open question, with greater probability of the latter 
view. An incomplete paralysis of the accommodation, 
with either normal or contracted pupils, may be a hyster- 
ical symptom, but occurs also in ataxia. 
4. When accommodation and sphincter of the iris are 
paralyzed together, the cause may be local or general 
belladonna influence, ptomaine poisoning, or lesions of the 
third nerve, particularly cerebral syphilis, less commonly 
ataxia. 
5. Spasm of the accommodation is a term often misap- 
plied in ophthalmic literature. The correction of far- 
sightedness by involuntary contraction of the ciliary 
muscle is not a spasm properly speaking, as it serves a 
useful purpose and is not maintained when the eyes are 
not used in the dark. It is distinguishable from true 
spasm by relaxing under ophthalmoscopic examination. 
True spasm simulating myopia is not common. It 
occurs perhaps more often in low degrees of astigmatism 
than in any other condition, and is brought on by over- 
use of the eyes and a neurotic disposition. The writer 
has once seen it accompany hemiplegia from brain 
lesion. 
IX. Asthenopia. 
1. The inability to use the eyes persistently, on ac- 
count of indistinctness of sight or discomfort and pain, 
headache, and other nervous symptoms induced by steady 
application, is so common a complaint, and due to so 
many different influences, that it deserves special men- 
tion in an article of the present scope. While the most 
important cause of asthenopia are optic defects, viz., 
hypermetropia, astigmatism, or insufficiency of tlie ac- 
commodative power, we cannot ignore accessory in- 
fluences due to conditions of the general system even in 
connection with ametropia. Besides asthenopia may oc- 
cur in optically perfect eyes. According to the writer's 
experience in private practice about twenty-five per cent, 
of the patients with asthenopic complaints do not belong 
to the class which can be relieved by glasses. 
2. The cardinal symptoms which indicate anomalies 
of refraction (II. or As.) or insufficient accommodation 
(presbyopia) are either blur on persistent eye-use or dis- 
comfort, described as fatigue and ache (much less com- 
monly as a burning or shooting pain) or both. But in 
patients with any neurotic disposition-and this com- 
prises a large class of civilized communities - these 
annoyances are apt to be complicated by headaches, 
feeling of pressure in the head, and, more rarely, ver- 
tigo, or even nausea. While such accessory neuroses 
can be checked just as promptly as the asthenopic 
symptoms proper by means of suitable glasses, and their 
dependence on eye strain be thus proven, a critical ex- 
perience shows that they occur only in individuals 
whose antecedents or family history indicate a neurotic 
disposition, or who have been subjected to damaging in- 
fluences, as continued overwork with confinement, anae- 
mia, or diseases deranging nutrition, like intestinal dis- 
turbances, or who are the victims of neurasthenia. In- 
deed, by removing such injurious factors, if possible, the 
neuroses can sometimes be relieved without attention to 
the eyes, although the eye strain persists. It can be 
further observed that the degree of ametropia which can 
exist in different persons without asthenopic complaints 
varies with the health and muscular vigor. While deli- 
cate individuals may at times be sensitive to half a diop- 
try of astigmatism, or three-fourths dioptry of hyperme- 
tropia, persons in perfect health do not necessarily suffer 
from two dioptrics of ametropia until age reduces their 
accommodation, or weakening influences of any kind en- 
feeble their power of endurance. 
3. Other ocular conditions which may cause asthen- 
opia are blepharitis and chronic conjunctivitis (especially 
when due to lachrymal obstruction), the intra-ocular irri- 
tation due to myopia (not the mere optic condition of 
AL), and slight choroiditis, perhaps not yet sufficient to 
damage sight. These causes are more apt to produce 
burning and smarting eyes, sometimes with blur, on us- 
ing the eyes, as contrasted with the predominance of ach- 
ing from accommodative or refractive anomalies. 
To what extent anomalous tension of the external 
muscles of the eyes is responsible for asthenopic symp- 
toms is at present a subject of much discussion. That a cer- 
tain class of authors have enormously exaggerated the im- 
portance of so-called " heterophoria," or want of balance 
of the recti muscles, cannot but be patent to any un- 
biased observer in practice. On the other hand, cases do 
certainly occur, even if they are not common, in which 
asthenopia and discomfort are associated with tendency to 
297 Eye Symptoms. 
Eye Symptoms, 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
strabismic deviation of the eyes whenever binocular vi- 
sion is obviated. But whether these two conditions bear 
a causal relation to each other, or whether both are in- 
dicative of neurasthenia, requires further study. 
4. Of extra-ocular causes of asthenopia nasal anoma- 
lies-stenosis or suppurative processes-are the most im- 
portant. Nasal influence manifests itself, however, more 
frequently in the form of itching and burning of the 
lids (especially in the morning), and irregular, dull, or 
shooting pains than in the form of typical asthenopic 
symptoms, although the latter, too, are sometimes refer- 
able to a nasal origin. A variety of influences-anaemia, 
recovery from exhausting diseases, stomach troubles, 
defective teeth-may cause asthenopia indirectly by en- 
feebling the accommodation, but such cases may be 
termed of accommodative origin, and can be benefited 
by glasses. In other instances, however, neurasthenia 
proper, or the nervous breakdown from disturbed diges- 
tion, leads to inability to maintain the use of the eyes 
without increasing discomfort, which no glasses can 
benefit. Foerster19 has described, under the name 
kopiopia hysterica, a variety of incurable asthenopia, 
dependent on chronic sclerosing parametritis. No con- 
firmation of his observations have as yet been recorded 
by others. 
X. Lens. 
1. Opacity of the lens, cataract, occurs w'henever any 
extensive rent is made in the lenticular capsule by 
any traumatism. It may result also from severe con- 
cussion of the eyeball, without perforating wound, fol- 
lowing the injury in such cases in the course of weeks or 
months. Of intra-ocular conditions which may lead to 
cataract may be mentioned recurrent attacks of iritis, 
chronic cyclitis, chronic or absolute glaucoma, chronic 
choroiditis, and retinal detachment, as well as high de- 
grees of progressive myopia. Senile cataract is very 
common in advanced age, even in perfect health and with 
ideal eyes, especially if we examine the extreme periphery 
of the lens. Fortunately not every instance of peripheral 
senile cataract proceeds to opacity of the pupillary area. 
2. The most common condition leading to premature 
senile cataract is diabetes mellitus. Whether kidney dis- 
ease has the same influence, as Deutschman has asserted, 
is not yet definitely decided. Hogg20 has called attention 
to the frequent association of prostatic enlargement and 
stricture of the urethra with senile cataract. 
3. Zonular, or lamellar cataract, commonly congenital 
and not rarely a family anomaly, has been referred by 
Horner and his disciples to the influence of rickets (some- 
times ante-natal). While the coincidence of the two 
affections has been shown to exist in about forty per cent, 
of the cases, no such relationship can be proven in other 
instances. 
4. Cataract has been known to come on rapidly in per- 
sons struck by lightning. 
Diffuse cataract can be produced in animals by naph- 
thalin poisoning. 
XL Choroid and Vitreous Body. 
1. Choroidal changes occur frequently in high degrees 
of myopia. The least dangerous lesion is pigmentary 
absorption, permitting a view of the choroidal vessels. 
More serious is hypertrophy of the pigment in the form 
of irregular masses. The gravest form is constituted 
by central white plaques (of inflammatory or atrophic 
origin ?) which damage central vision. Hemorrhages into 
the retina and vitreous body, evidently from choroidal 
vessels, are another familiar accident in strongly myopic 
eyes. 
2. In the more common forms of choroiditis, character- 
ized by yellowish plaques of infiltration, generally with 
pigmented border and later on by white atrophic spots with 
diffuse pigment proliferation, and not due to myopia, no 
cause can, as a rule, be ascertained, except it be syphilis. 
But the statements as to the frequency of syphilitic 
choroiditis vary very much. Extreme opinions are, per- 
haps, represented by Hutchinson21 and by Alexander.22 
While the former maintains that syphilis should be sus- 
pected in every case and its existence tested by mercury, 
although he admits that it is not the only cause of 
choroiditis, Alexander-from an exceptionally large ex- 
perience- believes that syphilis is not responsible for 
areolar or disseminate choroiditis, except when associated 
with opacities of the vitreous body. The same observer, 
in harmony with general experience, describes as syphi- 
litic the following forms, viz. : a, irido-choroiditis with 
vitreous opacities; b, vitreous opacities without visible 
choroidal change, except, perhaps, atrophic patches in 
the most anterior region ; c, gummata in the choroid ; d, 
diffuse chorio-retinitis, especially in the peripheral parts 
of the ocular tunics, simulating retinitis pigmentosa (the 
same form may occur in hereditary syphilis); and e, many 
of the cases of the ordinary areolar or disseminate cho- 
roiditis, if attended with vitreous opacities, and especially 
so, if they become complicated with a central exudative 
chorio-retinitis, characterized by the sudden appearance of 
a white plaque near the macula with opacity of the vitre- 
ous and deposits on the posterious surface of the cornea, 
as described by Bergmeister. Yet the present writer has 
seen three cases which correspond exactly to Bergmeister's 
description, except that they were not preceded by pre- 
vious choroiditis and pursued a less malignant course, 
but which occurred in patients/ree from syphilis. 
3. In the course of cerebrospinal meningitis a purulent 
choroiditis (sometimes irido-choroiditis), and always (?) 
binocular, characterized by a yellow reflex on illuminat- 
ing the pupil, is not uncommon. It necessarily leads to 
atrophy of the eyeball. Browne23 has described another 
variety of choroiditis, in the form of a few central whitish 
foci, either reabsorbed later on or leading to circum- 
scribed atrophy, as characteristic of a transient meningitis 
in children. A suppurative choroiditis due to septic em- 
bolism and leading rapidly to suppurative ophthalmitis, 
generally one-sided, but sometimes even affecting both 
eyes, is an occasional accident in pyaemia, particularly, 
but not exclusively, of puerperal origin, lielapsing fever 
is often followed by various forms of choroiditis, partic- 
ularly a serous irido-choroiditis, with opacities in the 
vitreous body (Logetschnikow). Malarial poisoning also 
may affect the uveal tract, manifesting itself in some in- 
stances by vitreous opacities even with hemorrhages, in 
others by a diffuse chorio-retinitis. 
4. Opacities in the vitreous body occur in many of the 
more acute forms of choroiditis. They may be formed, 
however, without ophthalmoscopically visible (or easily 
overlooked) changes in the choroidea, from traumatism 
by perforating or blunt force, in myopic eyes or in the 
course of syphilis and malaria. In many instances no 
local or constitutional cause can be detected. 
5. Hemorrhages occur in the vitreous body from 
trauma, violent exertions (probably only in the case of 
sclerotic or other vascular disease), in progressive myo- 
pia, in malaria, purpura, and in high degrees of anaemia, 
and in hypertrophy of the left ventricle of the heart. 
6. The vitreous may be the seat of a free cysticercus 
vesicle, the embryo of which has entered the eye through 
the blood-vessels in consequence of eating measly pork 
(more rarely from auto-infection from an intestinal taenia). 
7. In extensive miliary tuberculosis - and less fre- 
quently in tubercular meningitis-tubercles may be seen 
in the choroid by means of the ophthalmoscope, in the 
form of multiple yellowish raised exudations in the cho- 
roidal tissue underneath the normal retina, of a size less 
than that of the optic disk. Single larger tubercular 
tumors in the choroid are less common. Of course, tuber- 
culosis leads soon to further' inflammatory charges and 
opacity of the media. 
XII. Retina. 
1. Of all intra-ocular lesions, the affections of the ret- 
ina and of the optic nerve are of the greatest interest 
to the general practitioner on account of their frequent 
dependence on nervous or constitutional lesions which 
are not rarely revealed by this localization earlier than by 
any other symptoms. 
298 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Eye Symptoms. 
Eye Symptoms. 
In the normal eye ophthalmoscopic examination does 
not show any pulsation of the retinal arteries, but very 
often a slight pulsating movement is seen in the larger 
portions of the retinal veins as they are traced in their 
course across the bright optic disk. The systolic dilata- 
tion of the arteries is evidently too slight to be seen or- 
dinarily in vessels of such small calibre. But the in- 
creased intra-ocular tension caused by the systolic influx 
of blood suffices to compress visibly the more yielding 
veins. Where the intra-ocular tension is low, or where 
the sclera is freely distensible the venous pulsation is not 
visible. On compressing the eyeball with the finger, the 
pulsation of the veins becomes more distinct, and with 
increasing pressure the arteries also begin to pulsate visi- 
bly. When the intra-ocular tension is increased by glau- 
coma the arterial pulsation is likewise manifest. 
2. Pulsation of the retinal arteries without increased 
tension of the eyeball or other ocular symptoms is often 
found in insufficiency of the aortic valves, much less fre- 
quently in other cardiac or valvular anomalies. It has 
also been seen in rare instances of extreme anosmia (and 
sometimes in acute fever, pneumonia, and phthisis). 
Very feeble arterial pulsation has been observed in one 
eye in aneurism of the arch of the aorta, or of the large 
arteries of the neck on the corresponding side of the 
body. 
Dilatation of the retinal arteries up to the normal calibre 
of the veins was observed by Becker in exophthalmic goi- 
tre (four times in six cases). Of extreme dilatation of all 
retinal vessels, Knapp records a case in connection with 
general dilatation of the vascular system. Venous con- 
gestion due to compression of the jugular veins, by goitre 
and other tumors, or to pressure of any kind upon the 
venae cavae, may reveal itself, too, in the veins of the ret- 
ina. In a case of venous congestion due to cardiac mal- 
formation, Liebreich found the retinal veins distended 
and of a cyanotic appearance. 
3. Miliary aneurism of the retinal arteries coexistent 
with miliary aneurism of cerebral arteries (the most fre- 
quent cause of apoplexy) have been found at autopsies, 
but have but rarely been seen ophthalmoscopically. 
4. Sclerosis of the walls of the arterial system extends 
into the retinal vessels in about one-half of all cases 
(Raehlman 24). It reveals itself by tortuosity of the ves- 
sels, and thickening and opacity of their walls, so that 
the (normally invisible) walls are indicated by a marked 
double contour. There are irregular contractions in the 
calibre of the vessels, so that the column of blood may 
appear spindle-shaped in some of the branches. As long 
as hemorrhages have not occurred vision is not dis- 
turbed. 
Changes similar to those produced by arterio-sclerosis 
have been observed in the retinal arteries in advanced 
syphilis. Indeed, in this disease the thickening of the wall 
may proceed to obliteration of the calibre of an arterial 
branch. Fuerstner and Haab have shown that this oblit- 
erating syphilitic endarteritis co-exists in the retinal and 
cerebral arteries, and that the ophthalmoscope may hence 
facilitate the diagnosis of cerebral syphilis. Frequently 
the changes in the syphilitic retinal vessels, however, are 
accompanied by syphilitic retinitis. 
5. Very characteristic changes are found ophthalmo- 
scopically in embolism of the central artery. With im- 
mediate blindness the retinal arteries are found nearly 
empty (at least at first), the veins distended, and turbidity 
around the edges of the disk, with a cherry-red spot in 
the centre of the macula. The embolus is derived from 
some lesion in the heart or arterial system, but in some 
instances no source can be found. Kern25 has recently 
shown that the diagnosis of embolism in the alleged cases 
is often wrong, and that the lesion may be a thrombus in 
an atheromatous artery. Sometimes only a single retinal 
branch is obliterated. A few times the permanent blind- 
ness was preceded by short transient spells of blind- 
ness, perhaps due to temporary occlusion by an embolus 
too small to arrest the circulation completely, but in- 
creasing in size by gradual coagulation in the vessel. 
Remarkable narrowness of the arteries has been ob- 
served in a few instances of sudden blindness in persons 
with enfeebled circulation, but in whom no embolus ex- 
isted in the vessels (Alf. Graefe and Knapp). While 
the pathology of this "ischaemia retinae," as it was 
termed, is not clear, the influence of the retinal anaemia 
upon the sight was proven by the relief on lowering the 
intra-ocular tension (by paracentesis or iridectomy). 
6. Retinal hemorrhage may occur in the course of 
most forms of retinitis or severe inflammation of the op- 
tic nerve. They are very profuse and multiple in 
thrombosis of the central vein of the retina, a condition 
manifesting itself by intense congestion and tortuosity of 
all the veins, with hemorrhages along the vessels and in- 
flammatory cloudiness of the papilla.* Thrombosis of 
the vena centralis is sometimes referable to general ill-nu- 
trition (marasmus), sometimes to pulmonary emphysema- 
oftener to disease of the heart or arteries. It has also 
been observed after extensive burns of the skin, and 
after facial erysipelas. Emphysema of the lungs, if 
complicated with hypertrophy of the left ventricle, is also 
apt to cause retinal hemorrhages without thrombosis. 
Hemorrhages into the retina are observed as well in per- 
nicious anosmia, and even in ordinary severe anosmia 
from loss of blood in kidney disease, in diabetes, in gout 
(?), in disease of the liver with jaundice, after trauma of 
the eye, after violent exertions or coughing-spells, and 
after death by asphyxia. If produced in apparent 
health, without trauma to account for them, they indi- 
cate vascular disease, arterio sclerosis, fatty degeneration, 
or syphilitic endarteritis, and serve as a warning of 
threatening cerebral apoplexy. There has been observed, 
however, a rare form of extensive hemorrhage in young 
people (of fifteen to twenty-five years) in apparently per- 
fect health, in whom it has no such grave general signifi- 
cance. 
The disturbance of sight produced by hemorrhages 
depends on their size, extent, and location. 
7. Inflammations of the retina present so many differ- 
ent characteristics that the ophthalmoscopic observer can 
recognize their cause in the more typical forms with 
certainty and even in the less pronounced instances with 
some probability. The most common form, viz., the re- 
tinitis albuminurica complicating kidney disease-always 
bilateral-consists in its simplest form in turbidity of 
the edges of the disk, fatty-looking white patches, often 
with brownish border, in the retina, at first near the 
papilla and later on all over the fundus, dilatation of 
the veins, and hemorrhages partly along the vessels, partly 
in the form of small spots around the centre of the 
retina. Later on, a characteristic star-figure, made up of 
small white dots around the macula, is common. The 
walls of the vessels often appear as visible white con- 
tours. But deviations from this type also occur. The 
disease is sometimes limited to a narrow zone around 
the papilla, and still more rarely consists only in in- 
flammation of the optic disk with hemorrhages. 
Albuminuric retinitis, especially in the last-mentioned 
forms, may be simulated (rarely) by optic neuritis of 
cerebral origin. In its less pronounced type it resembles 
the retinitis caused by diabetes. In most instances, how- 
ever, the ophthalmoscopic examination can recognize 
kidney disease when manifested by retinal lesions. 
Retinitis occurs in at least seven per cent, of all cases 
of renal affection. It is most common in interstitial 
nephritis, less so in parenchymatous kidney disease, 
and rare in amyloid kidney. In nephritis following 
scarlet fever and the kidney trouble of pregnancy 
the retinal lesions are not considered of prognostic sig- 
nificance and may disappear without in jury to sight as 
the causative affection heals. But in Bright's disease, 
not coming under this etiological category, it is a sign of 
great importance. Miley26 examined 164 cases of Bright's 
disease with regard to the significance of the albuminu- 
ric retinitis. Of 51 patients who had retinitis, 27 died 
inside of two years ; while of 105 whose eyes were nor- 
mal only 28 succumbed within the same time (8 patients 
* It is not yet certain whether these appearances are necessarily due 
to thrombosis or whether there exists a hemorrhagic or apoplectic reti- 
nitis without thrombosis. 
299 Eye Symptom*. 
Eye Symptoms. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
had other ocular lesions independent of their disease). 
According to microscopic researches by the Duke 
Charles Theodore (of Bavaria) the retinal lesions are the 
result of hyaline degeneration and obliterating endarteri- 
tis of the retinal vessels. 
8. Diabetic retinitis in its most typical form consists 
of small white spots irregularly scattered throughout the 
centre of the retina, not arranged in star-figure, without 
colored border, and without involvement of the optic 
disk. The disease is bilateral, but often more advanced 
in one eye. If the ophthalmoscope shows in diabetes 
retinal lesions like those of Bright's disease, albumin 
will also be found in the urine. In other cases of dia- 
betes mellitus there occurs no typical retinitis, but 
simply hemorrhages followed by irregular patches of 
white retinal degeneration. Many such eyes become af- 
fected with glaucoma. 
9. Diffuse, but more or less striated retinal opacity with 
copious hemorrhages along the dilated vessels, especially 
near the retinal centre, is seen occasionally in leucocy- 
thasmia, while a similar form of retinitis, but, it is said, 
with more diffuse multiple but small hemorrhagic spots, 
is more characteristic of pernicious anosmia. 
10. Syphilis may affect the retina in various ways. The 
typical simple retinitis of syphilitic origin described by 
Jacobson appears as slight cloudiness of the papilla and 
retina with venous dilatation and, usually, fine vitreous 
opacities, but without plaques or hemorrhages, and gen- 
erally with but moderate interference of sight. It is an 
early form, usually occurring inside of two years after in- 
fection, and being protracted only if not treated. In other 
instances more marked opaque striae accompany the ves- 
sels as they emerge from the papilla. Ole Bull considers 
a very faint peripapillary opacity and vitreous turbidity 
as quite common in the first period after infection, and 
claims that it is characterized by an irregularly ring- 
shaped relative scotoma, which surrounds the point of 
fixation but includes the blind-spot (optic disk), but he 
states that the scotoma can only be detected with gray, 
not with white objects. 
Hirschberg,21 on the other hand, states that there oc- 
curs, commonly within the first two years of syphilitic in- 
fection, a form of retinitis, or perhaps syphilitic panoph- 
thalmitis, which is not rarely overlooked, as it need not 
reduce sight much, but may annoy the patient by flicker- 
ing. It is accompanied often by fine deposits on the 
■posterior surface of the cornea, and usually by fine vitre- 
ous dust, while in the retina there can be seen, on close 
examination, faint pinkish-yellow, later on, whitish spots, 
adjoining some of the smaller vessels in a manner com- 
parable to berries on a stem. The form of retinitis 
characterized by Von Graefe as a late manifestation of 
syphilis and termed by him central relapsing retinitis, as 
it appears in the form of a central grayish retinal cloudi- 
ness which relapseseven under specific treatment, does 
not seem to have been often observed. Late syphilis also 
manifests itself by obliterating endarteritis in the retina, 
sometimes with hemorrhages. The retina is likewise 
involved, as seen by its turbidity and the invasion of its 
anterior layers by pigment in the diffuse chorio-retinitis 
observed both in tertiary and in hereditary syphilis (the 
disease beginning peripherally in the latter case and re- 
sembling retinitis pigmentosa). 
11. In gout Hirschberg28 has described a retinitis 
characterized by white dots in the deeper layers and 
arranged in lines partly radiating from the' macula 
and partly crossing these so as to form a network, to- 
gether with small hemorrhages. Hutchinson considers 
a diffuse retinitis with hemorrhages suggestive of gout. 
Retinal hemorrhages with sclerosis in the form of opaque 
strife have been observed a few times in connection with 
marked oxaluria. 
12. A septic retinitis, in the form of white plaques, 
which speedily develops into panophthalmitis, is a dan- 
gerous accident due to embolism from some pyaemic 
source in puerperal fever, extensive phlegmons, malignant 
endocarditis, or surgical pyaemia. 
Retinitis of traumatic origin, macular injury by in- 
tense solar illumination and by lightning, extension of 
inflammation of the optic nerve into the retina, and par- 
ticipation of the retina in choroiditis, complete the list of 
retinal inflammations the etiology of which is more or 
less understood. There remain comparatively rare in- 
stances of inflammatory retinal affections-diffuse re- 
tinitis with turbidity of the entire membrane, central 
transient retinitis causing a circumscribed scotoma, reti- 
nitis punctata albescens, retinitis proliferans with con- 
nective (?) tissue strife-the origin of which are not 
known. 
An inexperienced observer may mistake patches of 
opaque (myelated ) nerve-fibres which sometimes radiate 
from the papilla in normal eyes, for retinitis or neuro- 
retinitis, but the normal vessels and the absence of all dif- 
fuse turbidity, as well as the location of the opaque spots, 
should guard against this error. 
13. The only etiological data we possess regarding the 
origin of pigmentary retinal degeneration ( retinitis pig- 
mentosa ) refer to consanguinity on the part of the parents 
of the victims in one-fourth to one-third of the cases, the 
occasional occurrence of the disease in several members 
of a family, as well as the comparative frequency of other 
degenerative conditions, like deaf-mutism, in such fam- 
ilies. 
XIII. Optic Nerve. 
1. The vascularity of the optic nerve varies within such 
wide physiological limits that the diagnosis of either pap- 
illary congestion or, on the other hand, of anaemia, must 
be received with caution. An intensely congested optic 
disk means really neuritis, while pathological pallor has 
only been observed in the last stages of cholera, in grave 
anaemia, and in quinine amaurosis. 
2. It is best to describe the inflammation of the in- 
tra-ocular end of the optic nerve as papillitis, since in- 
flammation of the trunk of the nerve back of the eyeball 
(retro-bulbar neuritis) is not necessarily visible ophthal- 
moscopically. Whenever the ophthalmoscope shows 
swelling and turbidity of the optic disk, indistinctness of 
its edges by reason of cloudiness, and dilatation of the 
veins (often with hemorrhages), we speak of papillitis, 
and if the cloudiness extends into the retina, of papillo- 
retinitis, while optic neuritis refers to inflammation of 
the nerve, no matter whether it extends down to the visi- 
ble end of the nerve or not. 
Papillitis of intra-ocular origin accompanies retinitis, 
especially the albuminuric form; the more violent forms 
of early syphilitic retinitis, also-sometimes-exudative 
choroiditis and acute forms of chorio-retinitis. Sympa- 
thetic ophthalmitis may also begin in the form of neuritis. 
3. Of extra-ocular causes facial erysipelas may lead 
to optic neuritis. One-sided papillitis-which is other- 
wise much less frequent than the bilateral affection-may 
be due to orbital disease, phlegmon of the orbit, inflam- 
mation of the sheath of Tenon, caries (tubercular or 
syphilitic) of the orbital walls or-least of all, numer- 
ically-orbital tumors. Suppuration of the antrum of 
Highmore or of the frontal sinus has also been found as a 
rare cause of optic neuritis. 
4. Papillitis of one or both eyes is sometimes, but not 
often, due to (late) syphilis of the optic nerve. More 
frequently, if syphilis is the cause, the neuritis is second- 
ary to its cerebral localization. Neuritis, usually bilateral 
and of grave danger to vision, although the visible papil- 
lary inflammation is generally very slight, has been ob- 
served after severe hemorrhages-especially hemorrhages 
from the stomach,-after measles, typhus and typhoid fever, 
mumps, and particularly often after influenza. In other 
instances rheumatism, suppression of menstruation and 
of bleeding from hemorrhoids, "taking cold," have been 
accused as causes of optic neuritis, but without definite 
proof. 
5. Papillitis may also result from poisoning by bi- 
sulphide of carbon, or more frequently from lead- 
poisoning. In most instances, however, poisons affecting 
the optic nerve cause retrobulbar neuritis, which can 
but exceptionally be recognized ophthalmoscopically and 
which will hence be referred to under the head amau- 
rosis (XIV., 6). 
300 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Eye Symptoms. 
Eye Symptoms. 
6. Of chief interest to the cliuicist is the relation of 
optic neuritis to diseases of the brain. Von Graefe made 
a distinction originally between ordinary optic neuritis 
of cerebral origin, which he called the descending 
neuritis, and the condition termed by him choked disk 
(Stauungspapille). While in the former case the autopsy 
shows a uniform inflammation of the nerves from the 
chiasm to the eye, choked disk may exist with but little 
evidence (to the naked eye) of neuritis of the nerve- 
trunk, but with intense swelling and venous stasis of the 
intra-ocular end. Accordingly von Graefe assumed a 
creeping down of the inflammation along the nerve in 
the former case, while he attributed the choked disk to 
interference with the return of venous blood by in- 
creased intracranial pressure. He based this explana- 
tion on the fact that choked disk commonly accompanies 
conditions which raise the intracranial pressure like 
tumors. But it was soon shown that this mechanical 
view was untenable on account of the free anastomoses 
of the veins of the orbit with the facial vein. Subse- 
quently Schmidt, and, later on, Manz, tried to prove that 
the venous interference was an indirect one. due to 
dropsical exudation between the sheaths of the optic 
nerve, which transmitted the intracranial pressure to the 
central vein after it enters the optic nerve. That this in- 
tervaginal dilatation does exist in such cases has been 
shown by autopsies. But its significance has been over- 
thrown by Deutschman." His experiments showed that 
any degree of compression of the nerve by intravaginal 
fluid comparable to what exists in pathological cases, is in- 
sufficient to produce optic neuritis. Its real pathogenesis 
he seeks in the influence of germs or toxines carried 
down the intravaginal space from the brain by the cur- 
rent of fluid, and he therefore considers the papillitis as 
a transmitted infection. While the distinction between 
ordinary optic neuritis and choked disk can be main- 
tained ophthalmoscopically in extreme cases of either 
type, average experience shows that the two conditions 
really merge into each other. 
The cerebral disease which most commonly leads to 
papillitis is tumor of the brain. The association of the 
two conditions is so frequent that in doubtful cases the 
diagnosis of cerebral tumor is materially confirmed by 
the presence of optic neuritis. According to Reich30 
neuritis (or the atrophy resulting from it later on) was 
found in 95.4 per cent, of eighty-eight cases of tumors 
examined during life and after death. In the analysis of 
ninety-six reported cases, Edmonds and Lawford31 found 
neuritis in eighty-six per cent, of all tumors of the cere- 
bellum, the cerebral ganglia, or the base of the brain, but 
only in forty-six per cent, of the tumors seated in the 
cerebral cortex. Hughlings Jackson, on the basis of a 
large personal experience, thinks that optic neuritis 
would ultimately set iy in every case of tumor were it 
not for the premature death of some patients. For 
sometimes the neuritis is a late accident. Occasionally 
it disappears without leaving any lesion, sometimes to 
relapse again. Oftener it changes into atrophy of the 
nerve. In spite of the intense swelling of the papilla 
vision is but little reduced in some patients. The affec- 
tion is almost invariably binocular. 
Inflammation of the optic nerve, but often with less 
intense papillary venous congestion than in the choked 
disk of brain tumors, occurs also in other cerebral affec- 
tions, but is not nearly so common as in tumors. It 
has been observed in instances of pachymeningitis, of 
meningitis, tubercular, syphilitic, and otherwise, but only 
very rarely in the cerebro-spinal form. It is not uncom- 
mon in abscess of the brain, especially abscesses of the 
temporal lobes from ear disease, and in such cases it is 
unilateral on the side of the abscess. It has also been 
seen in hydrocephalus internus and in thrombosis of the 
cavernous sinus. In cerebral embolism and softening and 
in apoplexy it is very uncommon, except when the effused 
blood gets in between the membranes at the base. In 
diffuse sclerosis, the noninflammatory forms of insanity, 
and degenerations in the brain, optic neuritis is a very ex- 
ceptional occurrence. A few times optic neuritis has 
been seen in connection with acute myelitis of the spinal 
cord. The disease has also been known to follow sun- 
stroke. 
7. Atrophy of the optic nerve shows itself by white 
discoloration of the papilla, often with a greenish-blue 
or grayish tint, and by failure of sight. If of intra-ocular 
origin or secondary to optic neuritis the vessels of the 
atrophied optic nerve are generally contracted. But if 
the atrophy is due to other causes the vessels may retain 
their normal calibre. 
Atrophy may follow any papillitis which does not 
speedily cease. It may also result from intra-ocular dis- 
ease in which the optic disk was not primarily inflamed, 
such as embolism of the central artery, persistent forms 
of retinitis (retinal pigmentary degeneration), choroid- 
itis, and chorio-retinitis, and especially glaucoma. It 
may be the consequence of previous optic neuritis, due 
to any of the causes mentioned in the former para- 
graph, as facial erysipelas, lead-poisoning, orbital dis- 
ease, syphilis, and the various brain troubles engender- 
ing inflammation of the optic nerves. With but little 
intra-ocular manifestation an optic neuritis, involving 
principally the trunk behind the eye, may follow loss 
of blood, especially from the stomach, measles, typhus 
or typhoid fever, mumps and influenza and lead to 
atrophy. Retrobulbar neuritis due to tobacco and alcohol 
poisoning rarely leads to extensive atrophy, but the in- 
flammation of the nerve caused by diabetes may ter- 
minate in complete degeneration. 
8. Atrophy may occur without previous neuritis by 
compression of the nerve from traumatic hemorrhages 
into the orbit or fracture of the walls of the optic canal, 
from exudation into the orbit or tumors of its walls, 
from irregular growth of the sphenoid bone (as in 
acromegaly) or exostoses on its upper surface, from sup- 
purative inflammation of the sphenoid sinus, from anom- 
alously situated or arterio-sclerotic vessels of the circle 
of Willis, constricting the nerve, or from aneurisms or tu- 
mors of any kind pressing upon it. If the compression 
occurs between the chiasm and the eye the atrophy 
becomes visible ophthalmoscopically in the course of 
weeks, while if the function of the optic tracts posterior 
to the chiasm be destroyed it will require many months 
or years before the atrophy descends to the intra-ocular 
end of the nerve. If the cause of the paralysis of the 
nerve is situated between the basal ganglia and the cortex 
of the occipital lobes, the atrophic changes may not 
reach the eye at all in adult life, although during in- 
fancy the degeneration pursues a more rapid course. 
The cerebral affections which may cause atrophy by 
compression of the region of the chiasm, are distention of 
the third ventricle by internal hydrocephalus and basilar 
meningitis (besides tumors of the bones of the base of 
the skull). Foci of softening and apoplectic effusion 
lead but rarely to atrophy by compression. Whenever 
the inducing cause is at the periphery of the brain, away 
from the chiasm, the affection is unilateral, but bilateral 
if the lesion is situated at or near the chiasm. 
9. Atrophy not traceable to compression of the nerve 
is frequent in multiple sclerosis of the brain and in general 
paresis ; somewhat less common in other forms of mental 
disease dependent upon degenerative changes. In these 
instances it is always bilateral, but often unequally ad- 
vanced in the two eyes, and does not necessarily proceed 
to complete optic paralysis. Blindness from atrophy is 
an occasional incident in the course of polio-encephalitis 
inferior-or in the progressive sclerosis of the nuclei of 
the upper cranial nerves. 
10. Atrophy of the optic nerve is often of spinal ori- 
gin. In locomotor ataxia optic atrophy has been counted 
in from twelve to twenty-six per cent, of all cases by 
different observers. It may be one of the earliest symp- 
toms. Its prognosis, if of spinal origin, is always bad, 
although a temporary standstill for some years is occa- 
sionally observed. It may complicate also-though less 
frequently-other spinal affections, such as myelitis of the 
lateral columns and injuries of the cervical cord. In Fried- 
reich's hereditary ataxia and similar forms of family 
afflictions (Sanger Brown) it has been noted as a frequent 
incident. Atrophy of spinal origin is always bilateral. 
301 Eye Symptoms. 
Eye Symptoms. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
In a moderate proportion of cases of progressive optic 
atrophy no cerebral or spinal cause can be established, 
although many of the patients present distinct neuro- 
pathic tendency, revealed either by their own antece- 
dents or by the family history. 
The disturbance of sight in optic atrophy may consist 
mainly in failure of central vision or in narrowing of the 
visual field, or it may depend on both factors. It is not 
possible to determine the cerebral, spinal, or idiopathic 
origin of optic atrophy by visual tests alone, except in 
cases secondary to retrobulbar axial neuritis (see XIV., 
6) or in affections of the chiasm (see XIV., 5). 
XIV. Amaurosis ; Amblyopia ; Hemianopsia. 
The present paragraph is to include all those instances 
of blindness and of impaired sight which are not due 
to intra-ocular disease, or to lesions visible ophthalmo- 
scopically, at least at the start. The causes are either 
affections of the optic nerves, diseases of the nervous 
system, or systemic morbid conditions. Amaurosis of 
cerebral origin may, in certain instances, be associated 
with optic neuritis, but this condition is but a complica- 
tion in such cases, and does not by itself account for 
the blindness. In default of objective signs, the loca- 
tion of the trouble must be determined by testing the 
vision in the centre and in the periphery of the retina, 
by measuring the visual field for white and colors, 
and by taking*into consideration the pupillary symp- 
toms and the condition of the ocular muscles, of course, 
with due reference to any nervous or systemic phe- 
nomena. 
1. Congenital poor vision, but with perfect visual field 
and normal color-sense, is quite common in an eye more 
hypermetropic or more astigmatic than its fellow. Oc- 
casionally patients discover this stationary defect only 
late in life. To what an extent such an eye loses still 
further in sight by non-use, in case of strabismus, is an 
open question. 
2. Sudden loss of sight in one eye may occur from com- 
pression of the optic nerve, by traumatic fracture of the 
orbital walls, by orbital hemorrhages and phlegmons. 
Gradual blindness can be due to slow compression by 
tumors and hypertrophic growth in the orbit, or of the 
sphenoid bone. In these cases the ophthalmoscope shows 
optic atrophy after the lapse of weeks. 
3. One-sided transient blindness has been attributed in 
some instances to reflexes from carious teeth of the same 
side. The cases are, however, few in number and mostly 
not of convincing character. Other instances of so-called 
reflex amaurosis attributed to neuralgic affections of the 
fifth nerve or sensitive cicatrices on the face, are perhaps 
better substantiated, but are also rare. Ziem, Berger (and 
a few others) have reported unilateral amblyopia with 
restricted field of vision in suppuration of the maxillary 
or of the frontal sinus. 
4. Unilateral so-called crossed amaurosis of cerebral ori- 
gin has been described by Charcot, in cases of apoplexy or 
embolism in the posterior part of the internal capsule of 
the other side of the brain, together with anaesthesia of half 
of the body (on the side opposite the lesion). But in these 
cases there was also concentric limitation of the visual 
field, and impaired color perception on the part of the 
other eye (on the side of the lesion). In other cases the 
blindness was not complete, but the impairment of sight 
■was simply more intense in the opposite eye, but of the 
same character as in the less involved eye. No anatomi- 
cal explanation can at present be given of these seeming- 
ly paradox observations. 
Very similar to these visual troubles due to organic 
cerebral lesions are the eye symptoms in hysteria. The 
most characteristic form is unilateral amaurosis (gener- 
ally with normal pupillary reaction), or amblyopia with 
concentrically constricted visual field and color-blind- 
ness, or restricted color-fields. The area sensitive to 
blue is often smaller than the field for red (contrary to 
the normal state). The affected eye corresponds to the 
side of the hemianaesthesia, if present, or to the side of 
the ovarian tenderness. Often the other eye, too, has a 
(SUPPLEMENT.) 
constricted field with diminished color-sense, but good 
central vision. 
In the so-called traumatic neuroses, the hysterical or 
neurasthenic conditions following sudden injuries, sub- 
jective failure of sight is but rarely noticed, but very 
frequently the visual field of both eyes for white and 
colors is found concentrically narrowed on testing. It 
has been noticed in such instances that the retinal periph- 
ery is quickly fatigued, so that in successive perimetric 
tests the visual field contracts during the examina- 
tion. 
5. Bilateral amblyopia is necessarily produced by all 
the causes mentioned in XIII., arts. 7 and 8, which 
lead to atrophy of the optic nerves, while at the very 
start it is sometimes impossible to recognize the atrophy 
ophthalmoscopically, at least with certainty. If in these 
cases the patient complains of one eye only, careful tests 
will still reveal a slight impairment of the sight, color- 
sense, or visual field of the other eye. 
In cases in wfliich both optic tracts back of the chiasm, 
or the posterior region of the chiasm itself, are injured 
by pressure of tumors or apoplectic effusions, or by 
hydrocephalic bulging of the floor of the third ventricle, 
the atrophy may not reach the intra-ocular end of the 
nerve until after the lapse of months. Yet there may 
be bilateral blindness or amblyopia. The seat of the 
cause is suggested in these instances by either symmetri- 
cal or homonymous sector-shaped restriction of the visual 
fields of both eyes (see explanation under the head of 
Hemianopsia). 
6. Bilateral impairment of central vision with normal 
or very slightly constricted visual field may be due to 
retrobulbar neuritis. The diagnosis is based on the de- 
tection of a small oval central scotoma for colors, at first 
only relative for red and green, later on absolute for 
these colors and sometimes even for blue, with, how- 
ever, almost normal color-sense in the periphery of the 
field. The lesion consists of neuritis limited to that bun- 
dle of fibres of the optic nerve which supplies the macu- 
lar region, and it extends throughout both nerves from 
the eyes to the chiasm (axial neuritis). If not checked 
this inflammation leads ultimately to barely visible 
atrophy of the temporal half of the optic disk. Some- 
times, but rarely, there is a slight diffuse cloudiness and 
congestion of the papilla from the start; occasionally 
there are small retinal hemorrhages. 
The most common causes of retrobulbar neuritis are 
chronic alcoholism, tobacco-poisoning, or the joint in- 
fluence of both agents, or diabetes mellitus. Almost the 
same form of optic neuritis may occur also in the course 
of multiple sclerosis of the brain, sometimes, however, 
with more diffuse involvement of the optic nerve. Lead- 
poisoning, too, may lead to the same form of retrobulbar 
neuritis, although more commonly the lead neuritis in- 
volves the entire area of the optic nerve. There is, be- 
sides, a so-called idiopathic retrobulbar neuritis, the cause 
of which cannot always be detected by clinical analy- 
sis, though menstrual suppression and exposure to cold 
are sometimes accused in a vague manner. 
7. Sudden blindness, complete or nearly so, of both 
eyes is (rarely) produced by a diffuse meningitis of the 
cortex, by cortical oedema, or increased intracranial 
pressure from tumors. Cortical lesions are the most 
probable cause in transient blindness after cerebro-spinal 
meningitis with retained pupillary reaction. Similar ob- 
servations have been made after scarlet fever, variola, 
measles, and other infective fevers, sometimes with re- 
covery, sometimes ending in permanent blindness. The 
nature of the lesion is not known. 
A cortical origin, too, we must assume in the transient 
blindness of both eyes during uraemia, sometimes with- 
out loss of pupillary reaction. The cause of the uraemia 
is kidney disease, generally that which occurs in preg- 
nancy, but also other varieties, as, e.g., that following 
scarlatina. Transient blindness in periodic spells has 
been observed as a malarial manifestation. Lead-poison- 
ing has also been known to cause a temporary blindness 
comparable to uraemic amaurosis. A similar blindness 
lasting several days has a few times been observed dur- 
302 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Eye Symptoms. 
Eye Symptoms. 
ing gastric disturbances, disappearing within some hours 
after the action of an emetic. 
There are on record a small number of cases of abso- 
lute blindness without intra-ocular cause, observed upon 
the cessation of a persistent blepharospasm, but followed 
by spontaneous recovery in every instance. 
8. Complete, though transient blindness, or, in less se- 
vere instances, marked reduction of vision, has been ob- 
served after large doses of quinine. There was marked 
pallor of the optic disk and narrowness of the retinal 
vessels. When sufficient sight had returned to measure 
the visual field, it was found enormously restricted, and 
in some of the instances it did not regain its full extent. 
A similar affection has been known to follow an over- 
dose of salicylate of sodium. 
9. A few instances have been reported of sudden inter- 
ference with sight, not due to any actual diminution of 
visual acuity, but to inability to interpret the visual per- 
ceptions, although the mind was otherwise not disturbed 
(Wilbrand32). The condition has been termed psychic 
blindness and referred to lesions of the occipital cortex. 
The same condition has been noticed rather often in gen- 
eral paresis of the insane, but on account of the mental 
failure of these patients it is more easily overlooked. 
10. Hemianopsia, or loss of one-half of the visual field 
of both eyes can only be produced by a lesion of the op- 
tic paths situated somewhere between the chiasm and 
the occipital cortex. It is either homonymous, involv- 
ing the internal half of the field of one eye and the ex- 
ternal half of the other, or it consists in loss of either 
the temporal halves or the nasal halves of the field of 
both eyes. » 
Homonymous hemianopsia is often described wrongly 
by the patient as failure of the eye on the side of the 
blind half of the field, and in such instances the nature 
of the disturbance is only recognized on perimetric 
measurement. The central vision is generally perfect. 
The onset is nearly always sudden. Since either optic 
tract supplies fibres to the external half of the retina of 
the same side, and to the nasal half of the retina of the 
opposite eye, the loss of one-half of the field of vision 
can only be due to a lesion of the optic fibres back of the 
chiasm and on the opposite side of the brain (see article 
''Visual Centres," by the writer, in Vol. VIL of this 
work). If the nerve-path involved be the optic tract in 
its continuity or at its central termination in the external 
geniculate body, the pulvinar of the thalamus opticus, 
or the anterior corpus quadrigeminum, the vertical line 
separating the blind half from the intact part of the vis- 
ual field runs exactly through the point of fixation (fovea 
centralis). Wernike has pointed out that in these cases 
the pupils will respond only if light is thrown into either 
eye from the perceiving side, while they remain immo- 
bile when the light is situated on the blind side (Wer- 
nike's hemiopic pupillary reaction). The lesion produc- 
ing this hemianopsia may be a hemorrhage or hemor- 
rhagic cyst, a focus of softening or a tumor, on the 
opposite side of the brain, in any locality where it can 
involve or compress the optic tract or its central termi- 
nation. 
If the lesion is situated in the occipital lobe, involving 
either the cortex or the white fibres which connect the 
cortex with the termination of the optic tract, the hemi- 
anopsia does not always extend quite up to the point of 
fixation, but may leave an area of a few degrees in width 
intact on the blind side of the fovea centralis. This was 
illustrated in a unique case reported by Foerster,33 in 
which left hemianopsia of cortical origin supervened in 
a man who had previously a right hemianopsia, likewise 
due to cortical lesion, and who still retained a central area 
of about three degrees with good sight. 
Hemianopsia of cortical (or subcortical) origin is further 
distinguished by the pupillary reaction when the light is 
on the blind side, as well as on the intact side of the field, 
since the lesion does not involve the reflex circuit of the 
pupillary fibres. The lesions found in the occipital cor- 
tex in a number of reported autopsies of cases of hemi- 
anopsia were generally foci of softening, less often effu- 
sions of blood or circumscribed tumors, involving the 
(SUPPLEMENT.) 
cuneus or its immediate neighborhood. As the cortical 
area representing the visual centre is an extensive one, it 
may be only partially destroyed by disease, and hence 
the hemianopsia is not always complete, viz., it does not 
always mean loss of the total half of each visual field, 
but may be limited sometimes to corresponding sections 
of each half of the two fields. Cases have also been re- 
ported-presumably of cortical origin-in which there 
was only color-blindness, but not impaired sight for 
white in the defective part of the field. 
11. Hemianopsia involving only the nasal or the tem- 
poral halves of both retinae can be caused exclusively by 
lesions injuring the fibres in the chiasm itself-tumors 
of the pineal gland or the sella turcica, localized perios- 
titis, and circumscribed tubercular or syphilitic menin- 
gitis. 
12. A transient form of homonymous hemianopsia has 
been termed amaurosis fugax, scotoma scintillans, or 
ophthalmic migraine. It is popularly known as blind 
headache. In the most typical cases a peripheral flicker- 
ing, setting in suddenly, is followed by more or less com- 
plete blindness of one-half the visual field, lasting from 
some minutes up to (exceptionally) over an hour, while 
the attack is terminated by severe headache. In other 
instances there may be general amblyopia instead of 
hemianopsia, or the visual disturbance may be so slight 
that the patient lays the most stress on the headache. 
While such spells have been observed in some patients 
with cerebral tumors, and often, too, in general paresis 
of the insane, they are, on the other hand, a very com- 
mon complaint, and generally of no grave significance. 
They are but a form of migraine, and like the latter may 
be of reflex origin, sometimes from nasal anomalies 
(Hack, and personal observations). In the writer's ex- 
perience these attacks of fugitive scotoma have also been 
averted by removing the eye strain of astigmatism, and 
by relieving chronic intestinal catarrh. Whether ophthal- 
mic migraine is occasionally the equivalent of epileptic 
attacks is an undecided question. 
XV. Diplopia. 
1. Double sight occurs whenever the tw'o eyes are not 
directed toward one and the same point-on account of 
paralysis or an ocular muscle or mechanical interference 
with the movements of the eyeball. In ordinary con- 
comitant strabismus diplopia is absent, by reason of the 
mental suppression of the images in the deviating eye, 
but the double sight can be made manifest by holding a 
colored glass in front of one of the eyes, or by shifting 
the retinal images from their usual position by means of 
prisms. 
2. In rare instances two or even more images of the 
same object are seen by one eye on closure of" its fellow' 
(monocular diplopia or polyopia). This may be due to 
an optic defect-facets of the cornea or lenticular irregu- 
larity from incipient cataract-whereby two separate 
retinal images are formed. Such diplopia is stopped by 
looking through a pinhole in a screen. But monocular 
diplopia-not of optic origin-has also been observed in 
pure hysteria, and in the hysteria complicating organic 
brain disease. 
XVI. External Muscles of the Eye (and Levator 
Muscle of the Lid). 
Strabismus, or the deviation of an eye from the posi- 
tion necessary for single binocular vision, is either con- 
comitant or paralytic. The significance of these two 
forms is entirely different. The former is due to abnor- 
mal tension of one of the recti muscles, while the latter 
is caused by paralysis of one or more ocular muscles. 
1. In concomitant strabismus the deviation of the eye 
is practically the same toward "whichever direction the 
patient looks, and the deviation remains the same which- 
ever eye the patient uses for fixation (with rare excep- 
tions). The patient may either depend on one eye exclu- 
sively (usually the better one) for vision, or he may use 
alternately either eye. The strabismus is more commonly 
303 Eye Symptoms. 
Fei Bovis. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
constant; sometimes, however, it is periodic. The causes 
of concomitant strabismus are usually intra-ocular. As a 
rule (but not without exceptions) convergent strabismus 
is associated with hypermetropia and divergent squint 
with myopia. Frequently, but not necessarily, the devi- 
ating eye is the weaker one. An eye whose vision is en- 
feebled by corneal opacity, or intra-ocular disease, is apt 
to turn outward. Convergent strabismus of hyper- 
metropic eyes sometimes comes on suddenly during 
childhood, especially after febrile diseases. In such 
cases the patients complain for a time of double sight 
without paralysis of any ocular muscle. As a rule, di- 
plopia is not observed in concomitant strabismus. 
2. Paralytic strabismus always causes an annoying 
diplopia. The paralytic deviation of the eye and the 
resulting double sight increase quantitatively when the 
eyes are turned in the direction of the weakened muscle, 
and diminish or disappear when the eyes are turned in 
the opposite direction. In paralytic strabismus the unaf- 
fected eye is used for fixation naturally,* and if it be 
covered and the affected eye be directed toward a given 
point, the so-called secondary deviation of the normal 
eye is greater than that of the affected eye. The trouble 
may vary from slight paresis to absolute paralysis of one 
or more muscles. 
3. Paralytic squint may be simulated by mechanical 
hinderances to the movements of the eyes, such as 
tumors in the orbit. The elongation of the eyeball in 
high myopia and its protrusion in exophthalmic goitre 
may interfere with the converging power mechanically, 
but this condition is not due to a paralysis. The only 
(and rare) cause known to damage the eye muscles di- 
rectly is trichinosis. 
4. The lesions causing paralysis of the ocular muscles 
may involve the motor nerves in their course through the 
orbit, in their intra-cranial portion, at their nuclei in the 
basal gray substance from the third to the fourth ventri- 
cle, or possibly in the paths connecting the nuclei with 
the cerebral cortex. The seat of the lesion can be diag- 
nosticated only by the careful consideration of all the 
symptoms presented by the case, and not always with 
certainty. It must be remembered that while the fourth 
and the sixth cranial nerves supply only one muscle 
each (viz., the superior oblique and the external rectus), 
the motor oculi innervates the superior, inferior, and in- 
ternal recti and the inferior oblique muscle as well as the 
levator of the lid and the sphincter of the iris, and that 
all these fibres of the third nerve are united in the trunk 
but separated at the central termination as well as at the 
peripheral distribution. Both anatomical reasoning and 
clinical observations show that isolated paralysis of either 
the pupil, the lid, or the three recti together (viz., supe- 
rior, inferior, and internal) can only be of central origin, 
but that a simultaneous involvement of all the muscles 
controlled by the motor oculi is more likely to be due to a 
lesion of the trunk of the nerve. It has, however, been 
learned that isolated paralysis of the internal rectus may 
be of peripheral origin. 
5. Many of the cases of paralysis of the internus or 
externus muscles cannot be referred to any constitutional 
cause, and are usually described as rheumatic, but with- 
out any proof of their rheumatic origin. The writer34 
has ascertained that many such paralyses are preceded by 
severe acute coryza, and are evidently due to extension of 
infection from the nose. Orbital causes of paralysis are 
represented by traumatism, fracture of the walls of the 
orbit or of the rim of the sphenoid fissure, phlegmon, and 
tumors. 
6. The intra-cranial part of the motor nerves may be 
compressed by hemorrhages, meningeal exudations, tumors 
of the brain or skull, or thrombosis of the cavernous si- 
nus, and in rare instances by aneurismal basilar arteries. 
Quite common are paralyses, usually multiple, from lo- 
calized syphilitic basilar meningitis. The nerves are also 
implicated often in fractures at the base of the skull. 
7. The nuclei of the motor nerves of the eye may be 
injured to a greater or less extent by hemorrhages, soften- 
ing, or tumors, especially syphilitic or tubercular, involv- 
ing the region between the basal ganglia and the medulla 
oblongata. There occurs, besides, a progressive oph- 
thalmoplegia externa, due to disease limited to the nu- 
clear gray substance, sometimes of syphilitic origin, in 
other cases due to a non-syphilitic polio-encephalitis infe- 
rior. Disease of the nuclei may also occur before birth, 
as isolated or multiple paralyses of the lid elevator and 
the recti muscles are not rarely congenital. 
Clinical evidence and scant autopsies have shown a 
nuclear origin as well in the isolated and often transitory 
paralyses which are often observed in syphilis, in tabes 
(where they may be one of the earlier symptoms), in 
multiple sclerosis, in diabetes, in pupura heemorrhagica, in 
poisoning by lead, tobacco, carbonic oxide, and ptomaines 
of spoiled meat. The same may be said of the relatively 
infrequent paralyses following diphtheria (while paraly- 
sis of the fibres of the third nerve supplying the ciliary 
muscle is so common from this cause). Transitory or 
even permanent palsies of ocular muscles have been 
known to follow the acute exanthemata, various infec- 
tious fevers, and especially influenza. Within some years 
comparatively many cases have been reported of periodic 
paralysis of the motor oculi nerve, sometimes complete, 
sometimes only limited to some of its branches. The 
spells are preceded by headache, last some days or 
weeks, and then cease entirely, but return after irregular 
intervals. The cause is probably central. 
8. Of lesions above the nuclei of the motor nerves but 
little is known in relation to ocular paralysis. Isolated 
ptosis-paralysis of the levator muscle of the lid-has 
been observed in disease of the posterior region of the 
parietal cortex of the opposite side. It is probable that 
the transitory and often variable pareses observed occa- 
sionally in hysteria are due to cortical influences. A few 
instances of paralysis of associated movements of both 
eyes (upward, downward, or lateral), but without para- 
lytic strabismus, have been observed (O. Bull),35 which 
on clinical evidence can only be referred to disease of 
the hemispheres of the brain. 
9. A not uncommon symptom of localized cerebral 
disease, especially apoplexy or softening, is conjugate 
deviation of both eyes to one side, attributable to spasm 
rather than to paralysis of the internal rectus of one eye 
and the external rectus of the other. It may be due to 
either irritative or destructive lesions of the hemispheres 
or of the basal region, especially the pons. Landouzy 
states that turning of the eyes toward the paralyzed side 
indicates a destructive lesion in the neighborhood of the 
pons, while hemispherical injury causes the eyes to turn 
away from the palsied side, but that in case of contract- 
ures the deviation toward the convulsed limbs means 
hemispherical, and away from the side of the spasm, 
pontine irritation. 
10. Nystagmus-rhythmic oscillation of the eyes-is 
generally congenital, or acquired during early childhood 
in connection with any intra-ocular disease or defect 
causing imperfect sight. But if it originates after early 
infancy its significance is entirely different. The ac- 
quired nystagmus is a comparatively frequent affection 
in coal-miners, brought on by the constrained position 
and the inevitable fatiguing turning of the eyes to one 
side, perhaps also by the insufficient illumination. If 
acquired without this provocation it is symptomatic of 
either malformation of the skull and brain or of multiple 
sclerosis, of hemorrhagic or embolic foci in the thalamus 
opticus, the fourth ventricle, the restiform body, or the 
cerebellum, of infantile encephalitis, or of Friedreich's 
hereditary form of ataxia. 
XVII. Orbit. 
1. Hemorrhage into the orbital cavity is quite rare 
from any but traumatic causes. In the latter case, if the 
force has not been directed against the orbit itself, the 
hemorrhage denotes fracture of the base of the skull. 
Severe coughing fits, scurvy, and vascular degeneration 
have caused effusion of blood in rare instances. Gas- 
eous infiltration of the orbit-emphysema-can only hap- 
* Except when its sight is much less than that of the other eye. 
304 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Fye Symptoms. 
Fei Bovis. 
pen from violent expiratory efforts after a fracture of 
the wall has established communication between the 
orbital and nasal cavities. 
2. Orbital affections may be simulated by empyema of 
the frontal or of the ethmoid sinus. But these suppura- 
tions can also extend into the orbital cavity, causing 
phlegmon or abscess. Other causes of orbital phlegmon 
may be facial erysipelas or furuncles, orbital traumatism 
and infection, thrombosis of the cavernous sinus or ex- 
tension of a suppurative meningitis. Phlegmons of 
pyamic origin have been observed, in surgical pyaemia 
and in severe infectious fevers. Inflammation of the 
sheath of Tenon occurs sometimes after severe coryza, 
and has been seen often secondary to influenza. Caries 
of the orbital wall may be due to syphilis, tuberculosis, 
or infection by pus microbes. 
3. Exophthalmus, or protrusion of the eyeball, is caused 
by any tumor or tumefaction in the orbital cavity and is 
somewhat simulated by the prominence of highly my- 
opic eyes. Exophthalmus forms a prominent symptom 
of Graves' (or Basedow's) disease-exophthalmic goitre. 
There are, however, rare cases of this disease without 
exophthalmus. 
Enophthalmus-the receding of the eyeball into the 
orbit-is a common appearance in all wasting diseases. 
Bibliography.-The numerous observations upon 
which this review is based are scattered throughout 
ophthalmological and neurological literature, and are 
summed more or less completely in the larger text-books 
on the eye and on the nervous system. Many details 
will be found in the different ophthalmic contributions to 
this Reference Handbook, especially the article by Dr. 
Moore on " Medical Ophthalmoscopy," in Vol. V. Very 
complete accounts of the connection of the nervous sys- 
tem, with optic nerve and retina can, be found in Leber's 
classical treatise in vol. v. of Graefe and Saeinisch's 
Ilandbuch der ges. Angenheilkunde, 1877, and in the arti- 
cles on the retina (1887) and optic nerve (1888) by De 
Wecker, and on amblyopia by Nuel (1887) in De 
Wecker and Landolt's " Traite complete d'Ophthal- 
mologie." Very full also is the part on muscular anoma- 
lies by Landolt and Eperon in the same wrork. Reference 
should also be made to the "Medical Ophthalmoscopy" 
by Gowers, 1879 (and second edition in 1881). Good re- 
sumes of the same subjects are given by Mauthner, "Ge- 
hiru und Auge," 1881, and "Die Nuclearlaehmungen der 
Augenmuskeln,'' 1885. The relations between the uterus 
and the eyes are summed up by Cohn in "Uterus und 
Auge," 1890. On the connection between the nose and 
the visual organ full references can be found in Berger, 
"Rapports entre les Maladies des Yeux et celles du 
Nez et des Cavites voisines,'' 1892, and in II. Gradle, " The 
Etiological Relations of Nasal Diseases to Affections of 
the Eyes," in "Transactions of the Ophth. Section of the 
Am. Med. Assn., 1892," (and Journal of the Am. Med. Assn., 
September 10, 1892). The importance of syphilis is well 
portrayed in Alexander's "Syphilis und Auge," 1889. 
A complete resume of eye symptoms in general pa- 
thology was first brought out by Foerster, in Graefe and 
Saemisch's Handbuch der ges. Augenheilknnde, vol. vii., 
1877. In 1885 Jacobson wrote his short but thorough 
monograph, " Beziehungen der Verauderungen und 
Krankheiten des Sehorgans zu Allgemeinleiden und Or- 
ganerkrankungen," in which-as in the present article- 
the relations are classified from the ophthalmic stand- 
point, while tabulation from the medical point of view 
is again the plan in Berger's large compilatory work, 
"Les Maladies des Yeux dans leur Rapports avec la Pa- 
thologic generale," 1892. The latest review of the sub- 
ject is the volume by Knies, "Die Beziehungen des Sehor- 
gans und seiner Erkrankungen zu den iibrigen Krank- 
heiten des Korpers," 1892. H. Gradle. 
(SUPPLEMENT 
7 Pelteeon : Berl. klin. Wochenschrift. 1891, No. 32. 
8 Widtnark : Transactions of the Tenth International Medical Con- 
gress, vol. iv. 
9 Arch, of Ophthalmr 1., vol. xv., p. 441. 
10 See Transactions of the Ophthalmic Section of the Tenth Interna- 
tional Medical Congress of Berlin, vol. iv., 1890. 
11 Centralblatt f. prakt. Augenheilknnde, 1888, p. 10.3. 
12 Archiv f. Psychiatric, Bd. ii., p. 289, u. Bd. iii., p. 169. 
13 Centralblatt f. prakt. AugenheilKunde, 1890. p. 489. 
14 Transactions of the Am. Ophth. Society, 1889. 
15 Hirschberg: Centralblatt f. prakt. Angenheilkunde, 1886, p. 97. 
16 Gradle : Annals of Ophthalmology, January. 1893. 
17 C. R. de la Societe de Biologie. April 9, 1886. 
18 Archiv. f. Ophthalmologie, vol. xiv., p. 107. 
19Handbuch d. ges. Augenheilknnde von Graefe und Saemisch, Bd. 
vii., p. 89. 
30 Lancet, 1872, ii., p. 708. 
21 Transactions of the Ophthalmological Society of the United King- 
dom, British Medical Journal, February 9, 1889. 
22 Syphilis und Auge. Wiesbaden. 1889. 
23 Royal London Ophthalmic Hospital Reports, January, 1889. 
24 Zeitschrift f. klin. Medicin, vol. xvi., H. 5 and 6, and Fortschritte 
d. Medizin, 1887. No. 24. 
25 ZurAetiol.d. Embolied. Art. Cent. Retinae, Inaugural Diss., Zurich, 
1892. 
28 Transactions of the Ophth. Society of the United Kingdom, January 
26, 1888. 
27 Centralblatt f. prakt. Augenheilknnde, 1888, p. 369. 
28 Ibid., 1882, p. 3<3. 
29 Ueber Neuritis optica, besonders die sogenannte Stauungspapille, 
etc. Jena, 1887. 
30Zehender's klin. Monatsblatter f. Aug., Hd. xii., p. 274. 
31 Ophthalmic Review, May, 1887. 
32 Die Seelenblindheit, etc. Wiesbaden, 1887. 
33 Archiv f. Ophthalmologie, Bd. 36. i., p. 94. (Another case by 
Schweigger, Archives of Ophth., 1891, vol. xx., p. 83.) 
34 Journal of the American Med. Assn., September 10, 1892. 
35 Archives of Ophthal., 1891, vol. xxi., p. 342. 
FALMOUTH. A popular sea-side resort in Cornwall, 
England. Falmouth, although nine hours by rail from 
London, is a fashionable sea-side resort, which has lately 
become quite prominent. The harbor is one of the finest 
in England, and the sandy beach is very attractive. The 
climate, though humid, is mild and agreeable. Bathing 
is the chief attraction. Invalids of various kinds live 
there in winter and spring, owing to the climatic and 
sanitary advantages of the place. Edmund C. Wendt. 
FEL BOVIS. The action of ox-gall in assisting the 
absorption of fats and oils, and its aid in maintaining 
intestinal antisepsis, has suggested its use as a proper 
means of treating typhoid fever. Dr. Adolph Zea re- 
ports the result of ten cases in his own wards, and forty- 
eight cases treated by medical friends, as very gratifying. 
His method of conducting the case is as follows : If seen 
early, a dose of calomel is given to relieve the digestive 
tract of its contents ; alcohol in the form of whiskey is 
given at first as a stimulant, and, if additional stimulation 
is required, strychnine, caffeine, ammonia, camphor, or 
small doses of quinine ; dilute muriatic acid in large quan- 
tities of water as a beverage, and fel bovis purificatum sic- 
cum, in doses of two to four grains, three to six times a day 
in pill form or capsule. The diet consists of fluids-milk, 
gruel, beef-tea-in small quantities frequently given. 
The milk should always be boiled, but may be given hot 
or cold according to the wish of the patient. Prepara- 
tions of beef extracts and juices may also be given. 
The benefit of this treatment is shown in a reduction 
of the temperature after the drug has been given for a 
few days, and a freedom from all distressing abdominal 
symptoms and complications. Convalescence is also 
thought to be more rapid than under any other line of 
treatment. 
It is urged that if bile is essential in health, it is still 
more so in such a condition as enteric fever, when the 
functions of all the organs are in abeyance and the nor- 
mal secretion of bile, so much required, is lacking. It is 
uncertain how it acts, whether by passing direct from the 
stomach into the intestines, or whether it is first absorbed 
and then secreted as human bile. If the article is pure 
and not altered by age it is perfectly unirritating and may 
be given without the fear of its causing any unfavorable 
results. Whenever pain, vomiting, or any symptoms of 
gastric irritation arise, it is due to the presence of proteid 
matter and other impurities in the drug, which have im- 
parted the poisonous properties. 
W. H. Porter contributes, in Merck's Bulletin, July, 
1 Centralblatt f. prakt. Augenheilknnde. 1891, pp. 14 and 47. 
2 Deutsche med. Wochenschrift, 1891, No. 2. 
3Centralbl. f. prakt. Augenheilknnde, 1891, p. 180. 
4 Beitrage zur Angenheilkunde. Heft, ii., p. 109. 
s Fuchs : Arch. f. Ophth., Bd. 36. i.. p. 234. and confirmed by personal 
observation by the author. See article on Disease of the Lids, in Hare's 
System of Therapeutics, vol. iii.. p. 1H88. 
6 See Noyes, Diseases of the Eye, 1890, p. 260. 
305 Fei Bovis. 
Fever. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
1890, an article on the properties of ox-gall. He has 
used it in great quantities for over ten years, giving as 
much as twenty-five or thirty pounds during a year. He 
insists upon the necessity of procuring good preparations, 
both free from impurities and not spoiled by exposure to 
the atmosphere. He recommends that only the purified 
inspissated bile should be used. 
The physiological action of ox-bile is summed up by 
him as follows : 1. It acts on the fats and promotes their 
absorption by the lacteals. In all forms of milk diet he 
thinks that two grains of the purified gall in capsules 
should be given before the diet is commenced in the 
morning, and repeated during the day according to the 
quantity of milk ingested. 2. It contains a diastatic fer- 
ment and has an important action in the conversion of 
starch into glucose. 3. It promotes a normal peristalsis 
of the intestine which favors absorption and prevents con- 
stipation. 4. The bile-acids stimulate the minute muscles 
of the villi, the contractions of which force the contents 
of the lymph-sacs onward and favor absorption. 5. The 
presence of the bile stimulates the activity of the epi- 
thelium and promotes a secretion of fluid from the folli- 
cles. 6. It prevents putrefactive changes and may be 
looked upon as nature's chief internal antiseptic. 7. It 
aids the final solution of albuminoids and their conver- 
sion into the diffusible peptones. Beaumont Small. 
FELIXSTOW. A rising spa on the Suffolk coast, 
England. 
Location.-Felixstow Spa is about twelve miles from 
Ipswich, and two and a half hours from London. Having 
a southerly aspect, comparatively dry air, a bracing cli- 
mate, a fine beach, and a chalybeate spring, it is growing 
in popular and professional favor. In The Lancet of 
November 12, 1892, Dr. Macnaughton Jones gives the 
following particulars of the place : 
"Facing the German Ocean, between Harwich on the 
south and Bawdsey at the mouth of the Deben River on 
the north, Felixstow beach occupies an amphitheatre 
which has at one point of the crescent Landguard Fort, 
commanding the entrance to Harwich, and at the other a 
picturesque villa perched just above the cliffs of red crag 
and London clay that bound this part of the coast and 
over which there is a delightful walk to Felixstow ferry. 
The famous golf grounds and the well-known golfing 
club-the links of which are splendidly placed on the 
side of the Deben river, close to the sea, about two miles 
from the eastern side of the town-attract many visitors. 
The capital bathing beach and the safe sands render Fe- 
lixstow a typical place for children, and each year it is 
growing more in popular favor as a children's holiday 
resort. Dr. Taylor, having tested personally and with 
others the medicinal properties of the spa, was induced 
to try its aeration by artificial means, hoping thus to get 
rid of the smell and unpleasant taste due to the decom- 
position of the pyrites which is found in the London 
clay of the soil. In this he has been most successful. 
The taste reminds one of the Weinbrunnen spring at 
Schwalbach-sparkling and mildly chalybeate." 
Analysis.-According to Dr. Frankland, one hundred 
thousand parts of the water yield the following ingredi- 
ents : 
Parts. 
Total solid residue dried at 130° C 85.30 
Lime as carbonate 11.76 
Magnesia as carbonate .. 2.16 
Total magnesia as carbonate 5.78 
Soda 22.25 
Potash 1.21 
Chlorine 30 44 
Sulphuric anhydride 3.40 
Silica 1.51 
Alumina and peroxide of iron 0.11 
Organic carbon 0.063 
Organic nitrogen 0.019 
Ammonia ... 0.070 
Nitrogen as nitrates 0.0 
Phosphoric acid 0.0 
These constituents are probably combined in the water 
in the following manner : 
(SUPPLEMENT.) 
Parts. 
Carbonate of lime 21.00 
Carbonate of magnesia 4.54 
Sulphate of lime 4.01 
Sulphate of magnesia 1.52 
Chloride of magnesium 7.36 
Chloride of sodium 39.60 
Chloride of potassium 1.92 
Silicate of sodium 3.07 
Alumina and peroxide of iron 0.11 
Indications.-According to Dr. Jones, the consti- 
tution of such a water would justify the belief that it 
must prove of use in cases of atonic dyspepsia, and as a 
mild purgative, from the sulphate and chloride of mag- 
nesia which it contains ; both used internally and as a 
bath such a spa should prove of efficacy in gouty rheu- 
matism and muscular neuralgias. A spring which can 
yield an unlimited supply within a few yards of the beach 
of one of the most salubrious of English sea-coast resorts, 
in a neighborhood with a singularly dry climate and a soil 
that quickly absorbs moisture, free from moist exhala- 
tions, and that by its situation is protected from the se- 
verity of the east winds, is well worth developing. The 
drinking-water of Felixstow is singularly pure, being 
drawn from an artesian well which is sunk in the chalk. 
Accommodation.-There are plenty of good apart- 
ments, charmingly situated villas, and an excellent hotel, 
which is beautifully situated and within a few hundred 
yards of the spa. There are many pleasant drives in the 
vicinity (Jones). There is a " Spa House," resembling 
somewhat a German Kursaal. There is also a large 
" Convalescent Home." Edmund C. Wendt. 
FEVER. Recent investigations have somewhat modi- 
fied our views of fever, particularly as regards its dan- 
gers. They have taught us, among other things, not to 
base the prognosis of a disease upon the height of the 
fever that is present, to the neglect or exclusion of other 
symptoms. The term fever is here limited in its signifi- 
cation to elevation of temperature, although it is still 
frequently employed to designate a group of symptoms 
of which elevated temperature is one of the most promi- 
nent and one of the most important. 
Elevation of temperature and increased heat-produc- 
tion are not synonymous terms, neither is the one a 
measure of the other. The temperature curve, as de- 
scribed by the record of thermometric readings, serves 
but to denote the balance between opposing tendencies, of 
which heat-production and heat-dissipation are the most 
important, but possibly not the only factors. Macalister 
has aptly said, " The constancy of the temperature of the 
body in health, under widely varying internal and exter- 
nal conditions, is a fact so familiar that we have ceased to 
wonder at it; yet it rests upon a perpetual balance of op- 
posing tendencies which is as mysterious and as beautiful 
as anything in our frames." And the same may be said 
of the temperature in fever, except that the conditions are 
abnormal. No one, perhaps, has given us a more lucid 
explanation of the nature of fever than the author re- 
ferred to in his Gulstonian Lectures of 1887, which have 
done much to mould the thought of succeeding years. 
Macalister 1 considers the fever mechanism under three 
heads, namely, first, a thermogenic, or heat-producing 
mechanism ; second, a thermolytic, or heat-dissipating 
mechanism ; and third, a thermotaxic mechanism, whose 
office is to exert a controlling or equalizing influence 
upon the mechanisms for the production and dissipation 
of heat. Our definite knowledge of these three mechan- 
isms is by no means equal, but like that of most physio- 
logical phenomena, grows less as we ascend farther from 
the lower animal kingdom. Our knowledge therefore of 
thermolysis is comparatively full, for this mechanism is 
found even in the cold-blooded animals. We know less 
of thermogenesis, and have only recently learned any- 
thing of its connection with the nervous system ; while 
w'e have little more than inferential knowledge of ther- 
motaxis, which is believed to reach full development 
only in the mature human being. 
Thermolysis.-Thermolysis, or the mechanism of 
heat-dissipation, is too well understood to justify extend- 
306 REFERENCE HANDBOOK OF THE .MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Fei Bovis, 
Fever. 
ed description in this place. It acts.chiefly through the 
blood-vessels and sweat-glands of the skin. It is under 
the supervision of the vaso-motor centres of the medulla 
and spinal cord. These centres are perhaps of two 
kinds, vaso-constrictor and vaso-dilator in character. A 
certain part of heat-dissipation, amounting, perhaps, to 
twenty per cent, of the total heat-loss, is accomplished 
through the respiratory organs, and these are also under 
the control of a centre in the medulla oblongata, with, it 
is believed, a motor and inhibitory action. It has fur- 
ther been determined that these centres governing ther- 
molysis are susceptible to elevation of temperature in 
such a manner that the result is an increase of the dis- 
charge of heat from the body. This mechanism is be- 
lieved to be a common property of the animal kingdom, 
being found well developed in the cold-blooded animals 
as well as in the warm. 
Thermogenesis.-The muscles are the seat of heat- 
production, the " thermogenic tissue par excellence." 
They produce four-fifths of the body-heat in health, and 
perhaps a larger ratio of it in pyrexia. The remaining 
fraction is supplied by the secreting glands and the ali- 
mentary canal during digestion. As secretion and diges- 
tion are at a low ebb during fever, this fraction becomes 
less, and the muscles remain almost the sole producers 
of heat. 
Modern investigations have but confirmed the old 
doctrine that the formation of heat is materially in- 
creased in fever, that the process of heat-formation in 
the muscles is chemical in nature, and for the most 
part a process of oxidation (combustion). Oxygen is ab- 
sorbed and carbonic acid is discharged. The absorption of 
oxygen and the discharge of carbonic acid do not always, 
however, bear a constant relation to each other. A 
measure of the one cannot be used for the estimation of 
the other in a given case. The more recent investiga- 
tions of Finkler and others have yielded results differing 
but little from those obtained in 1877 by Colasanti. 
The latter observer found the average increase in the 
amount of oxygen absorbed in fever to be 18 per cent., 
and the increase in the excretion of carbonic acid 24 per 
cent. Finkler found, under circumstances fairly similar 
to those of Colasanti, that the increase of oxygen absorp- 
tion was 13.8 per cent., and of carbonic acid discharge 
15.3 per cent. He found, further, that the increased ab- 
sorption of oxygen kept pace with the stage of the fever ; 
that it increased as the fever rose, remained stationary 
in the fastigium, and declined with defervescence. The 
highest percentage he found was 36.6 per cent, of oxygen 
increase, and 37.6 of carbonic acid lost. It is admitted 
by all investigators, however, that we have no means of 
determining with absolute precision the amount of oxy- 
gen which is absorbed in fever. This fact is largely 
accounted for by the uncertainty which must exist as to 
the respiratory quotient, or the ratio of oxygen that is 
used in the production of carbonic acid in respiration. 
It is probable, too, that, just as in health, a certain part 
of the oxygen that is absorbed in fever is used in the 
production of other combinations than carbonic acid, 
particularly in the production of water. But the respira- 
tory quotient is admitted to be lower in fever than in 
health, since in fever only fats and proteids are oxidized. 
Colasanti2 and Lilienfeld,3 while admitting this fact, as- 
sert that the respiratory quotient in fever does not mate- 
rially differ from that of the same animal in health, un- 
der the conditions of nutrition which are present in 
fever. Finkler4 thinks the reduction of the respiratory 
quotient more rapid than occurs in hunger, owing to the 
greater rapidity of oxidation that takes place. All agree, 
however, that the oxidation-products in fever are the 
same as those of health, and that additional products, if 
formed, are produced in very small amounts. Accord- 
ing to Regnault and Reiset,5 a fourth to a third of the 
absorbed oxygen, in hunger, is available for combination 
with hydrogen to form water. If. as is claimed by Cola- 
santi and Lilienfeld, the same ratio exists in fever, heat- 
production ought to be proportionate to the amount of 
oxygen absorbed. But if, as Regnard6 asserts, the res- 
piratory quotient is always very markedly reduced in 
fever, and a larger amount of oxygen is available than 
in health for the oxidation of hydrogen, the increment 
of heat-production should be still greater ; for a greater 
amount of heat is produced by the same amount of oxy- 
gen, when employed for the oxidation of hydrogen, than 
when it combines with carbon. And another source of 
variation lies in the fact that the same quantities of hy- 
drogen and carbon, in their oxidation, yield varying 
amounts of heat, according to the chemical compounds 
in which they are contained, and we cannot say positively 
that the compounds oxidized are the same in fever as in 
health under like conditions of nutrition (Welch).1 
Ord 8 has given us yet another, and a very ingenious, 
hypothesis in reference to a source of at least a part of 
the fever-heat. He suggests that chemical processes 
occur in the body by winch, in health, heat-energy is 
stored up or rendered latent, as in the up-building of tis- 
sues. Since, therefore, tissue-formation is in abeyance 
during pyrexia, he argues that the heat of the body may 
be increased not only by processes of disintegration, but 
as well by the persistence, in the form of heat, of energy 
which, under normal conditions, would have taken an- 
other form. But, as Welch remarks, the amount of en- 
ergy appropriated in the form of heat by these construc- 
tive processes bears only a very small ratio to the total 
heat-energy set free by heat-producing processes, so that 
their cessation would not bring a very large increment to 
the heat of the body. Welch,9 while he does not attach 
much importance to figures purporting to express the 
actual heat-production in fever, believes that we are jus- 
tified in drawing one conclusion from the results of di- 
rect and indirect calorimetric observations: " This is, 
that while an individual in fever produces more heat 
than he would in health under similar conditions as to 
food and muscular movements, he does not produce nec- 
essarily in fever more heat than lie would in health on 
a full diet. And it is certain that he usually produces 
far less heat in fever than he often does under circum- 
stances which normally increase heat-production, such 
as a cool environment and muscular exercise. . . 
That in health vastly increased heat-production may 
occur with comparatively little change of temperature, is, 
of course, due to the fact that the dissipation of heat is 
proportionately increased. It is self-evident, and, so far 
as I know, has never been disputed, that in fever the 
equilibrium is so disturbed that heat-loss does not corre- 
spond to heat-production, as it should in health." 
Many very interesting experiments have been made 
with a view to determine the relation, if any, which ex- 
ists between heat-production and work-production in the 
muscles. It has been found that a muscle stimulated to 
action by an electric current produces both motion and 
heat, but that under long-continued stimulation the 
muscle becomes fatigued as a heat-producer much sooner 
than as a work-producer. The heat-producing function 
may even be abolished through fatigue without total or 
even very marked loss of the power of work-production. 
Cold is also capable of depressing or abolishing thermo- 
genesis without notably affecting the motor function. 
The two functions are further distinct as to time, for 
while muscle-action causes heat-production, it is not nec- 
essary to it. A muscle which is at rest, so far as motion 
is concerned, continues to be a heat-producer so long as 
its nutrition and innervation remain intact. In other 
words, heat-production is constant, work-production in- 
termittent. There cannot, therefore, be any constant 
relation between muscle-force and heat-production. Drs. 
Mead Smith, Macalister, and Lukjanow10 conclude, from 
their experiments in Ludwig's laboratory, that the two 
processes are independent of each other in nearly all 
features, and in all such external relations as fatigue, 
exhaustion from inanition, rest, and temperature. 
Macalister, basing his conclusions on his own experi- 
ments and those to which reference has just been made, 
says : " The conclusions I have adduced, and especially 
those relating to the power of recovery in a fatigued 
muscle, under the influence respectively of rest and of 
the blood-supply, point to the conclusion that the two 
metabolisms are in some way different; in other words, 
307 Fever. 
Fever. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
that the ' contractile stuff ' in the muscle is not the same 
as the ' thermogenic stuff.' Both of them are stored up 
in the muscle ; so far as function is concerned they are 
the muscle. The store of each can be exhausted by re- 
peated stimulation, but in some cases the thermogenic 
store sooner than the other. Both can be upbuilt again 
by the circulating blood, but in some cases the contractile 
store sooner than the thermogenic. Both the metabo- 
lisms are affected by cold, but the thermogenic much 
more intensely than the contractile. We know little of 
the chemical changes involved in either form of metabo- 
lism. Oxygen is taken up in each and carbonic acid is 
discharged, but the processes passed through between 
these terminal stages are much more complex than mere 
oxidations. The evidence rather goes to show that it is 
the living substance, as a whole, contractile stuff and 
thermogenic stuff, which is continually being decom- 
posed and as continually recomposed by the blood." 
The independent character of these two functions of 
the muscles has suggested the probability of an indepen- 
dent nervous control over each function, but no separate 
nerve-supply for the government of them has yet been 
discovered. It is believed by some investigators that 
thermogenesis is under a motor and inhibitory nervous 
mechanism similar to that which governs the thermolytic 
and so many other mechanisms with which we are fami- 
liar ; but nothing is known of the path by which these 
motor and inhibitory impulses reach the muscles, unless 
they are conveyed by the same nerve-trunks which carry 
the impulses for the control of the work-producing func- 
tion. Probably they are in some manner transmitted by 
the motor fibres, or if a special nerve-channel exists, it 
may probably be so associated with the former as to be 
undistinguishable from it. Mead Smith attempted to 
demonstrate the existence of separate fibres for thermic 
and motor impulses by means of the injection of curare, 
but without success. Mosso,11 however, found that by 
the administration of moderate doses of this drug the 
motor nerve-endings may be completely paralyzed with- 
out obliterating the sensibility of the thermic nerves ; he. 
also found that the injection of strychnia into animals 
thus moderately curarized produced elevation of tem- 
perature, but no excitation of the motor function of the 
muscles. The centre which controls thermogenesis has 
been located by nearly all investigators in the corpus 
striatum. The. evidences which have led to this con- 
clusion have been both clinical and experimental, the 
former class beginning with Sir Benjamin Brodie's case 
of fracture of the cervical vertebrae and spinal-cord in- 
jury ; the latter class with Bernard's experimental sections 
of the sympathetic in the necks of animals with resultant 
rise of temperature. Subsequent experimenters, among 
whom none have been more painstaking and conscien- 
tious than H. C. Wood, of our own country, have arrived 
at fairly uniform results, although differing widely as to 
details. Following up the experiments of Tscheschichin, 
this investigator found, by calorimetric experimentation, 
that an actual increase of heat-production occurs after 
section of the nerve-matter at the junction of the pons 
and medulla. From this he concludes that there are 
situated above this point thermo-inhibitory centres. More 
definite conclusions have been arrived at in regard to the 
location of these centres by Ott, Aronsohn and Sachs, 
Baginsky, and others. Ott12 concluded that there are 
four heat-centres in the cerebrum, one in the vicinity of 
the corpus striatum, one in the caudate nucleus, a third 
in the anterior inner end of the optic thalamus, and the 
fourth near the median line between the optic thalamus 
and corpus striatum. Injury of the centre in the optic 
thalamus caused the most pronounced rise of temperature. 
Aronsohn and Sachs13 found that puncture of the an- 
terior part of the caudate nucleus, near its median con- 
vexity, causes rapid rise of temperature, amounting to 
three or more degrees, and continuing for two or three 
days, and that electrical stimulation of the same region 
causes a similar rise of temperature. This was accom- 
panied by increased absorption of oxygen and el innnation 
of carbonic acid and nitrogen. They, therefore, con- 
clude that there is here located a thermo-excitory centre. 
(SUPPLEMENT 
As further evidence of the existence in the corpus striatum 
of a nervous mechanism intimately connected with the 
production of heat, White14 cites the fact that this body 
is larger in warm-blooded animals than in cold, and 
largest in those which are subject to the highest rise of 
normal temperature, especially birds. 
Thermotaxis.-The thermotaxic mechanism to which 
reference has been made has for its office to maintain a 
balance between thermogenesis and thermolysis, probably 
by causing modifications in the action of one or other of 
these mechanisms, or both. It is supposed to reside in 
the nervous system, but its precise location is not known. 
Ott locates it in the cortex in the vicinity of the fissure 
of Rolando, with some fibres at the base of the brain in 
some way connected with it; but Corin and Van Benedin 15 
deny that any cortical centres are in any way connected 
with the heat-mechanism, since they were able to remove 
the hemispheres in pigeons without causing any change 
of temperature. Probably absent altogether from cold- 
blooded animals, the thermotaxic mechanism is much 
better developed in man than in the lower warm-blooded 
animals, a fact supported by the much greater stability 
in man of normal temperature. That it is but poorly 
developed in infants is indicated by the ease with which 
trifling causes produce marked disturbances of tempera- 
ture, depressions on exposure to cold, and elevations on 
the occurrence of slight functional disturbances, as of the 
digestive organs. White believes that the human embryo 
is, until quite the late months of intra-uterine life, a cold- 
blooded animal, depending for its warmth upon that of 
surrounding media. Welch16 believes that fever-pro- 
ducing agents must act directly or indirectly upon the 
mechanism which regulates the harmonious relation of 
heat-loss to heat-production. Macalistcr does not limit 
the production of fever to the disturbance of thermotaxis, 
but believes that there are three degrees of disturbance 
ordinarily produced. "Fever necessarily implies (1) a 
disorder of the thermotaxic mechanism ; (2) an excessive 
production of heat, associated with excessive chemical 
changes in the tissues, the excessive production being 
more or less than that of a normal patient in full diet 
(perhaps oftener less than more), but more than that of a 
normal patient on fever diet; (3) that the body tempera- 
ture depending upon the balance between production 
and discharge, fluctuates as the one or the other is in the 
ascendant, and is not, per se, a true measure of either, or of 
the consumption of tissue that may be going on. When 
thermotaxis alone is disturbed, the result is a peculiar 
rising and falling of the temperature, depending upon 
variations of production and loss, without the normal 
controlling influence of the affected centre. This has 
been termed thermal ataxia. The next degree of dis- 
turbance is that which is probably present in ordinary 
fever, namely, a disturbance of thermotaxis and thermo- 
genesis, resulting in a loss of the controlling influence 
and an increase of heat-production. With this is asso- 
ciated, as a rule, a stimulation of thermolysis, an in- 
creased dissipation of heat. When, however, we have, in 
addition to the disturbance of thermotaxis and thermo- 
genesis, a diminution of the dissipation of heat, the result 
is hyperpyrexia. The reduction of heat-dissipation thus 
produced is supposed to be in great measure a result of 
the action of high temperature, and to denote an exhaus- 
tion of the nervous mechanism controlling thermolysis ; 
it is in part also, no doubt, a result of the action of the 
toxic matter which is the cause of the increased tempera- 
ture." Fever, in other words, according to Macalistcr, is 
a process of dissolution from above downward, affecting 
first the centres most recently evolved and therefore most 
liable to disturbance, and last, those which are most 
stable (White). In recovery, too, this author maintains, 
with apparent correctness, that control is regained from 
below upward. First the thermolytic mechanism is in- 
cited to action, which is frequently indicated by the oc- 
currence of more or less profuse sweating. As thermo- 
genesis becomes more and more inhibited the temperature 
rises less and less high on succeeding days ; but uhtil 
thermotaxis becomes fully established the rhythm of 
thermogenesis and thermolysis is easily disturbed by such 
308 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Fever. 
Fever. 
trifling causes as errors in diet, fatigue, etc., the con- 
dition of the convalescent in this regard resembling some- 
what that of the infant. 
Wood 11 maintains that the cerebral centre is inhibitory 
in character, its disturbance permitting rather than pro- 
ducing increased thermogenesis. Heat-dissipation he 
places under control of the vaso-motor centres. In a 
contribution to the American Association of Physicians 
he thus recently summarized his theory of pyrexia : 
First. " Fever is a disturbance of calorification in 
which, through the nervous system, heat-dissipation and 
heat-production are both affected. If there be a fever 
which is produced by the direct action of a poison, inde- 
pendent of the nervous system, we have at present no 
proof of its existence. 
Second. "Heat-production is regulated by a nervous 
apparatus of which the knowledge is still imperfect. 
There is certainly an inhibitory centre which depresses 
or controls the production of heat. It probably does this 
by acting on the trophic cells of the gray matter of the 
spinal cord. It is possible also that there is a centre 
which, when excited, increases tissue-change, but its ex- 
istence has not yet been proved. 
Third. " Heat-dissipation is regulated through the vaso- 
motor system, so that vaso-motor paralysis is followed 
by an enormous loss of animal heat, and, under favor- 
able conditions, by death from cold." 17 
Hanfield Jones 18 adopts a yet simpler view in the sup- 
position that elevation of temperature is a paralytic phe- 
nomenon due, as is also the increased heart action and 
rapid respiration, to a toxic depression of nerve-centres 
similar in character to the depressant action more easily 
recognized in the clouding of the intellect and impair- 
ment of muscular mobility. 
Immediately after the lectures of Macalister, Macla- 
gan 19 published a series of articles on pyrexia and hy- 
perpyrexia. He considers these not as different degrees 
of the same condition, but as essentially different in their 
causation. He states two theories of fever', first the com- 
bustion theory, according to which there is abnormal 
activity of the heat-producing process ; a second, the 
neurotic theory, according to which the elevation of tem- 
perature is due to the impairment of the inhibitory 
force which keeps heat-production within normal bounds. 
He does not regard the two theories as antagonistic, but 
believes that each has its sphere of applicability. The 
combustion theory applies to all such specific fevers as 
malaria, rheumatism, and pneumonia-to all, in short, in 
which the poisons may be supposed to be micro-organ- 
isms, whose morbific action depends upon their organic 
development. He thinks it probable also that the fever 
of all inflammations is thus produced, not that all are 
necessarily due to foreign organisms, but because exces- 
sive activity of the minute cellular elements of the tis- 
sues may have the same effect on their metabolism as the 
propagation in them of foreign organisms. The neurotic 
theory explains probably all cases of hyperpyrexia result- 
ing from non-inflammatory lesions in the nerve-centres, 
and probably most forms of so-called ephemeral fever. 
Austin Flint20 believes that the cause of fever is two- 
fold, the more important factor being an exaggeration of 
the chemical changes taking place within the organism 
which generates the animal heat within normal limits, the 
other factor being a disturbance of the process of equali- 
zation of temperature, which acts mainly through the 
skin. He believes that the original cause of most, if not 
of all, the essential fevers is a micro-organism, different 
in character in different forms of fever. The author does 
not, however, in this connection enter into a discussion 
of the theory of nervous supervision over the heat-mech- 
anism. 
Causes of Fever.-The study of the etiology of 
fever has confined itself for the most part to the investi- 
gation of the action of ferments and putrid matters when 
introduced into the circulation, and to the effects pro- 
duced by the entrance into the organism, experimentally 
or otherwise, of the micro-organisms of disease and their 
products. Fever sometimes undoubtedly occurs, how- 
ever, which is due to the direct impression on the nerve 
(SUPPLEMENT.) 
centres of influences arising in the body, even in the ner- 
vous system itself, quite independently of the action of 
chemical products of any kind. 
The chemical agents which produce fever are of two 
kinds, namely (a) those which are a result of metabo- 
lisms going on in the organism independently of micro- 
organisms, and (b) those which result from the action 
of micro-organisms. The former bear close resem- 
blance, if not relationship, to the physiological ferments, 
or are identical with them. Instances of their action are 
believed to be seen in the so-called aseptic fever fol- 
lowing the receipt of severe injuries and the fracture of 
large bones, which are removed from infection or are 
cared for in the most rigidly antiseptic manner. Some 
of these agents are supposed to exist in small amount 
in the healthy organism, others to result from the de- 
composition of extravasated blood or other tissue. The 
fever of anaemia is also supposed to be, in some instances 
at least, a result of this kind of intoxication. 
The second class of fever-producing agents, resulting 
from the action of micro-organisms, are of two kinds, 
agreeing with the pathogenic or non-pathogenic nature 
of the organisms of which they are the products. The 
term non-pathogenic is here used in its usual significa- 
tion, designating micro-organisms which are not capable 
of propagation within the human body, although in 
some instances capable of producing disease when in- 
troduced into it. Large numbers of these organisms, 
for the most part saprophytes, reside at times in the 
body. They exist in great numbers and in great variety 
in the alimentary canal, into which they gain entrance 
with the food. The products of their metabolism alone 
gain access to the circulation, and the fever thus pro- 
duced, as also its degree and the character of the accom- 
panying symptoms, depend in part upon the amount and 
the character of the substance absorbed and the character 
of the organisms producing them, and in part upon the 
nature of the soil on which the organisms have grown, 
the character of the environments, etc. Examples of the 
pyrexia thus induced are abundantly seen in the fever 
caused by digestive disorders, particularly in children ; in 
the fever which results from the absorption of toxic mat- 
ters deposited by micro-organisms, upon the surfaces of 
the mucous membranes of the fauces and tonsil, includ- 
ing perhaps some cases of diphtheria ; in the elevation 
of temperature which follows wound-infection ; and in 
many of the cases of poisoning which follow the eating 
of such unsound food as decayed meat or fish. 
Most, if not all, the acute infectious diseases are now 
attributed to the presence and growth within the body of 
micro-organisms, the so-called pathogenic bacteria. Fever 
in these diseases is believed to be due to the chemical 
products of these organisms, and therefore we attribute 
the symptom to the organism which produces the poison. 
Although the organisms exist and grow within the 
blood-vessels, spleen, lymph nodes, and other glandular 
organs, few symptoms ever, and fever probably never, 
result from the direct action of the bacteria. Their 
chemical products, carried by the circulating blood, act 
directly upon the centres governing the heat-mechanism 
in the manner that has already been described. 
Comparatively little is known concerning pyrexia re- 
sulting from the disturbance of the thermotaxic mech- 
anism by any other than chemical irritants. Instances 
of it are, however, supposed to be presented in the ele- 
vations of temperature occurring in hysteria, in pro- 
nounced nervous excitement, particularly of children, 
and in convalescence. The elevation of temperature 
which sometimes occurs in convulsions may be regarded 
as of this character only when the convulsive phenomena 
are due entirely to nervous excitation in the absence of 
any toxic influence. 
Effects of Fever.-The list of disastrous results 
which can be attributed to fever has been greatly 
shortened during the last few years. Formerly nearly 
all functional disturbances and all tissue-changes which 
occurred during the existence of a pyrexia were attrib- 
uted to the elevation of temperature, and so great was 
the fear of fever that its reduction became almost the 
309 Fever. 
Field Surgeons. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
sole object of treatment. A reversion from these views 
has occurred, however, which is so complete that we no 
longer look upon an occasional rise of temperature to 
104° or 105° F. with much alarm, and there are those 
who maintain, with probable correctness, that elevation 
of temperature is one of nature's methods of combat- 
ing disease-a vis medicatrix natures. 
To determine the effects of high temperature many 
clinical observations and many experiments have been 
made by a large number of investigators. Probably the 
method which has yielded the most satisfactory results 
has been that of observing the effect of external high 
temperature on man and animals. By this means we have 
produced not only the desired elevation of internal tem- 
perature, but also the elimination of the influence of 
toxic elements which must always be taken into con- 
sideration when observations are made at the bedside. 
As a result of the observations referred to, all experi- 
menters agree that a mammalian animal, artificially 
heated, dies when its temperature reaches 44° or 45° C. 
(111.2° or 113° F.). The death is preceded by convul- 
sions, is quickly followed by rigor mortis, and is attrib- 
uted to heart paralysis. Most of the animals experi- 
mented upon show signs of illness at a temperature sev- 
eral degrees below the lethal point, and it was inferred by 
most observers that toxic changes were produced by the 
increased temperature. But Naunyn reasonably attrib- 
utes the cause of death, in many of the reported experi- 
ments, to the fact that the animals experimented upon 
were confinedin small, ill-ventilated compartments, suffi- 
cient alone to cause their illness. By correcting these 
errors he succeeded in keeping a rabbit alive for thirteen 
days at an average temperature of 41.5° C. (106.7° F.). 
Welch,21 by following Naunyn'ssuggestion, succeeded in 
keeping two black rabbits alive three weeks with an 
average temperature of 41.8° C. (107.3° F.) and 41.4° C. 
(106.6° F.), respectively. His observations are probably 
the most accurate that have yet been made. Although 
the animals lay most of the time stretched out, they took 
their food greedily and manifested no symptoms of ill- 
ness. It was found essential to the success of the ex- 
periments, however, that the temperature be gradually 
raised. It was found that no factor is more important in 
determining the effects of external heat than the animal's 
power of temperature regulation. Failure of this power 
(paralysis of the thermotaxic mechanism) is followed by 
a sudden rise of internal temperature (hyperpyrexia) 
which may quickly attain a point incompatible with life. 
This point varies with different animals, and with the 
same animal at different times. The condition of the 
blood was found to affect the animal's resistance to a 
marked degree, a state of anaemia greatly reducing its 
power of resistance. The experiments of Maurel22 are 
also of interest as indicative of the cause of death in high 
elevation of temperature. He found that a temperature 
of 44° to 45° C. (111.3° to 113° F.) destroys the vitality 
of the leucocytes within a few minutes, a temperature of 
43° to 44° C. (109.4° to 111.3° F.) within an hour, and 
from 42° to 43° C. (107.6° to 109.4° F.) within three hours. 
But if the temperature be reduced, the leucocytes regain 
their vitality. 
Welch concludes, from his own observations and those 
of Naunyn, that a considerable part of the current argu- 
ments based upon experiments concerning the injurious 
effects of high temperature, must be revised. " Because 
an animal may be killed by raising its temperature to 
111° F. (43.9° C.), or 113° F. (45° C.), it does not follow 
that an increase of temperature up to within 4° or 5° F. 
of this fatal point involves danger to life, or even any 
serious disturbance of the functions of the body. 
Although experiments in hot-air chambers show that in 
man brusque elevations of the temperature by only a few 
degrees give rise to serious symptoms, Krishaber23 
found that by habituation his temperature could be 
raised to 106.5* F. (41.4° C.), or 107.2° F. (41.8° C.) with- 
out much discomfort." From a clinical stand-point, 
therefore, much depends upon the gradual accession of 
the fever and the intervals of depression between the 
maximal points of elevation. 
One of the earliest and most striking symptoms of 
fever is an increased rapidity of respiration, a symptom 
which has been generally attributed to the direct action 
of the high temperature upon the respiratory centres. 
Sihler24 has, however, shown that another factor, and 
probably a more important one in experimental pyrexia, 
at least, enters into its production, namely, the stimula- 
tion of the skin. Although it is probable that the stimu- 
lation of the skin by heated blood may in a measure in- 
fluence the rapidity of respiration in man, it undoubtedly 
does so to a much less degree than in the animal ; and 
the truth still remains that increased respiration is due 
chiefly to the direct action of the warm blood upon the 
respiratory centres. 
The heart is stimulated to increased action in pyrexia 
by the direct impression of the heated blood. Martin 25 
has demonstrated that the heart beats quicker when sup- 
plied with warm blood than when supplied with cold 
blood, and that its rate of action depends much more 
upon the temperature of the blood in the coronary arte- 
ries than on that in the right auricle or ventricle. 
Although this fact has been demonstrated, we are not 
justified in supposing that the elevation of temperature 
is in a given case the only element in the production of 
the accelerated heart's action, for this may result in a 
great measure also from the action of the chemical irri- 
tants which are more or less directly the cause of the 
pyrexia. 
Changes in the arterial tension and blood-pressure in 
fever have been attributed to the action of increased 
heat, but they are probably due, as Welch has shown, 
much less to increased temperature than to other causes, 
especially to the infectious agents which have induced 
the elevation of temperature. 
Fatty degeneration of the heart, liver, kidneys, and 
other organs, and of some of the voluntary muscles, 
has been more or less generally observed as a conse- 
quence of continued high temperature ; but there is not 
a unanimity of opinion as to how far these changes may 
be attributed to the elevation of temperature, and in how 
far they are the result of other causes. Heat is at least 
not the only element capable of producing the degenera- 
tion in these cases. 
Many other phenomena, more or less generally at- 
tributed to the influence of high temperature, might be 
mentioned did space permit and their importance jus- 
tify. In many instances, however, the conclusions that 
would have to be drawn are more or less speculative in 
character. Among the phenomena referred to may be 
mentioned the almost universal wasting of tissues in 
fever, the reduction of digestive power, the constipation, 
the increased absorption of oxygen and increased dis- 
charge of carbonic acid to which reference has been 
made, the clouding of the intellect, the prostration, the 
coma-vigil, disturbances of tendon reflexes, muscular 
weakness and twitchings, and other manifestations of 
nervous disturbance. There can, however, be no doubt 
that in most of these instances the phenomena are at- 
tributable as much to the action of poisons circulating in 
the body as to the elevation of temperature. Flint26 
believes that while the special morbific cause of the dis- 
ease in these cases is the cause of the delirium, etc., it is 
rational to suppose that it acts as a secondary cause of 
these phenomena, by virtue of changes induced directly 
by the prolonged elevation of body temperature. This 
statement is supported by the fact that the abstraction of 
heat, by means of cooling applications to the exterior of 
the body, is sufficient to arrest these nervous phenomena. 
The leading premise from which certain writers have 
drawn their argument of the beneficial action of fever is 
the fact that the vitality of micro-organisms is destroyed 
by heat. Few of them can withstand a temperature of 
40° C. (104° F.) except for a short time, the activity of 
their growth diminishing as the temperature approaches 
this limit. From this fact it is concluded that a moder- 
ate amount of fever is sanatory in its effects on the infec- 
tious diseases. 
Treatment of Fever.-Fever being no longer re- 
garded as of necessity an element of great danger, the 
310 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Fever. 
Field Surgeons. 
object of treatment is rather to exert a judicious control 
over it than to entirely overcome it. A reaction has set 
in against the too free administration of antipyretics, 
owing in great measure to the disappointment which has 
followed their universal adoption by the profession. 
Liebermeister21 has given us a judicious summary of 
the treatment of fever. He says that in many cases of 
febrile disease the height of the temperature constitutes 
a danger ; that in these cases the therapeutic problem is 
to reduce the temperature. The basis of antipyretic 
treatment is the direct withdrawal of heat by means of 
cooling baths ; yet in many cases the administration of 
antipyretic medicaments is at the same time necessary. 
Flint's classification of the methods of treating fever is 
as follows :26 
1. Reduction of the general temperature by the external 
application of cold. 
2. Reduction of the temperature by the internal ad- 
ministration of antipyretics. 
3. Promotion of general nutrition by alimentation. 
4. Measures to supply to the system matters that can 
be consumed in the excessive production of heat, thereby 
retarding the destruction of tissues. 
Directions for the reduction of temperature by means 
of the application of cold to the exterior of the body may 
be found in the Reference Handbook of the Med- 
ical Sciences, Vol. III., p. 69. 
Treatment by the internal administration of antipyret- 
ics has not proved so successful as was anticipated a few 
years ago, upon the introduction of the synthetically 
prepared agents of the coal-tar series. Although these 
remedies as a class have the power to promptly and com- 
pletely overcome fever, it has been found that they other- 
wise exert no beneficial action on the course or duration 
of the disease. In some instances, too. peculiar to the 
case no less than to the antipyretic agent employed, their 
administration has been followed by phenomena of ex- 
ceedingly unpleasant or even alarming character. 
No definite statements can be made as to the manner in 
which antipyretics reduce the temperature. Many ex- 
periments have been made for the solution of this prob- 
lem, but the results have not been altogether satisfactory. 
Lauder Brunton is doubtless correct in classifying all 
antipyretics under the two heads of those which lessen 
the production of heat and those which increase the dis- 
sipation of heat. It is maintained by some writers, how- 
ever, that these agents act largely by stimulating the 
thermotaxic mechanism. 
Acetanilide, antipyrine, and phenacetine fairly repre- 
sent the synthetically prepared antipyretics, and are 
probably more frequently prescribed than any other at 
the present time. Acetanilide is not only frequently 
administered alone, but is the active ingredient in nearly 
all so-called antipyretic compounds which have been in- 
troduced by manufacturing pharmacists of this country. 
Antipyrine, once the most popular of its class, has suf- 
fered much on account of unfavorable reports of its 
action. Gastric irritation, occasionally persistent vomit- 
ing and diarrhoea, a depressant action on the heart, 
syncope, are among the evil results attributed to it ; but 
they are doubtless in great measure the result of its im- 
proper administration, particularly the giving of unnec- 
essarily large doses. Phenacetine by many is esteemed 
as the safest of the antipyretics, and few instances of ill 
effects have been recorded. 
For a thorough consideration of the subject of antipy- 
retics, the reader is referred to works on materia medica, 
and to the articles in the present volume which treat of 
the individual drugs belonging to this class. 
James M. French. 
9 Welch : loc. cit., p. 370. 
10 Du Bois Reymond's Archiv. 1886. 
11 Mosso : Virchow's Archiv, Bd. 106. 
12 Ott : Journal of Nervous and Mental Diseases, vol. ii.. 1884; Medi- 
cal News, vol. xlvii., 1885; Therapeutic Gazette, September, 1885. 
13 Aronsohn and Sachs : Pfliiger's Archiv. Bd. 37. 
14 White : American Journal of the Medical Sciences. 1890, vol. c. 
15 Corin and van Benedin : Archives de Biologie, 1887. 
18 Welch : loc. cit. (see 7, supra). 
17 Wood : Transactions of American Association of Physicians, Medi- 
cal News, 1887, vol. 1. 
18 Hanfield Jones : Practioner, 1887. 
19 Maclagan; Lancet (London), 1887, vol. ii. 
20 Flint : Address on Fever, General Session Internat. Med. Congr., 
1887, Medical News, vol. Ii. 
21 Welch : loc cit. 
22 Maurel: La Semaine medicale, September 27, 1891. 
23 Krishaber : Gazette med. de Paris, 1887, (Cited by Welch, loc. cit.) 
24 Sihler : Journal of Physiology, vol. ii. 
25 Martin: Philosophical Transactions of Royal Society, pt. 2, 1883. 
28 Flint : Medical News, 1887, vol. ii. 
27 Liebermeister : Deutsche Medizinische Wochenscrift, January 5 
1887. 
FIELD SURGEONS AND MEDICAL DEPART- 
MENTS, UNITED STATES ARMY. Since the publi- 
cation of the Reference Handbook, in 1886, the 
United States has participated in no great wars. Its ex- 
perience, however, in Indian hostilities has been con- 
stant, and certain knowledge regarding the duties and 
responsibilities of the Field Surgeon of the Army has 
thereby been increased and perfected. 
With a medical staff into which are constantly re- 
ceived young men representing the highest education 
and culture, whose predecessors, now older, have pos- 
sessed the same qualities, and in addition now possess 
the enthusiasm springing from success, and the knowl- 
edge born of experience, it is manifest that progress was 
to have been expected. 
Accordingly I shall attempt to indicate such differences 
as have arisen in the past six years in the administration 
of the Medical Department in the United States Army, 
especially as to those duties and conditions treated of in 
the article on the duties of Field Surgeons which was 
published in Vol. III. of the Reference Handbook. 
Organization of the Medical Department of 
the Army.-For the single Assistant Surgeon-General, 
the Chief Medical Purveyor, and four Sur- 
geons, with the rank of colonel, existing in 
1886, have been substituted by law, six As- 
sistant Surgeon-Generals, with the rank of colonel. 
Instead of the eight Surgeons and two Assistant Med- 
ical Purveyors, with the rank of lieutenant-colonel, 
have been substituted ten Deputy Surgeon- 
Generals,with the rank of lieutenant-colonel. 
In consequence, a Medical Purveying Depart- 
ment, separate and distinct, has been abolished. 
The motives influencing Congress to legislate for the 
above changes were principally two. The first was to 
assimilate the titles borne by the higher officers of the 
Medical Department to the titles borne by the higher 
officers of some of the other staff corps of the army. 
Thus in the Quartermaster and Pay Departments the 
colonels were styled, respectively, Assistant Quarter- 
master-General and Assistant Paymaster-General, and 
the lieutenant-colonels were Deputies. But, besides 
this, it had become manifest that the best work in pur- 
veying could be accomplished by allowing the Surgeon- 
General to select for purveying duties, from time to time, 
such men as had shown aptitude and taste for this spe- 
cial and peculiar business. 
The men hitherto who, in natural sequence under the 
law, had become medical purveyors, were not necessarily 
those the best fitted for or the most desirous of discharg- 
ing the duties of a purveyor, nor had they always been 
able or willing to give the bonds required of medical 
purveyors by law. 
It had therefore been found necessary, for the reasons 
above stated and other reasons, to obtain the interference 
of the President of the United States, by whom alone 
medical purveyors could be assigned under the law to 
other duties than purveying. To obtain such interfer- 
ence when suddenly required was not always easy or 
convenient, and the Surgeon-General therefore found it 
Rank o f 
medical offi- 
cers. 
Purveying 
Department 
abolished. 
1 Macalister : Gulstonian Lectures on The Nature of Fever, 1887 ; 
also Lancet (London). 1887, vol. ii. 
2 Colasanti : Pfiiiger's Archiv, Bd. 14. 
3 Lilienfeld : Pfiiiger's Archiv. Bd. 32. 
4 Finkler : Pfiiiger's Archiv, Bd. 29. 
1 5 Regnault and Reiset: cited by Welch (see infra). 
8 Regnard : Recherches exp. sur les Variations pathologiques des 
Combustions respiratoires (Welch). 
7 Welch : Cartwright Lectures. 1888, Medical News, vol. lii. 
8 Ord : British Medical Journal, 1885, vol. ii. 
311 Field Surgeons. 
Field Surgeons. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
necessary to recommend legislation on the subject. In 
future the most suitable medical officer will be selected 
and detailed as medical purveyor. 
The number of surgeons, with the rank of major, 50, 
remains unaltered ; also the number of assistant sur- 
geons, viz., 125 ; of whom those under five 
years in service have the rank of first lieu- 
tenant, and those of more than five years' ser- 
vice the rank of captain. 
The full number allowed are not, however, actually in 
the service ; that is, the casualties have been more 
numerous than the successful candidates who have 
passed the examination before the Medical Board, so that 
at the present writing there are thirteen vacancies among 
the assistant-surgeons. A less number, however, are 
on leave of absence than when the Reference Hand- 
book, Vol. III., was published. 
The strength of the army is unchanged, the last Army 
Register showing an aggregate strength of 28,526, so that 
the proportion of medical officers to the whole army is 
unchanged in the last six years. Certain changes in the 
army, however, have rendered, medical administration 
somewhat easier. 
The number of military posts has been sensibly dimin- 
ished by the concentration of troops. Consequently it 
has been found possible, with the same number of med- 
ical officers in the army, to supply a greater number of 
military posts with more than one medical officer, and in 
consequence the additional medical officer has been 
found available to accompany detachments or larger 
commands for field service, when formerly the com- 
mands would have been obliged to proceed without a 
medical officer, and to have sent their sick and wounded 
to the nearest military post for treatment. Manifestly 
this course was only possible when, in consequence of 
operating in its own country, as the United States army 
has done, the moving troops were sufficiently near to 
military posts to send there the sick and wounded with- 
out too much inconvenience and suffering. 
During the past eight years the National Guard of the 
different States have assembled at different and suitable 
places as camps for purposes of discipline and 
inspection. The surgeons and assistant sur- 
geons have accompanied the various military 
organizations to these camps, but not always 
in the full numbers authorized by law. The 
most of these camps have been inspected by duly author- 
ized inspectors ; and without attempting to give the re- 
ports of all these inspectors (the great majority of which 
I have not seen) as to the medical organization and its 
fitness to bear the strain of a campaign, I may say that 
while none has been perfect, none has been found abso- 
lutely unfit for its work, and most have merited praise, 
while the medical officers have been of more than ordi- 
nary intelligence. 
The allowance of medical officers to each regiment 
has been one surgeon and two assistant surgeons with 
the same rank as in the regular army. 
The experience of the past six years does not change 
our conclusion that the size of the medical corps of the 
United States army is not too large or too 
small in proportion to the size of the army; 
and that the most proper number of medical 
officers to a regiment of the strength now au- 
thorized by law, where the medical officers 
also are regimental, is one surgeon and two assistant 
surgeons. 
A new law passed by the last Congress requires that 
assistant surgeons shall pass an examination before pro- 
motion to the grade of captain ; this in addition to the 
examination required by former laws. 
Recruits.-Inasmuch as the necessity for soldiers is 
greater in time of war than in time of peace, 
the physical examination of recruits becomes 
more lax in the former period, and so it hap- 
pens that in the army of the United States 
physical examinations have been more strict 
for soldiers, cadets, and officers in recent 
years. In regard to the examinations, the directions 
(SUPPLEMENT.) 
which appeared at the bottom of column first, page 106, 
Vol. III., of the Reference Handbook, are no longer 
issued, and the rules and entire system of examination 
have been arranged for the better. 
So late as at the beginning of 1892, the adjutant-gen- 
eral of the army issued a memorandum of instructions 
practically forbidding the enlistment, save as musicians, 
of any persons under twenty-one years of age. 
These instructions are in entire harmony with the 
views expressed, concerning the minimum age of enlist- 
ment, on page 106, Vol. III., of the Handbook. 
In the effort to raise the standard of examination, the 
present system gives much attention also to 
the intellectual and moral. On these subjects 
the Epitome (which is the standard of instruc- 
tions for the army) uses the following lan- 
guage : " Intellectually, although no educational standard 
officially is established, a soldier should be able to read 
and write, and should also be quick and clear in his un- 
derstanding. The advance in the science and art of war 
and the improvement in modern fire-arms call for a 
higher degree of intelligence than was required of the sol- 
dier in the past. This is recognized by the Government 
by establishment of schools and libraries, by providing 
reading-rooms that are liberally supplied with periodicals 
and newspapers, and by opening the way for promotion 
to all who avail themselves of these opportunities for 
advancement. The care and attention that the soldier 
is required to give to his weapon and ammunition, 
the drill which its use entails, and the skill which may 
be attained by the practice of rifle-firing develop individ- 
uality, excite interest and ambition, and tend to make 
the profession attractive. It is therefore desirable that 
men should be selected who can appreciate this life and 
who have the mental capacity to profit by it. The moral 
character should be scrutinized with care in order that 
enlistments from the vagrant and criminal classes may 
be avoided. The recruiting rendezvous is a favorite 
haunt for these men, and a study of their personal char- 
acteristics will well repay the recruiting officer for his 
labor. The vagrant seeks admission to the army, usually 
at the beginning of winter, for shelter, food, and cloth- 
ing, without any intention of completing his enlistment 
or of performing any more service than he is compelled 
to perform. The criminal seeks to bury his unsavory his- 
tory under an assumed name, and, by service in distant sta- 
tions, to escape the observation of those who know him. 
The evil influence in a company of even one of this class 
cannot be over-estimated, and no degree of physical per- 
fection or soldierly bearing should induce a recruiting 
officer to accept his service. Happily, as a rule, the evi- 
dence of a life of debauchery is so plainly marked in the 
features and in the person that an ordinary observer is 
able to estimate the true character of such an applicant 
without difficulty." 
This is almost an ideal picture, and it is to be desired 
that the candidates for enlistment may all be scholars and 
Christian gentlemen. But it has been found in the past 
that the degree of education and virtue is not always to 
be discovered and measured by the appearance of the 
subject, and both uneducated criminals and vagrants are 
often able to elude the examination of surgeon and re- 
cruiting officer combined. 
Further remarks concerning the physical examination 
of recruits will be here omitted, as it is understood that 
the subject will be fully treated elsewhere in this vol- 
ume. 
Standard Supply Table of the Medical Depart- 
ment, United States Army.-In the course of the past 
six years, from time to time as occasion demanded, vari- 
ous articles have been added to the army list of medical 
supplies and various articles dropped therefrom. 
Various officers contributed their views on what was 
needed and not needed, for the medical supplies of the 
army in field and garrison, and finally a Board was or- 
dered to convene in New York City for the purpose 
(among others) of revising the Standard Supply Table of 
the Army Medical Department. 
The result of all the consideration of the subject has 
Number 
of medical 
officers. 
Intellectual 
and moral 
examination. 
R e gimen- 
tal medical 
officers i n 
the National 
Guard. 
Proper pro- 
portion of 
medical offi- 
cers to army. 
Qualifica- 
tions and 
disqualifica - 
tions for be- 
coming sol- 
diers. 
312 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT. 
Field Surgeons, 
Field Surgeons. 
been that the following articles have been dropped from 
the Supply Table, page 108, Vol. HI., Reference 
Handbook. 
Articles. 
Allowance for posts 
having official popula- 
tion of: 
100 
200 400 
>00 
SOO 
1,000 
Medicines, Expendable.-(Continued.) 
Cannabis indica, tincture, tablets, 1 m. (100 in 
bottle), bottles 
1 
1 
1 
1 
2 
2 
Cardamom, compound tincture, in 1-lb. bottles, 
ounces 
10 
10 
10 
32 
32 
32 
Cerium oxalate, in 1-oz. bottles, ounces 
Cocaine hydrochlorate, in drachm vials, ounces 
1 
1 
1 
2 
•) 
2 
X 
X; 
3/ 
1 
IX 
2 
Cocaine hydrochlorate, hypodermic tablets, '/« 
gr., tubes ... 
2 
4 
0 
8 
10 
12 
Coniine, hydrobromate, hypodermic tablets, >/80 
gr.. tubes '. 
2 
2 
3 
3 
4 
4 
Conium, tincture, tablets, 2 m. (100 in bottle), 
bottles 
1 
1 
2 
2 
3 
3 
Cubebs, oleoresin, in 2-oz. bottles, ounces 
2 
2 
4 
4 
6 
8 
Digitaline, hypodermic tablets, '/joo gr-, tubes . 
Elaterine, tablets, '/so Sr- (50 in bottle), bottles. 
1 
1 
2 
2 
3 
3 
1 
1 
1 
1 
1 
1 
Ergotine, tablets, 2 gr. (100 in bottle), bottles.. 
2 
3 
3 
4 
4 
5 
Eserine sulphate, hypodermic tablets, '/eo gr., 
tubes ... 
1 
1 
2 
2 
8 
3 
Eserine sulphate, ophthalmic disks, Vaooo gr- 
(50 in box), boxes 
1 
1 
1 
1 
2 
2 
Eucalyptol, in 2-oz. bottles, ounces ... 
4 
6 
8 
10 
12 
14 
Gentian extract, in 4-oz. jars, ounces 
4 
4 
8 
8 
8 
16 
Glycyrrhiza, fluid extract, in 1-lb. bottles, 
ounces 
10 
32 
48 
64 
96 
128 
Glycyrrhiza, powdered extract, in 1-lb. bottles, 
ounces 
32 
32 
04 
96 
96 
128 
Grindelia robusta, fluid extract, in 8-oz. bottles, 
ounces 
8 
8 
8 
16 
16 
16 
Guarana, fluid extract, in 8-oz. bottles, ounces. 
32 
32 
04 
64 
96 
96 
Hydrastis, fluid extract, in 8-oz. bottles, ounces 
8 
8 
8 
16 
16 
16 
Hydrogen, peroxide solution.* pints 
6 
0 
0 
12 
12 
12 
Hyoscine sulphate, hypodermic tablets, Vioogro 
tubes 
1 
1 
1 
1 
1 
1 
Ichthyol, in 1-oz. bottles, ounces 
1 
o 
3 
4 
4 
5 
Jalap, powdered, in 2-oz. bottles, ounces 
2 
2 
2 
4 
4 
6 
Lavender, compound tincture, in 1-lb. bottles, 
ounces 
10 
32 
48 
64 
SO 
96 
Menthol, in 2-oz. bottles, ounces 
2 
2 
4 
4 
6 
6 
Mercury protoiodide, tablets. ]/6 gr. (200 in bot- 
tle), bottles 
2 
2 
2 
3 
8 
3 
Morphine sulph., hypodermic tablets, 78 gr., 
tubes 
10 
15 
20 
30 
40 
50 
Morphine sulph., tablets, '/g gr. (100 in bottle), 
bottles 
2 
4 
0 
8 
10 
12 
Morphine sulph., */8 Kr> (hypodermic tablets, 
Atropine sulph., '/ioo gr. f tubes 
2 
4 
8 
12 
16 
20 
Nitro-glycerine, hypodermic tablets, )/100 gr., 
tubes 
1 
2 
2 
3 
3 
4 
Nitro-glycerine, tablets, ]/ioo Kr-> (100 in bottle), 
bottles 
1 
1 
1 
1 
2 
2 
Nux vomica, tincture, in 8-oz. bottles, ounces.. 
8 
8 
10 
24 
24 
32 
Oil, cotton-seed, in 1-quart bottles, bottles 
24 
32 
48 
64 
80 
96 
Oil, sassafras, in 4-oz. bottles, ounces 
4 
8 
« 
16 
16 
20 
Pancreatine, in 1-ounce bottles, ounces 
1 
1 
2 
3 
3 
Pepsine. pure, in 2-oz. bottles, ounces 
-1 
4 
8 
12 
16 
20 
Phenacetine. 5-gr. tablets (200 in bottle), bottles. 
1 
1 
2 
2 
3 
4 
Pilocarpine hydrochlorate, hypodermic tablets, 
7e gr., tubes 
2 
4 
0 
8 
10 
12 
Potassium carbonate, in 8-oz. bottles, ounces... 
8 
8 
10 
16 
32 
32 
Quinine bimuriate, hypodermic tablets, J/2 gr., 
tubes 
2 
2 
3 
3 
4 
4 
Quinine bisulphate, in 1-oz. bottles, ounces .... 
1 
1 
1 
2 
2 
2 
Salol, in 5-gr. tablets (125 in bottle), bottles.... 
2 
3 
4 
6 
8 
10 
Senega, fluid extract, in 8-oz. bottles, ounces ... 
8 
8 
8 
16 
16 
16 
Senna, fluid extract, in 8-oz. bottles, ounces.... 
8 
8 
10 
16 
24 
24 
Sodium hypophosphite, in 8-oz. bottles, ounces 
10 
10 
21 
24 
32 
40 
Sodium phosphate, in 8-oz. bottles, ounces. ... 
10 
10 
24 
24 
32 
40 
Strophanthus, tincture, in 4-oz. bottles, ounces 
Strychnine sulph., hypodermic tablets, '/so gL> 
tubes 
4 
4 
4 
8 
8 
8 
4 
0 
10 
15 
20 
25 
Sulfonal, 5-gr. tablets (200 in bottle), bottles... 
1 
2 
4 
4 
6 
8 
Terebene, in 8-oz. bottles, ounces 
10 
32 
32 
48 
48 
Tragacanth, gum, in flakes, in 8-oz. bottles, 
ounces 
8 
8 
10 
32 
32 
Zinc phosphide, in 1-oz. g. s. bottles, ounces.... 
1 
1 
1 
1 
1 
1 
Disinfectants, Expendable. 
Lime, chloride, in 25-lb. jars, pounds 
12 
24 
48 
72 
84 
96 
Mercury, corrosive chloride, in 1-lb. bottles, 
bottles 
1 
1 
2 
3 
4 
Hospital Stores, Expendable. 
Beef peptonoids or meal, pounds 
4 
6 
8 
10 
12 
15 
Gin, in 24 or 32-oz. bottles, bottles 
2 
2 
4 
6 
8 
10 
Surgical Instruments and Appliances, not 
Expendable.^ 
Apparatus, compressed air, number 
" restraint, number 
1 
1 
1 
1 
1 
1 
1 
1 
1 
1 
1 
1 
" steam sterilizing, number 
1 
1 
1 
1 
1 
1 
Bags, rubber, hot water, number 
1 
1 
1 
2 
2 
2 
Articles Dropped from Old Supply Table. 
Medicines. 
Instruments, Expendable. 
Acacia (Gum Arabic). 
Iron, solution of tersulphate. 
Morphine, acetate of. 
Oil, olive. 
Pepsin, lactated. 
Pills, mercury, green iodide of. 
Potassium bichromate. 
Acid hydrobromic. 
Arsenic and mercury, solution of 
iodide of. 
Brayera. 
Bromine. 
Cinchona, pulv. 
Codeine. 
Extract castanea, fluid. 
Extract eucalyptus, fluid. 
Extract glycyrrhiza, fluid. 
Extract Indian cannabis. 
Extract pilocarpus (jaborandi). 
Extract physostigma (calabar bean). 
Extract taraxacum, fluid. 
Mercury, metallic. 
Oil of lemon. 
Oil of rosemary. 
Pills, arsenic. 
Pills, arsenic, iodide of. 
Potassium, cyanide of. 
Potassium, nitrate. 
Strychnine, sulphate 
Tar (wood). 
Tincture cimicifuga. 
Tincture sanguinaria. 
Tincture serpentaria. 
Wax, white. 
Zinc, solution of chloride of. 
Zinc, oleate. 
Hospital Stores. 
Arrow-root. 
Chocolate. 
Cinnamon. 
Corn starch. 
Farina. 
Gelatine. 
Ginger. 
Meat juice, Valentine's. 
Nutmeg. 
Pepper, black. 
Pepper, cayenne. 
Tapioca. 
Tea. 
Wine. 
Nipple-shields. 
Dressings. 
Antiseptic dressings for use with 
spray apparatus. 
Cotton wadding. 
Splints in sets. 
Stenta book. 
Stationery. 
Blocks, memorandum. 
Sealing-wax. 
Miscellaneous, Expendable. 
Mugs, delft. 
Spoons, medicine, delft. 
Instruments, Non-expendable. 
Atomizer, steam. 
Meteorological instruments. 
Ophthalmoscope. 
Speculum for ear. 
Cloithng and Bedding. 
Bedsacks. 
Blankets, gray. 
Blanket cases. 
Counterpanes, striped. 
Mattresses, felt. 
Pillow-cases, linen. 
Pillow-ticks. 
Sheets, linen. 
Drawers. 
Gowns, dressing. 
Socks, woollen. 
Miscellaneous, Non-expendable. 
Bed-pans, metal. 
Bed-ticket, frames. 
Clothes-pins. 
Clothes-wringers. 
Hatchets. 
Medical saddle-bags. 
Medicine-cases. 
Medicine-panniers. 
Medicine-wagons. 
Pails, chamber. 
Pitcher, britannia. 
Sad-irons. 
Saw, wood. 
Washboards. 
This list of articles dropped is not as extensive as the 
list of articles which have been added to the old Supply 
Table and which follows. 
In a certain number of cases a certain preparation of 
medicine is dropped from the old table, and a different 
preparation of the same medicine appears in the list of 
articles added, so that it is merely a case of a substitution. 
Articles Added to Supply Table. 
Articles. 
Allowance for posts 
having official popula- 
tion of : 
600 800 
1,000 
100 200 
400 
Medicines, Expendable. 
Acetanilide, 3-gr. tablets (500 in bottle), bottles. 
1 
6 
8 
10 
12 
14 
Acid, boracic, powdered, in 1-lb. bottles, ounces 
16 
16 
16 
32 
32 
32 
Acid, lactic, concentrated, in 2-oz. g. s. bottles, 
ounces 
2 
2 
4 
6 
8 
8 
Antipyrine, 5-gr. tablets (200 in bottle), bottles . 
1 
2 
3 
4 
5 
6 
Asafnetida, in 8-oz. tins, ounces 
8 
» 
8 
8 
8 
8 
Atropine sulphate, hypodermic tablets, '/joo gr., 
tubes 
5 
5 
10 
15 
20 
Atropine sulphate, ophthalmic disks, '/son 8r- 
(50 in box), boxes 
1 
1 
1 
2 
2 
2 
Benzoin, compound tincture, in 1-lb. bottles, 
ounces 
16 
16 
32 
32 
48 
48 
Caffeine, hypodermic tablets, 1 gr., tubes 
1 
1 
2 
3 
4 
5 
Calabar bean, tincture, tablets, 1 m. (100 in 
bottle), bottles 
1 
1 
1 
2 
2 
3 
* To be made as needed at post from special outfit furnished. 
+ See contents of cases of instruments, farther on. 
313 Field Surgeons. 
Field Surgeons. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Articles. 
Allowance for posts 
having official popula- 
tion of: 
100 
200 
400 
600 
800 
1,000 
Surgical Instruments and Appliances-(Cent.) 
Bags, rubber, ice spinal, number 
1 
1 
1 
2 
2 
2 
Bougies, flexible, number 
as 
req 
uir 
ed. 
Box, fracture, folding, number 
1 
1 
1 
2 
2 
2 
Brush-holder for larynx, number 
1 
1 
1 
2 
2 
2 
Case, aspirating.* number 
1 
1 
1 
1 
1 
1 
" dental,t number 
1 
1 
1 
1 
1 
1 
" emergency, number 
as 
n e 
e d 
ed. 
" field, number 
ne 
e d 
ed. 
" field, operating, when specially approved, 
number 
1 
1 
1 
1 
1 
1 
" forceps, haemostatic, 12-inch set, number. 
1 
1 
1 
1 
1 
1 
" genito-urinarv, number 
1 
1 
1 
1 
1 
1 
" pocket, aseptic. + number 
1 
1 
2 
2 
2 
3 
" trial lenses, number 
1 
1 
1 
1 
1 
1 
Catheter box, number 
1 
1 
1 
1 
1 
'' flexible, number 
Curettes, number 
as 
ne 
e d 
ed. 
as 
n e 
ed 
ed. 
Forceps, needle (Tiemann's), number 
1 
1 
1 
1 
1 
1 
Inhaler and vaporizer, number... 
1 
1 
1 
2 
2 
2 
" ether, number 
1 
1 
1 
1 
1 
1 
Lavage-tube, number 
1 
1 
1 
1 
2 
2 
Microscope, number 
1 
1 
1 
1 
1 
1 
Pouch, hospital corps, number 
" orderly, number 
as 
n e 
e d 
ed. 
as 
n e 
e d 
ed. 
Sprinkler, iodoform, h. r., number 
1 
1 
1 
2 
2 
2 
Stethoscope, double, number 
1 
1 
1 
1 
1 
1 
Surgical pump, number 
Table, chair, or sofa, operating, as approved, 
1 
1 
1 
1 
1 
1 
number 
0 
0 
0 
0 
1 
1 
Thermo-cautery (Paquelin's), benzine, s. g. not 
over 0.724, as needed, number 
1 
1 
1 
1 
1 
1 
Surgical Dressings, etc., Expendable. 
Bandages, rubber (Martin's), 4 yds. X 2)^ in., 
number 
1 
1 
1 
2 
2 
2 
First-aid packets, number 
12 
18 
24 
32 
56 
70 
Gauze, absorbent, plain, yards 
5 
10 
15 
20 
25 
30 
" iodoform, 5 percent., in 5-yd. tins, 
yards.. 
5 
5 
5 
10 
10 
15 
Needles, surgical (Hagedorn's), assorted, set.... 
1 
1 
1 
1 
1 
. 1 
Paper, dressing, oiled, in 25-yard rolls, rolls.... 
1 
1 
2 
3 
4 
5 
Sponges, chloroform, number 
1 
1 
1 
2 
2 
2 
Tents, laminaria or tupelo, number 
6 
6 
12 
12 
18 
18 
Wire, suture, silver, in loops, loops 
2 
2 
3 
4 
5 
6 
Stationery, Expendable. 
Blotters, hand, number 
.) 
2 
2 
2 
2 
2 
Letter-press, brushes, number 
1 
1 
1 
1 
1 
1 
" cups, number 
1 
1 
1 
1 
1 
1 
Pads, prescription, number 
18 
24 
36 
36 
48 
48 
" letter, number 
6 
10 
10 
18 
18 
18 
Paper-fasteners, box 
1 
1 
1 
1 
1 
1 
Paper, writing, typewriter, quires 
18 
20 
24 
24 
Ribbons, copying, for typewriter, number 
as 
req 
uir 
ed. 
" record, for typewriter, number 
as 
req 
uir 
ed. 
Bedding, Clothing, etc., not Expendable. 
Mattress covers, number 
10 
15 
20 
25 
30 
40 
Quilts, colored, number 
20 
20 
30 
40 
60 
Furniture, etc., not Expendable. 
Baskets, letter, number 
2 
2 
2 
2 
2 
2 
" waste-paper, number 
2 
2 
2 
2 
2 
Bed-cradle, number 
1 
1 
2 
3 
3 
Bed, invalid, number 
1 
1 
1 
1 
2 
2 
Bedsteads, with woven wire mattresses, number 
as 
req 
uir 
ed. 
Bedstead casters, rubber, number 
as 
req 
uir 
ed. 
Bell, hand, number 
1 
1 
1 
1 
1 
1 
Book-case, number 
1 
1 
1 
1 
1 
1 
Cabinet for blanks, number 
1 
1 
1 
1 
1 
1 
Chairs, arm. number 
12 
15 
20 
30 
40 
50 
" invalid, rolling, number 
1 
1 
1 
2 
2 
2 
" office, revolving, number 
1 
1 
1 
2 
2 
2 
Cups, sponge, number 
Desks, office, cloth top for, number 
2 
2 
2 
2 
2 
2 
as 
req 
uir 
ed. 
Dish, soap, with' cover, for office, number 
1 
1 
1 
1 
1 
1 
Inkstands, number 
3 
3 
3 
4 
4 
4 
Letter-press, number .... 
1 
1 
1 
1 
1 
1 
" " copying-board for, number 
1 
1 
1 
1 
1 
1 
Matting, cocoa, yards 
" " zinc ends for, number 
as 
req 
uir 
ed. 
, as 
req 
uir 
ed. 
" rubber, yards 
req 
Oil-cloth, for table, yards 
Paper-cutters, number 
" weights, number 
2 
2 
o 
2 
2 
2 
o 
2 
2 
Pen-racks, number 
? 
J 
f 
Pitcher, ice, silver-plated, number 
1 
1 
i 
1 
1 
1 
Safe, iron, number 
1 
1 
1 
1 
1 
1 
Articles. 
Allowance for posts 
having official popula- 
tion of; 
100 
200 
400 
600 
800 
1,000 
Furniture, etc.-(Continued.) 
Screen, bed, folding, number 
Screens, door, wire, number 
*• window, wire, number 
" wire netting for, yards 
as 
req 
uir 
ed. 
Stamp, rubber, penalty, number 
1 
1 
1 
1 
1 
1 
Tables, dining, extension, number. 
1 
1 
1 
1 
2 
2 
" plain, number 
as 
Typewriter, number 
1 
1 
1 
1 
Dispensary Accessories, not Expendable. 
Apparatus, distilling, 1-gal., if required, num- 
ber 
1 
1 
1 
1 
1 
1 
Bandage roller, number 
1 
1 
1 
1 
1 
1 
Brushes, flesh, rubber, number 
1 
1 
2 
2 
2 
2 
" nail, number 
1 
1 
1 
1 
2 
2 
" " holder for, number 
1 
1 
1 
1 
1 
1 
Dispensing set, labels for, set 
1 
1 
1 
] 
1 
1 
Drawer-pulls, with labels, number 
uir 
Mortar and pestle, glass, 4-inch, number 
1 
1 
1 
1 
1 
1 
Prescription file, number 
1 
1 
1 
1 
1 
1 
Pus-basin, number 
1 
1 
1 
2 
2 
2 
Stove, coal-oil, if required, number 
1 
] 
1 
1 
1 
1 
Tape-measures, 100 feet, number 
1 
1 
1 
1 
1 
1 
Tray, antiseptic, number 
1 
1 
1 
1 
2 
2 
Twine-boxes, number 
2 
2 
2 
2 
2 
2 
Dispensary Accessories, Expendable. 
Atomizers, hand, number 
2 
2 
3 
3 
4 
4 
Boxes, ointment, impervious, dozen . 
12 
15 
20 
25 
30 
35 
Corks, large (No. 10), dozen.. 
2 
2 
3 
3 
4 
4 
Envelopes for tablets, 2 X 2% inches, dozen ... 
20 
25 
30 
35 
40 
50 
Eye-shades, number 
1 
2 
3 
3 
4 
4 
Glue, liquid, in ^-pint cans, cans 
1 
1 
1 
2 
2 
2 
Measures, glass, graduated, 16-oz., number ... 
2 
2 
2 
2 
2 
3 
Needles, sailmaker's, number 
1 
1 
1 
1 
1 
1 
Paper, urinary test, assorted, packages 
1 
1 
1 
1 
2 
2 
" wrapping, brown, quires 
1 
2 
3 
4 
5 
6 
Percolator, glass, number 
1 
1 
1 
1 
9 
2 
Test-tubes, stand for, number 
1 
1 
1 
1 
1 
1 
Vials, 1-drachm, dozen 
2 
3 
4 
5 
6 
7 
Kitchen and Mess Utensils, not Expendable. 
Eggbeater, number 
1 
1 
1 
1 
1 
1 
Forks, table, silver-plated, number 
M 
•36 
48 
56 
72 
72 
Knives, table, silver-plated, number 
24 
48 
56 
72 
72 
Meat-covers, wire netting, assorted, number ... 
6 
6 
9 
9 
12 
15 
" cutters, number 
1 
1 
1 
1 
1 
1 
Pails, milk, with strainer, number 
1 
1 
1 
9 
9 
2 
Pans, muffin, number 
1 
2 
3 
3 
4 
4 
Potato-masher, number 
1 
1 
1 
1 
1 
1 
Rolling-pin. number 
1 
1 
1 
1 
1 
1 
Saw, butcher's, number 
1 
1 
1 
1 
1 
1 
Sieves, flour, number 
1 
1 
1 
2 
2 
2 
Skimmers, number 
1 
1 
1 
9 
9 
2 
Spoons, basting, agate ware, numtier 
2 
2 
2 
2 
3 
3 
" table, silver-plated, number 
18 
24 
3li 
48 
56 
72 
" tea, silver-plated, number 
18 
24 
36 
48 
56 
72 
Trays, bed, with legs, number 
2 
2 
4 
6 
8 
8 
Bowls, sugar, with lid. number 
2 
2 
4 
4 
6 
G 
Dishes, vegetable, with covers, number 
4 
4 
6 
8 
10 
12 
Gravy-boats, number 
2 
2 
4 
4 
5 
6 
Pickle-dishes, number 
2 
2 
4 
4 
5 
G 
Pitcher, sirup, glass, number 
2 
2 
3 
3 
4 
4 
Plates, invalid, number 
2 
2 
4 
4 
6 
G 
Miscellaneous, not Expendable. 
Blowers for insect-powder, number 
1 
1 
1 
1 
2 
2 
Chart, anatomical, in case, set 
1 
1 
1 
1 
J 
1 
Clothes-baskets, number 
2 
2 
2 
3 
4 
4 
Crutches, pairs 
4 
G 
11 
10 
12 
Cups, spit, number 
4 
6 
8 
10 
12 
15 
Grindstone, complete, number 
1 
1 
1 
1 
Hose, canvas, feet 
ed. 
• 
'' couplings, number „■ 
as 
req 
uir 
ed. 
" nozzles, plain and spray, of each number 
1 
1 
1 
1 
1 
1 
" reel-cart for, number 
1 
1 
1 
1 
Ladder, step, number 
•1 
"1 
1 
1 
1 
1 
Lawn-mower, number 
1 
1 
1 
1 
1 
1 
Litters, canvas for, pieces 
" straps for, number 
Litter-slings, pairs 
Manikin, physiological, or its equivalent, num- 
ber 
1 
1 
1 
1 
1 
1 
Oil-can. with pump, 5-gal., number 
1 
1 
1 
1 
1 
1 
Pots, watering, number 
1 
1 
1 
1 
1 
1 
Scissors, lamp, number 
1 
1 
1 
1 
1 
1 
Settees for porch or hall, number 
Sickle, number 
1 
1 
1 
1 
1 
1 
Skeleton, in cabinet, number 
1 
1 
1 
1 
1 
1 
Stencil, with outfit, for marking hospital cloth- 
ing. set 
1 
1 
1 
1 
1 
1 
Trowel, garden, number 
1 
1 
1 
1 
1 
1 
* Will not be issued where surgical pump is supplied. 
+ Will not be issued where the services of a dentist can be obtained. 
i This pattern of pocket-case will not be issued for post use until the 
supply of personal and post cases is exhausted. 
314 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Field Surgeons, 
Field Surgeons. 
Articles. 
Allowance for posts 
having official popula- 
tion of: 
100 
200 
400 600 
800 
1,000 
Miscellaneous, Expendable. 
Bath brick, number 
2 
2 
4 
4 
6 
6 
Brooms, whisk, number 
2 
2 
2 
2 
2 
2 
Crutches, rubber tips for, number 
as 
req 
1 
ed. 
Dusters, feather, long-handled, number 
1 
1 
2 
2 
2 
" " short-handled, number 
2 
2 
3 
3 
4 
4 
Hand-grenades, number 
12 
18 
24 
36 
48 
48 
Lamp chimneys, number 
as 
req 
uir 
ed. 
" shades, number 
as 
uir 
•d. 
" wicks, number 
as 
req 
req 
2 
uir 
ed. 
Lantern wicks, number 
as 
uir 
ed. 
Mousetraps, number 
2 
2 
2 
2 
2 
Naphthalin, in 10-lb. boxes, pounds 
as 
uir 
ed. 
Paper, tarred, in 100-ft. rolls, rolls 
as 
req 
uir 
ed. 
" toilet, packages 
10 
15 
20 
30 
40 
50 
Sapolio, pounds 
6 
8 
10 
15 
20 
25 
Talcum (French chalk), 1-lb. packages, ounces. 
as 
req 
uir 
ed. 
erences." In the second place, it was officially announced 
that " requisitions for articles not on the Supply Table, 
and which have been approved of as of value in the 
treatment and care of the sick, will be favorably con- 
sidered by the Surgeon-General when the amount of ap- 
propriation for medical and hospital supplies will war- 
rant. " 
The gratification of individual preferences has not 
been so fully provided for in the new Supply Table ; but 
in view of the progressive and far-seeing policy which 
has characterized the official doings and utterances of 
the medical bureau for the past thirty years, it can 
hardly be believed that a liberal spirit will not guide it 
in its action in the future, regarding the issue of articles 
not in the Supply Table. Certainly all tools are not 
equally fit for the same purpose, and equally truly dif- 
ferent men use with differing skill the same tool and 
different tools. 
Property Accountability.-Medical officers receiving 
and receipting for medical and hospital property are held 
strictly accountable therefor, and should fully acquaint 
themselves with the regulations on the subject. In con- 
sequence of their failure to obtain this knowledge, or 
their neglect, for any reason, to comply with those regu- 
lations, it has happened very frequently that young or 
inexperienced medical officers of the regular army, the 
volunteer forces, or the militia have found (and hereafter 
are in grave danger of finding) themselves confronted 
with considerable pecuniary losses, to meet which their 
pay is stopped. Medical property is not difficult to ac- 
count for if properly cared for. It is divided into ex- 
pendable and non-expendable, and in reference to the 
latter the greatest losses to the medical officer occur, but 
are unnecessary. 
Property non-expendable must be either accounted 
for by the receipt of some one else, or, if worn out, 
broken, or destroyed, evidence of such fact must be pre- 
sented to the propel' person, sometimes called an in- 
spector, sometimes a board of survey, sometimes the 
accounting officer, who receives the returns of property, 
which have elsewhere been named as required of officers 
accountable for property. 
Remembering these simple facts, medical officers will 
see the necessity of familiarizing themselves with the 
regulations on the subject, which can easily be complied 
with, and thus will save themselves the annoyance of 
pecuniary loss. 
In one special case the military surgeon may destroy 
property in his discretion, for the regulations of the 
Supply Table provide that tents, clothing, hospital furni- 
ture, and other articles used in the treatment of con- 
tagious diseases, will be disinfected or burned under the 
supervision of a medical officer; and the articles de- 
stroyed to prevent contagion must be accounted for by 
a certificate of the officer responsible, setting forth fully 
the circumstances necessitating such destruction. 
" The medical officer has discretionary powers, which 
are based on his knowledge of specific contagions and 
methods of disinfection. The efficiency of many of 
these methods is now so well established that they su- 
persede the necessity for burning." 
Since the publication of the Supply Table in Vol. III., 
the medical department has assumed the charge of sup- 
plying disinfectants for general post sanitation, and di- 
rects post surgeons as follows : 
" (a) Chloride of lime should be used only as a disin- 
fectant, properly so called, the cheaper sulphate of iron 
being used as an antiseptic and deodorant in privies, 
slop-barrels, etc. When a jar of chloride of lime has 
been opened, and a part of the contents removed, it 
should be sealed again with plaster of Paris. Solution 
of chlorinated soda will be issued in small amounts only 
for special personal disinfection. 
" (6) The selection and use of proper disinfectants and 
deodorants will be determined by the senior medical 
officer, who should not issue them unless, in his opinion, 
their use is necessary and proper. He will give explicit 
instructions as to the quantities to be used, strength of 
solutions," etc. 
Some of the articles above mimed were habitually issued prior to this, 
but their issue being authorized since the former Supply Table, or never 
having been formally authorized at all, their names now appear for the 
first time in a Supply Table. 
In looking over the names of the new medicines added 
to the list it will be noticed that a portion are : 
1. New remedies, whose properties have been made 
public since the former Supply Table was published. 
2. A certain portion are alkaloids and concentrated 
principles, a little of which goes a long way. 
3. A very large portion, almost one-half, or twenty- 
seven out of sixty-four, are in the form of tablets or 
disks, convenient like Class 2 for transportation and use 
in the field. And 
4. (It may seem a little strange), but a portion of the 
articles are the same as those which have been dropped 
from a Supply Table anterior to that published in this 
Handbook. 
This latter fact simply shows a change of fashion in 
medication, as well as the difficulty, and even impossi- 
bility, of any one man, or set of men, legislating or mak- 
ing rules that will be satisfactory and convincing to all 
others, or that should not be changed as time progresses. 
No differentiation has yet taken place of a Supply Table 
merely for the field, although, in all probability, ere 
many months one will be made out by competent au- 
Seiection of thority. In the meantime, the surgeon must 
medicines for select from the table for field service such 
field service, articles of medicine as may commend them- 
selves to his taste, his experience, and his judgment. 
For field service the Supply Table is largely redundant, 
and in selecting what he will take into the field-where 
transportation is scarce and hard to obtain-the surgeon 
must discriminate wisely, taking what he will need and 
use the most,-what is most concentrated and easy of 
transportation. 
The same principle must guide him in the selection of 
his instruments and other surgical supplies, and he must 
bear constantly in mind that, after a battle, 
the wounded will ordinarily be cared for 
not by the regimental surgeon, but by other 
surgeons detailed for that purpose; and 
that ordinarily the cases of sickness, serious and of long 
duration, will be treated elsewhere than at the regiment. 
The experience of the medical director will also come 
to the aid of the field surgeon, as by the first-named 
officer requisitions of regimental surgeons will be modi- 
fied before they are sent to the medical supply depot for 
issue; and it is the business of this officer to see that 
surplus supplies are at the depot, to make good unex- 
pected and unusual losses and deficiencies, by capture or 
otherwise. 
By the regulations governing the issue of medical sup- 
plies heretofore, the fact that different medical officers 
might differ in their choice of medicines was more than 
recognized. In the first place, it was officially stated that 
a supplementary list of drugs and medicines had been 
published, to " permit the indulgence of individual pref- 
Selection of 
inst r u m e n t s 
for field ser- 
vice. 
315 Field Surgeons. 
Field Surgeons. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Sterilized dressings, etc., will be supplied in small 
quantities only for post use. Their preparation is so 
simple and so well understood that they should be pre- 
pared as needed. 
Meteorological instruments will not, in future, accord- 
ing to the new Supply Table, be issued by the medical 
department. When required for use at designated 
posts, they will be obtained by application direct to 
the Chief of the Weather Bureau, Department of Agri- 
culture. 
As will appear further on, meteorological reports by 
medical officers are discontinued. It is not clear that 
this new rule is wise, and many medical officers will 
regret that they are deprived of their meteorological in- 
struments. 
In this country the army surgeon has been the pioneer 
in weather observations, which, for many years, have 
been taken by them at every military post and forwarded 
to the War Department when, of other observers, there 
were none on the unsettled frontier. The familiarity 
with hygrometric and temperature conditions thus 
acquired by the military surgeon accustomed him to 
see relations and connections between these conditions 
and certain coincident pathological conditions, and 
often much to the advantage of the patient and the 
community-an advantage not precisely to be defined 
sometimes, and therefore properly to be called immeas- 
urable. 
It is not to be denied that, for the community at large, 
the meteorological observations regularly taken by the 
skilled observers of the Agricultural Bureau will take 
the place of those formerly taken by the military sur- 
geon. Still, it woidd seem that it might be to the ad- 
vantage of all concerned, were medical officers to con- 
tinue to make such observations regularly at their 
hospitals. 
No list of medical books for issue is included in the 
present Supply Table, and the reason given therefor is 
that, owing to the rapid advances in medicine, a large 
part of any fixed literature soon becomes obsolete. To 
a certain extent this is true, but the truth is only on the 
surface. The Table further provides that such new 
books as may be selected by the Surgeon-General will be 
furnished without requisition, and nothing is said con- 
cerning the issue of any other books than those so 
selected. 
This provision seems also unwise. In the first place, 
there are a certain proportion of books on medicine and 
surgery published that are standard, and that every med- 
ical man feels the need of, and this independently of their 
selection by any one man. In the second place, a large 
number of medical men have well-defined and consid- 
ered preferences for certain authors and certain books. 
Of these books none other will take the place, and it 
is hard to see why these preferences should be ignored, 
or how any Surgeon-General or other man could know 
them. 
It is to be hoped that ere long this regulation may be 
changed, and a list of such books be published for issue 
as will meet the general consensus of the military sur- 
geons, for whose study and information the books are 
issued. 
It is important that the military surgeon of the Na- 
tional Guard and Militia, as well as of the Regular 
Army, should know precisely what tools will be pre- 
sented to him to do his Work with, both in field and gar- 
rison. 
The new Supply Table divides the supplies under the 
following headings: 
Some notice is now required of some of those articles 
included in Class 4. 
1. Dispensing set (bottles and 
jars). 
2. Apparatus, spray - producing, 
(for petrolatum). 
3. Case, aspirating. 
4. " capital operating, No. 1. 
5. " capital operating, No. 2. 
6. " eye and ear. 
7. " field operating. 
8. " genito-urethral. 
9. " urethal. 
10. " minor operating. 
11. " obstetrical and gyneco- 
logical. 
12. " pocket personal. 
13. " post-mortem. 
14. " dissecting. 
15. " stomach-pump. 
16. " tooth-extracting. 
17. Inhaler and vaporizer, 
18. Microscope and accessories. 
19. Surgical pump. 
20. Syringe, hypodermic. 
21. Thermo-cautery, Paquelin's. 
22. Type-writer. 
23. Vision-test set. 
24. Amputating case. 
25. Exsecting case. 
26. General operating case. 
27. Trephining case. 
28. Chemical set with measuring 
apparatus, 
29. Tool-chest. 
30. Commode chest (No. 3). 
31. Pack-saddle for medical and 
surgical chests. 
32. Folding field furniture. 
No. 1. The dispensing set consists of a suitable and 
sufficient number of bottles and jars. 
Nos. 4 and 5. The contents of these cases vary but lit- 
tle from each other. 
No. 6 contains all that is needed, save by the ad- 
vanced specialist, for ordinary eye and ear surgery. 
Nos. 8 and 9. The latter does not differ much from the 
genito-urinary case, whose contents are given farther on. 
The large-sized sounds in the genito urinary case make 
it preferable to either 8 or 9 in certain cases where ure- 
thral dilatation is required. 
Nos. 13 and 14. The issue of No. 14 will cease when 
those now on hand are exhausted, as No. 13 can fully 
supply its place. 
No. 18. The Medical Department have issued the 
"Universal" and the " Investigator"-two different pat- 
terns of microscopes-manufactured by the Bausch & 
Lomb Optical Company. Beck's Popular Binocular, 
also, has been issued to a limited number. 
No. 28. This is supplied only in special cases where 
analytic and other chemical work is to be prosecuted. 
No. 29 is a small set of carpenter's tools. 
No. 32 comprises a few articles, such as folding 
chairs and tables, that may be easily packed and carried 
in the field. 
Concerning the other articles in the above list it seems 
unnecessary to say more than that they do not materially 
differ from other similar cases and instruments with 
which every surgeon is familiar. 
In regard to the list of cases, etc., which follows, it 
seems necessary to name the contents, either because they 
differ from the ordinary cases of the same name, or be- 
cause they possess peculiarities due to their preparation 
for use in the military service. 
1. Apparatus, compressed air. 
2. " restraint. 
3. Case, dental. 
4. " emergency. 
5. " field. 
6. " forceps, haemostatic. 
7. " genito-urinary. 
8. " pocket, aseptic. 
9. " " post. 
10. " of trial lenses. 
11. Pouch, hospital corps. 
12. Pouch, orderly. 
13. Bacteriological set. 
14. Medical chest, U. S. Army, 
No. 1. 
15. Surgical chest, U. S. Army, 
No. 2. 
16. Field-desk, No. 4. 
17. Mess-chest. No. 5. 
18. Food-chest, No. 6- 
19. Reserve-chest, No. 7. 
20. Ice machine. 
21. Articles issued by the Quarter- 
master's Department. 
22. Articles issued by the Ord- 
nance Department. 
Contents of foregoing: 
Apparatus, Compressed Air. 
Air-container, with gauge, num- 
ber 1 
Force-pump, number 1 
Tubing, thick rubber, silk cov- 
ered, connecting container 
with cut-off, exp., feet 8 
Tubing, thick rubber, connect- 
ing container with force- 
pump, exp., feet 4 
Davidson's sprays, in set, viz: 
Atomizer-tubes, h. r., number 3 
Bottles with h. r. caps, number 3 
Cut-off, metal, number 1 
Stand for bottles, number.... 1 
Tube connector, h. r., exp., 
number .. 1 
Tube wires for cleaning, exp. 2 
1. Medicines, expendable. 
2. Disinfectants, expendable. 
3. Hospital stores, expendable. 
4. Surgical instruments and ap- 
pliances, not expendable. 
5. Surgical dressings, etc., expend- 
able. 
6. Stationery, expendable. 
7. Bedding, clothing, etc., not ex- 
pendable. 
8. Furniture, not expendable. 
9. Dispensary accessories, not ex- 
pendable. 
10. Kitchen and mess utensils, not 
expendable. 
11. Miscellaneous, not expenda- 
ble. 
12. Miscellaneous, expendable. 
Anklets, pair 1 
Keys to lock buckles, number.. 5 
Muff, leather, number 1 
In wooden box, with handle and 
lock. 
Apparatus, Restraint. 
Strap, bed, as per circular, num- 
ber 1 
Strap, waist, number 1 
Wristlets, pair 1 
316 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Field Surgeons. 
Field Surgeons. 
Case, Dental. 
(SUPPLEMENT.) 
Case. Pocket, Post. 
Burnishers (Nos. 3, 29, 36), num- 
ber 3 
Chisels (Nos. 77, 135), number.. 2 
Explorer (No. 5), number 1 
Excavators (Nos. 10, 14. 16, 21, 
41, 82, 86, 141,143, 145), num- 
ber .... 10 
Files (2 each of Nos. 00, 0, 1) 
number . 6 
Forceps, college, number 1 
In small morocco case. 
Gutta-percha, exp., ounce 1 
Handles for instruments, num- 
ber 6 
Hone, number 1 
Mirror, number 1 
Paper, bibulous, (xp., sheets... 6 
Scaler (No. 3), number 1 
Spatula (No. 1), number 1 
This name will be used when reference is made to the red morocco 
pocket-case with chamois cover issued during the past few years for post 
The list of contents is the same as that of the aseptic pocket-case, but 
the aneurism and exploring needles, knives, and tenaculum are de- 
tachable from the two hard-rubber or ivory handles. Some cases con- 
tain a combined needle and fenestrated artery forceps and a haemostatic 
forceps; others a plain artery and a dressing forceps. 
Case of Trial Lenses. 
Bausch & Lomb. 
Case, Emergency. 
Twenty pairs spherical convex lenses. 
Twenty pairs spherical concave lenses, both from 2 to 160 English 
inches focus (D. 20-0.25). 
Eleven cylindrical convex lenses. 
Eleven cylindrical concave lenses, both from 8.888 to 160 English 
inches focus (D. 4>50-0.25). 
Six prisms, 2°, 3°, 4°. 5°, 8°, 12°. 
Five disks, one white and one ground glass, one plain metal, one 
metal with hole in centre, and one metal with stenopaic slit. 
Four colored glasses-red, blue, green, and brown. 
One graduated trial frame, No. 3, double cell. 
One graduated trial frame, No. 2 (double cell, adjustable). 
In mahogany case, with lock and two keys. 
Tablets in half-ounce bottles : 
Acetanilide, gr 3 
Acid boracic, gr 5 
Acid tannic, gr 5 
Alum, gr 5 
Ammonium chloride, gr 5 
Antipyrine, gr 5 
Calomel, gr 2 
Camphor, gr. 2, and opium, 
gr. 1 * 
Cathartic compound * 
Colchicum, fluid extract, in.. y 
Cough * 
Diarrhaia * 
Dover's powder, gr 5 
Ergotine, gr 2 
Ipecac, gr . 1 
Morphine sulphate, gr Ji 
Nitro-glycerine, gr t/luo 
Opium, gr 1 
Phenacetine, gr 5 
Potassium bromide, gr 10 
Potassium chlorate, gr 5 
Quinine sulphate, gr 3 
Sodium salicylate, gr 5 
Sulphonal, gr 5 
Tincture aconite root, m... . 2 
Tincture digitalis, m 5 
Tablets, hypodermic, in tubes. 
Apomorphine hydrochlorate,* 
Kr i/io 
Atropine sulphate, gr A/ioo 
Cocaine hydrochlorate, gr.. -t/8 
Digitaline. gr Vino 
Ergotine,* gr i/J0 
Morphine sulphate,* gr.... Ji 
( Morphine sulphate,* gr. Ji 
( Atropine sulphate,*.... >/] 00 
Pilocarpine hydrochlorate, gr. Ji 
Quinine bimuriate, gr % 
Strychnine sulphate, gr '/so 
Queen. 
Twenty pairs spherical convex lenses. 
Twenty pairs spherical concave lenses, both from 2 to 48 inches focus. 
Eight cylindrical convex lenses. 
Eight cylindrical concave lenses, both from 9 to 72 inches focus. 
Five prisms, 2°. 3°, 4°. 5°, 8°. 
Three metal disks, one plain, one with hole in centre, and one with 
stenopaic slit. 
Four colored glasses-red, blue, green, and brown. 
One single lens-holder. 
One trial frame. 
In mahogany case, with lock and key. 
Syringe, hypodermic, not expendable, number I 
Thermometer, clinical. (See par. 44), number 1 
* Tablets marked thus are in the hypodermic syringe case. 
Case, Fields 
Bistoury, curved, number 1 
Catheter, silver, jointed, num- 
ber 1 
Director and aneurism needle, 
number 1 
Forceps, artery and needle, 
combined, number 1 
Forceps, bone, number 1 
Forceps, bullet, number 1 
Forceps, dressing, number.... 1 
Knife, amputating, blade, num- 
ber 1 
Knife, amputating, handle, 
number 1 
In wooden case, with leather 
pouch and sling strap, with buckle 
and snap hooks. 
Ligature silk, exp., cards 2 
Needles, surgeon's, exp., num- 
ber 12 
Probe (Nelaton's), number.... 1 
Saw - blade, movable back, 
number 1 
Saw-blade, handle, number... 1 
Scalpel, number 1 
Scissors, straight, number 1 
Serre-fines (Langenbeck's), 
number 4 
Tenaculum, number 1 
Wax, exp., piece 1 
Wire suture, silver, exp., loops. 3 
Ammonia, aromatic spirits, 
exp., oz 1 
Bandages, roller, exp., num- 
ber 4 
Candle, in tin box, exp., num- 
ber 1 
First-aid packet, exp., number. 1 
Forceps, dressing,* number... 1 
Iodoform sprinkler, number... 1 
Jackknife, number 1 
Lint, sublimated, exp., oz 2 
Needles, medium, exp.,* paper. 1 
Pouch, Hospital Corps. 
Petrolatum, carbolized, exp., 
°z X 
Pins, common, exp.,* paper... 1 
Pins, safety, exp.,* number.. . 6 
Plaster, adhesive, exp., spool.. 1 
Scissors, medium,* number . . 1 
Splints, wire, number 2 
Sponges, small, in bag, exp., 
number 2 
Thread, linen, exp.,* yds ... 20 
Tourniquets, field, number.... 2 
Wool, boracic, exp., oz 2 
* Articles marked thus are contained in special case. 
Pouch, Orderly. 
+ This is the case recently issued as " surgeon's field case. " 
Case, Forceps, Heemostatic. 
Ammonia, aromatic spirits, 
exp., oz 1 
Bandages, roller, exp., number. 2 
Basin, pus, number 1 
Case, medicine, with tablets,* 
number 1 
Catheter, elastic (No. 8), exp., 
number 1 
Chloroform, exp., oz .. 4 
First-aid packet, exp., number. 1 
Glass, medicine, exp., number. 1 
Lint, sublimated, exp., oz ... 2 
Petrolatum, carbolized, exp., 
oz % 
Pins, common, exp., paper.... 1 
Pins, safety, exp., number.... 6 
Scissors, medium, number 1 
Sponges, small, in bag, exp., 
number 2 
Syringes, hypodermic, with 
tablets, number 1 
Tags, diagnosis, exp., with 
pencil, book 1 
Tourniquet, Esmarch, num- 
ber 1 
Wool, boracic, exp., oz 2 
Halsted's straight, number.... 1 
Halsted's curved, number 1 
Jones's angular, number 1 
Jones's straight, number 1 
In morocco case. 
Little's fenestrated, number... 1 
'Tait's long grip, number 1 
Tait's short grip, number 1 
Thornton's T, number 1 
Wood's [Pean's] large, number. .2 
Wood's [Pean's] small, number. 2 
Case, Genito-Urinary. 
Bistoury for meatus (Otis's), 
number 1 
Bougies A bottle (Otis's), metal, 
nickel-plated, Nos. 8 to 40, 
inclusive, number 33 
Endoscopes (Otis's, h. r.), Nos. 
22, 26, and 32, number 3 
Gauge (Otis's) steel, number... 1 
Guides (Otis's), whalebone, 
number 2 
Sounds (Otis's), short beaked, 
steel, nickel-plated, Nos. 20 
to 40, inclusive, number 21 
In mahogany case. 
Urethrometer (Otis's), hinged, 
number...- 1 
Urethrometer, rubber covers 
for, exp., number 12 
Urethrotome. Maisonneuve's 
No. 8 (Otis's) gauge, with 
two blades, two filiform bou- 
gies and one extra tunnelled 
tip for whalebone guide, 
number 1 
Urethrotome, dilating (Otis's), 
straight, with two blades, 
number 1 
* The six half-ounce bottles in this case contains the following tablets : 
Acetanilide, gr 3 
Antiseptic 
Compound cathartic 
Cough 
Diarrhoea 
Quinine, gr 3 
The following articles constitute the Bacteriological Set, which will be 
issued in special cases : 
Bacteriological Set. 
Apparatus : 
Apparatus, filling, and stand, 
number 1 
Bath, water, copper, num- 
ber 1 
Bath, tripod for, number ... 1 
Burner (Koch's) number.... 1 
Burner and regulator (Bun- 
sen), number 1 
Burner, stand for, number.. 1 
Dishes, double (Petri's), num- 
ber .. . 12 
Filters (Pasteur), mounted 
in flask, number 2 
Flasks (Erlenmeyer's), 8 oz., 
number....: 12 
Flasks, graduated, 500 c.c., 
number 4 
Apparatus : 
Flasks, graduated, with lip, 
1,000 c.c., number 4 
Incubator, lead-lined, 40 x 
25 x 25. number 1 
Micro-burner, 1 flame, num- 
ber 1 
Paper, filtering, exp., q 1 
Paper, filtering (Swedish), 
exp., q 1 
Pipettes, 1 c.c., number .... 4 
Pipettes, 2 c.c., number .... 4 
Pipettes, 5 c.c., number .... 4 
Pipettes, 10 c.c., number ... 2 
Platinum wire, fine, 4-inch, 
pieces 3 
Platinum wire, medium, 4- 
inch, pieces 3 
Bistoury, curved, number 1 
Bistoury, curved, probe-point- 
ed, number 1 
Bistoury, straight, number. ... 1 
Catheter, jointed, male and fe- 
male tips, number 1 
Caustic holder, number 1 
Forceps, needle and fenes- 
trated, artery, number 1 
Forceps, long-jawed, number.. 1 
Lancet, thumb, number 1 
Ligature silk, exp., card 1 
In leather ca-e, with metal clips 
and chamois cover. 
Case, Pocket, Aseptic. 
Needle, aneurism, number 1 
Needle, aneurism, and grooved 
director, number 1 
Needle, exploring, number.... 1 
Needles, surgeon's, exp., num- 
ber 12 
Probe (N61aton's), number.... 1 
Probe, silver, number 1 
Scalpel, number 1 
Scissors, number 1 
Tenaculum, number 1 
Tenotome, number 1 
Wax, exp., piece 1 
Wire suture, silver, exp., loops. 3 
317 Field Surgeons. 
Field Surgeons. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Bacteriological Set.- (Continued.) 
Medical Chest, C. S. Army, No. 1.-(Continued.) 
Apparatus : 
Platinum wire, heavy, 4-inch. 
pieces 3 
Regulator, gas (Reichert's), 
number 1 
Rods, glass, X'inch, exp., lb. X 
Sterilizer, hot-air, 23 X 30 X 
20, number 1 
Sterilizer, steam (Arnold's) 
number 1 
Stoppers, solid rubber, as- 
sorted, exp., lb X 
Syringe, sterilizable 
(Koch's), 1 c.c., number.. 1 
Test measures, footed, 5 c.c. 
number 1 
Test measures, footed, 10 
c.c., number 1 
Test measures, footed, 100 
c.c., number 1 
Test measures, footed, 500, 
c.c , number 1 
Test tubes, bath for, 1X6 
inches, copper, with extra 
cover, number 1 
Test tubes, thin glass, 6 X X 
inch bore, exp., number .. 300 
Thermometer, 0-50° C., num- 
ber 1 
Thermometer, 0-200° C., 
number 1 
Apparatus : 
Tubing, glass, X, Vje, X- 
inch bore, exp., lbs 3 
Tubing, rubber, exp., ft 12 
Culture media and staining 
reagents : 
Agar-agar, lbs 2 
Aniline oil, pure, lb 1 
Bismarck brown, oz 1 
Carmine, best, oz 1 
Eosine, oz X 
Fuchsine, oz 1 
Gelatine, best, lbs 2 
Glycerine, c. p., lb 1 
Htematoxylon, dr 2 
Methyline blue, oz 1 
Peptone (Witties's), lb X 
Saffranine, oz 1 
Zylol, pure, lb 1 
(These are expendable.) 
Bacteriological Technology (Sa- 
lomonsen), copy 1 
Bakteriologische Diagnostik 
(Eisenberg), copy 1 
Die Mikroorganismen (Fliigge), 
copy 1 
Objective, oil immersion, '/i2 
or 716 inch, number 1 
Nose-piece, double or triple, 
number 1 
Condenser (Abbe), number).... 1 
Drawer No. 1.-(Continued.) 
Miscellaneous : 
♦Syringe, hypodermic, 
number 1 
Thermometer, clinical, num- 
ber 1 
♦Tongue-depressor, number 1 
Drawer No. 2. 
Bandages, suspensory, num- 
ber 5 
Flannel, red, yds 1 
Jute, salicylated, in '/v'b. 
pkgs., pkgs 4 
♦Syringe, rubber, self-inject- 
ing, number 1 
Drawer No. 3. 
Book, prescription, number.. 1 
♦Forceps, dressing,* number. 1 
♦index of Medicine (Carpen- 
• ter), copy 1 
Plaster, blistering, yd 1 
Plaster, mustard, yds 4 
♦Reagent case. § number.... 1 
♦Scissors, number 1 
♦Spatula, number 1 
Spoon, tea, number 1 
♦Stethoscope, h. r., number.. 1 
Contents of Drawers.-(Continued.) 
Drawer No. 3.- {Continued.) 
Syringes, p. g., in wooden 
case, number 3 
Syringes, p., h. r., number... 5 
Tags, diagnosis, 24 in book, 
book 1 
♦Towels, number 2 
Drawer No. 4. 
Beef extract, in 4-oz. cans, lb. 1 
Jute, salicylated, */4-)b. pkgs., 
Pkgs 6 
Drawer No. 5. 
Bandages, roller, assorted, 
number 30 
Cotton, absorbent, !/4-lb. 
pkgs., pkgs 4 
Soap, castile, oz 8 
Drawer No. 6. 
Candles, number 18 
Flaxseed meal, lbs 2 
Drawer No. 7. 
♦Cupping tins, number 4 
Gauze. sublimated, 1-yd. 
pkgs., pkgs 3 
Lint, absorbent, 1 /4-lb. pkgs., 
pkgs 4 
♦Scarificator, number 1 
With list of contents stamped on morocco pad which is carried, re- 
versed, under the cover of chest. 
+ The contents of tubes of hypodermic tablets hereafter issued to re- 
place those expended should be placed in the screw-cap bottles. 
J For the convenient removal of cotton from tablet bottles. 
§ Consisting of 1 tube citric acid ; 1 medicine-dropper : blue litmus 
paper ; 1 tube potassium ferrocyanide ; 1 tube sugar-test powder; 1 test 
tube; *1 urinometer. With circular of directions. 
The contents of the medical and surgical chests are expendable with 
the exception of those to which an asterisk is prefixed. 
Medical Chest, V. S. Army, No. 1. 
Contents of Tray. 
Left of tray-4-oz. bottles : 
Acetanilide, tablets, gr 3 
Camphorand opium, tablets .. 
Cathartic compound, tablets .. 
Cathartic compound, veg., 
tablets 
Copaiba compound, tablets.. 
Cough, tablets 
Diarrhoea, tablets 
Dover's powder, tablets, gr.. 5 
Liniment, tablets, gr 20 
Potassium bromide, tablets, 
gr 10 
Quinine sulphate, tablets, gr. 3 
Sodium bicarbonate, tablets, 
gr 5 
Sodium salicylate, tablets, gr. 5 
Magnesium sulphate, oz.... 4 
(And two empty bottles.) 
Back of tray-8 and 16 oz. bottles : 
Alcohol, oz 16 
Ammonia, stronger water, oz. 8 
Brandy, oz 16 
Chloroform, oz 8 
Ether, oz 16 
Oil, castor, oz 8 
Turpentine, oz 8 
Whiskey, oz 16 
Stoppers, rubber, for above, 
number 10 
Centre of tray : 
Cotton-wool... q.s. 
Envelopes, small, for tablets, 
number 100 
Graduates, glass, 2-oz., num- 
ber..., 1 
Graduates, glass, minim, 
number 1 
Labels for vials, number.... 50 
♦Links, split, for pack sad- 
dle, number 4 
Ointment boxes, in nests of 
three, nests 4 
♦Pocket stove, number 1 
Vials, 2-oz.. number 10 
Front of tray-X-°z- bottles: 
Acid, arsenious, tablets, gr.. >/40 
Alterative, tablets 
Capsicum, tablets, gr X 
Colchicum, fl. ext., tablets, 
m X 
Croton-oil, tablets, m 1/J0 
Ergotine, tablets, gr 2 
Iodine, oz X 
Nitro-glycerine, tablets, gr..1/100 
Podophyllin, tablets, gr X 
Santonin, tablets, gr X 
Silver nitrate, fused, oz X 
Tr. digitalis, tablets, m 5 
Tonic, tablets 
Right of tray-2-oz. bottles : 
Acid boracic, tablets, gr .... 5 
Acid tannic, tablets, gr 5 
Alum, tablets, gr 5 
Ammonium chloride, tablets, 
gr 5 
Antipyrin, tablets, gr 5 
Bismuth subnitrate, tablets, 
gr 5 
Blue mass, tablets, gr 5 
Calomel, tablets, gr 2 
Chloral, tablets, gr... 5 
Ipecac, tablets, gr 1 
Lead acetate, tablets, gr.... 3 
Morphine sulphate, tablets, 
gr X 
Opium, tablets, gr 1 
Peptic, tablets 
Phenacetine, tablets, gr 5 
Potassium chlorate, tablets, 
gr 5 
Potassium iodide, tablets, gr. 5 
Salol, tablets, gr 5 
Tr. aconite root, tablets, m.. 2 
Zinc sulphate, tablets, gr... 5 
Surgical Chest, U. S. Army, No. 2. 
Contents of Tray. 
4-oz. Bottles : 
Acid boracic, tablets, gr. 5, 
bott 1 
Antiseptic tablets, botts 2 
Compound cathartic tablets, 
bott 1 
Opium, tablets, gr. 1. bott... 1 
Potassium bromide tablets, gr. 
10, bott 1 
♦Bucket, folding, canvas, num- 
ber 1 
♦Catheters, flexible, number ... 1 
Dressing paper, roll 1 
Ether, lb 1 
Felt for splints, pieces 2 
♦Links, split, for pack saddle 
number 4 
Muslin, yds 3 
8-oz. Bottles : 
Carbolic acid, pure, bott 1 
Chloroform, botts 2 
Glycerine, bott 1 
Laudanum, bott 1 
Whiskey, botts 2 
Stoppers, rubber, for above, 
number 10 
Petrolatum, lb 1 
♦Pocket case, aseptic, num- 
ber 1 
♦Pus-basin, number 1 
♦Razor, number 1 
♦Razor-strop, number 1 
♦Towels, number 2 
Contents of Drawers. 
Drawer No. 1. 
Bandage, rubber, number.... 1 
Brush, nail, number 1 
Gauze, sublimated, yds 2 
Goggles, number 2 
♦Iodoform sprinkler, num- 
ber 1 
Ligature, catgut, carbolized, 
spools 3 
Ligature silk, cards 5 
Needle, thread, etc., in case, 
case 1 
Pencil, indelible, leads for, 
number 3 
Pins, common, paper 1 
Pins, safety, assorted, doz... 4 
Plaster, Isinglass, yds 10 
♦Speculum for ear and nose, 
number 1 
Tape, piece 1 
♦Tape measure, number 1 
♦Tourniquet, Esmarch's, 
number 1 
Drawer No. 2. 
*C a se, tooth-extracting,t 
number 1 
Cotton, absorbent, pkgs 2 
Drainage-tubes, rubber, yds.. 3 
Plaster, adhesive, 1-in., spools 4 
Plaster, adhesive, 2-in., spool. 1 
Sponges in bags, bags 2 
♦Syringe, fountain, num- 
ber 1 
Drawer No. 3. 
' Bandages, suspensory, num- 
ber 2 
Beef extract, in 1-lb. can, can, 1 
♦Brush, shaving, number ... 1 
Cotton, absorbent, pkgs 2 
Medicine measuring glass, 
number 1 
Minim measuring glass, num- 
ber 1 
Needle, sail, number 1 
Needle, upholsterer's, number 1 
♦Pencil, indelible, number .. 1 
♦Scissors, number 1 
♦Surgery, Operative, copy... 1 
Syringe, p. h. r., number. 2 
Tags, diagnosis, 24 in book, 
book 1 
♦Tool, universal, number ... 1 
Drawer No. 4. 
Bandages, flannel, number... 4 
Bandages, roller, number.... 6 
♦Emergency case, complete, 
number 1 
Drawer No. 5. 
Gauze, sublimated, yds 4 
Jute, salicylated, in '/^Ib. 
pkgs., pkgs 6 
♦Lantern, small, number... 1 
Soap, castile, ozs 8 
Drawer No. 6. 
Bandages, roller, assorted, 
doz 4 
Contents of Drawers. 
Drawer No. 1. 
Hypodermic tablets : t 
Apomorphine hydrochlo- 
rate, gr. ,/i0, bott 1 
Atropine sulphate, gr. 
'/mo- bott 1 
Cocaine hydrochlorate, gr. 
*/«, bott 1 
Ergotine, gr. Vie, bott.... 1 
Morphine sulphate, gr. */s, 
bott t 1 
Pilocarpine hydrochlorate, 
gr. Ve, bott 1 
Quinine bimuriate, gr. Vj, 
bott 1 
Strychnine sulphate, gr. 
bott,....... 1 
Ophthalmic disks: 
Atropine sulphate, gr. 
Vboo, 50 in box, box 1 
Eserine sulphate, gr. V2000, 
50 in box, box 1 
Miscellaneous ; 
♦Caustic holder, rubber, 
number 1 
♦Corkscrew, folding, num- 
ber 1 
Medicine-droppers, number. 2 
♦Pencil, indelible, num- 
ber 1 
Pencil, indelible, leads for, 
number.... 6 
Pencils, camel's-hair, num- 
ber 12 
With list of contents stamped on morocco pad, which is carried, re- 
versed, under the cover of the chest. 
+ This tooth-extracting case consists of: Case, leather, rolling, 1 ; 
lancet, gum, 1; elevator, 1 ; forceps, " half-curved root," 1; forceps, 
" lower wisdom," 1 ; forceps, " wisdom," 1. 
318 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Field Surgeons, 
Field Surgeons. 
Field Desk, No. 4. 
Tins for the following articles : 
Beans. 
Butter. 
Coffee. 
With the exception of books and inkstands, the contents of this desk 
are expendable. 
Salt and pepper. 
Sugar (2 tins). 
Tea. 
Books: 
Army Regulations, copy 1 
Epitome of Tripier's Manual, 
Greenleaf's, copy 1 
Handbook for the Hospital 
Corps, Smart, copy 1 
Information slip book. copy.. 1 
Manual of Drill of Hospital 
Corps, copy 1 
Morning Report. H o s p it a 1 
Corps, copy 1 
Morning Report, sick and 
wounded, copy 1 
Order and letter book. copy... 1 
Standard Supply Table, copy. 1 
Transfer book, copy 1 
Stationery : 
Book, blank, 8vo, number.... 1 
Elastic bands, assorted, gross '/j 
Envelopes, official, large, num- 
ber 12 
Envelopes, official, letter, 
number 50 
Envelopes, official, note, num- 
ber 25 
Eraser, steel, number 1 
Ink, black, bott 2 
Ink, red, bott 1 
Inkstands, number 2 
Mailing tubes, number 4 
Pads, prescription, number... 4 
Paper, blotting, sheets 4 
Paper-fasteners, number 12 
Paper, writing, legal cap, qr.. 1 
Paper, writing, letter, qrs 2 
Paper, writing, note, qr 1 
Pencils, lead, number 4 
Pens, steel, number 12 
Pen-holders, number 2 
Portfolio for Medical Depart- 
ment blanks, number 1 
Blanks : 
Medical Department : 
Examination of recruits, 
monthly report, number 4 
Hospital fund statement, 
number 4 
Medical property, return of, 
number 2 
Medical supplies, invoice of, 
single sheet, number 6 
Medical supplies, receipt for, 
single sheet, number 6 
Medical supplies, special 
requisition for, number... 8 
Report of sick and wounded, 
number 12 
Report of completed cases, 
number 12 
Return of personnel, etc., 
H. C.. number 6 
Quartermaster's Department: 
Clothing and equipage, quar- 
terly return of, number .... 2 
Clothing and equipage, requi- 
sitions for, number 4 
Fuel, forage, and straw, requi- 
sitions for, number 4 
Invoices, abstract " E," num- 
ber 2 
Receipts, abstract " E," num- 
ber 2 
Requisitions, special (No. 48), 
number 6 
Stores, quarterly return of, 
number 2 
Subsistence Department: 
Ration returns, number 12 
Ordnance Department: 
Invoices, number 2 
Quarterly statements, number 2 
Receipts, number 2 
Adjutant-General's Department: 
Certificates of disability, num- 
ber 2 
Descriptive lists, number 2 
Discharges, number 2 
Final statements, number.... 4 
Furloughs, number 2 
Inventory of effects of de- 
ceased soldiers, number.... 2 
Muster and pay rolls, hospital, 
number 8 
Outline figure cards, number.. 6 
Physical examination of re- 
cruits. form for, number.... 6 
Surgeon's certificate of disa- 
bility for officers, number.. 2 
Reserve Chest, No. 7. 
The contents of this chest will be stated subsequently. 
Outfit of Schuehle Ice-Machine as per Latest Contract. 
Ice-machine, complete, Jacob Schuehle's patent, capacity 3,000 pounds 
in 24 hours, consists of : 
1 double ammonia compressor. 
1 steam-engine. 
1 boiler, 20-horse power, complete, with feed-pump. 
1 ammonia condenser. 
1 3/16-inch boiler-steel freezing-tank, encased in 1-inch pine floor- 
ing, with the requisite number of ice-cans. 
1 steam condenser, capacity sufficient to furnish in 24 hours distilled 
water for 3,000 pounds of ice. 
1 brine-pump. 
1 patent oil eliminator. 
1 side-feed lubricator. 
300 fire-brick. 
Bedplate, necessary pipes, gauges, valves, connections, etc. 
Anhydrous ammonia and lubricating oil sufficient to run the ma- 
chine for two years. 
In most cases additional or improved parts have been purchased for 
these machines, and this list can be considered as approximate only. 
The ammonia drum, or cylinder, is a container of the ammonia furnished 
by contract, and unless purchased from the ice fund does not form a 
part of the Schuehle machine, being returned when a fresh drum of 
ammonia is received. The Wood-Bailie machine, of which four are now 
in use, has an ammonia drum as part of the original machine. See par. 
48 and Circular S. G. O., June 13, 1891. 
For convenient reference the following lists are ap- 
pended, although the articles are not issued by the Medi- 
cal Department: 
Ambulance. 
Ambulance, harness for. 
Axe. 
Clothing, uniforms, etc. 
Cooking utensils. 
Dippers. 
Flags.* 
Gas-fixtures. 
Hand-cart. 
Hatchet. 
Ladder. 
Lamps, bracket. 
Lamps, hanging. 
Issued by the Quartermaster's Department (see par. 51). 
Lanterns. 
Lockers. 
Piping for ranges and stoves. 
Range and fixtures. 
Shovel. 
Shelter for meteorological instru- 
ments. 
Spade. 
Stoves, heating. 
Tentage, etc. 
Travois. 
Wheelbarrow. 
Wood-saw. 
Mess Chest, No. 5. 
Basin, wash hand, agate ware, 
number 1 
Boilers, double, agate ware, 
number 1 
Bowls, soup, agate ware, num- 
ber 6 
Box for salt, number 1 
Box for pepper, number 1 
Brush, scrubbing, exp., number. 1 
Can-openers, exp., number 2 
Cleaver, number 1 
Cook-book. Army, number 1 
Cups, coffee, agate ware, num- 
ber 6 
Cups, large, agate ware, num- 1 
ber 1 
Dippers, agate ware, number... 1 
Graters, nutmeg, number 1 
Gridiron, number 1 
Hatchet, number 1 
Kettles, steel, nested, with 
covers, number 3 
Knife, butcher, number 1 
Knife and fork, carving, of 
each, number 1 
Knife and saw, combined, num- 
ber. 1 
Knives and forks, of each, num- 
ber 6 
Ladles, agate ware, number.... 1 
Lantern, candle, number 1 
Matches, in waterproof case, 
exp., boxes 12 
Meat-cutter, small, number 1 
Meat-dishes, agate ware, num- 
ber 2 
. Mill, coffee, number 1 
Nails, assorted, exp., lbs 4 
Pan, frying, steel, number 1 
Pans, mess, agate ware, number 2 
Pans, sauce, steel, tinned inside, 
with cover, number 1 
Plates, dinner, agate ware, num- 
ber. 6 
Pot, coffee, agate ware, num- 
ber 1 
Pot, tea, agate ware, number... 1 
Rope, '/4 inch, exp., feet 50 
Sickle, number 1 
Spoons, basting, agate ware, 
number 1 
Spoons, table, number 6 
Spoons, tea, number 0 
Steel, number 1 
Towels, crash, number 6 
Tray, metal, japanned 1 
Tumblers, agate ware, number. 6 
Wire, exp., coil 1 
* See A. R. 1848, as amended by G. O. 83,1880. Except guidons, these 
flags will rarely be issued. 
Issued by the Ordnance Department. 
Blanket bag. 
Blanket bag, shoulder straps, pair. 
Blanket bag, coat straps. 
Canteen. 
Canteen strap. 
Cup, tin. 
Fork. 
Haversack. 
Haversack strap. 
Knife. 
Knife, hospital corps. 
Knife, hospital corps, scabbard. 
Meat can. 
Revolver.* 
Rifle, Springfield, muzzle loading.! 
Shot-gun, Springfield.^ 
Shot-gun, reloading, outfit. § 
Spoon. 
Sword-belt for hospital steward. 
Sword-belt plate for hospital stew- 
ard. 
Sword frog for belt. 
Waist-belt. 
Waist-belt plate. 
♦ Revolvers will be obtained from the Post Commander for service in 
an Indian country, when necessary. If it is impracticable to obtain them 
for temporary service in this way, they may be procured by requisition 
on the Chief Ordnance Officer of the Department.-Circular S. G. O., 
April 30, 1891. 
+ The issue of two Springfield muzzle-loading rifles to each military 
post for company-bearers' drill is authorized.-Decision Acting Secretary 
of War. 1888. 
J " Upon requisition of the Post Surgeon (through the usual military 
channels), duly approved by the Surgeon-General, the Ordnance Depart- 
ment will issue, for use at posts west of the Mississippi River, a shot-gun 
with necessary appendages and ammunition for the use of members of 
the Hospital Corps."-Decision Chief of Ordnance. 1889. 
§ The reloading outfit of the shot-gun consists of the following : The 
articles with * prefixed are expendable, and may be replaced by annual 
requisitions upon the Chief Ordnance Officer of the Department: 
Food Chest, No. 6. 
In this chest, as issued, considerable vacant space is left in order to 
allow latitude to each medical officer as to the exact character of the sup- 
plies he may wish to carry. 
The printed plan inside the cover of each gives the general arrangement. 
Tins labelled •'corn starch," "chocolate," and "arrow-root" are 
included, although not mentioned in the official list of contents, as it is 
thought that they may contain articles of more general use. 
Brush-wiper, number 1 
Canister, tin, for powder, 2-lbs., 
number 1 
Canister, tin, for powder, 5-lbs., 
number 1 
♦Cartridge primers, number. 1,000 
♦Cartridge shells, 20 gauge, 
number 50 
Charger, adjustable, number... 1 
♦Cotton cloth, yard 1 
♦Cotton waste, lbs l'/4 
Drift, number 1 
Funnel, number 1 
♦Gun-wads, No. 18, pink edge, 
number 2,000 
Packing-box, number 1 
♦Powder, musket, lbs 7 
Priming tool (Frankford), num- 
ber 1 
♦Shot, No. 8, lbs 50 
Beef extract or an equivalent prep- 
aration. 
Candles. 
Condensed milk, in original cans, 8 
pounds. 
Soap. 
Vinegar, in 1-quart wicker-covered 
bottles, 2 bottles. 
Yeast powder, in */2-pound original 
cans. 
319 Field Surgeons, 
Field Surgeons, 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Below follows the composition of the tablets, etc., 
which are referred to in the Supply Table. 
These amounts may be compared with the amounts in 
the ration of Moleschott, Pettenkofer and Voit, Ranke, 
and of the English Army, which amounts were not given, 
however, in the previous article in terms as below. 
The words tablets and pills are used synonymously throughout the 
Supply Table : 
Tablets, expendable. 
Alterative. 
Mercury protiodide, gr '/s 
Opium, gr Via 
Antiseptic : 
Mercury bichloride, gr 7.7 
Ammonium chloride, gr.... 7.3 
One tablet to one pint of water 
makes a 1 to 1,00(1 solution. 
Camphor and Opium: 
Camphor, gr 2 
Opium, gr 1 
Compound cathartic : 
Same as compound cathartic pill. 
Compound cathartic, vegetable : 
Ext. colocynth, compound, 
gr Vs 
Podophyllin, gr '/< 
Pulv. resin scammony, gr... '/a 
Pulv. aloes socotrine, gr.... 1V4 
Pulv. cardamom, gr V9 
Saponis, gr '/a 
Copaiba compound : 
Balsam copaiba, gr I'/a 
Resin guaiac, gr 3/8 
Ironcitrate.gr % 
Oleo-resin cubebs, gr 3/s 
Cough : 
Extractlicorice.gr */>o 
Camphor, gr Vas 
Acid benzoic, gr 1/.ii 
Oil anise, gr '/jg 
Opium, gr >/25 
Tartar emetic, gr Vbo 
Each tablet is the practical equiv- 
alent of one teaspoonful of brown 
mixture. 
Diarrhoea : 
Calomel, gr >/a 
Morphine sulphate '/16 
Capsicum, gr '/io 
Ipecac, gr '/aa 
Camphor, gr Vis 
Liniment: 
Camphor, gr O'/a 
Capsicum, gr 6'/a 
Ext. belladonna, alcoholic, 
gr 6Va 
Dissolve one tablet in one ounce 
of alcohol. 
Peptic : 
Pepsin, gr 2 
Pancreatin, gr 2 
Bismuth subnitrate, gr 2 
Tonic : 
Iron pyrophosphate, gr 1 
Quinine sulphate, gr '/a 
Strychnine sulphate, gr '/eu 
Albumi- 
nates. 
Fatty 
material. 
Carbo- 
hydrates. 
Ounces. 
Ounces. 
Ounces. 
Moleschott 
4.587 
2.964 
14.247 
Pettenkofer and Voit 
4.83 
4.12 
12.40 
Ranke 
3.52 
3.52 
8.46 
English Army 
8.736 
1.44 
12.71 
If we contrast these figures, it appears that the heaviest 
ration of the United States Army, increased 
by the vegetable ration, exceeds in albumi- 
nates and carbo-hydrates each of the four 
rations given in the last table, but is ex- 
ceeded by each of them in fats, except the 
ration of the English Army, the fat in whose 
ration is slightly less. The salt beef ration of 
the United States Army, also so increased, is 
in a trifling degree less than that of Petten- 
kofer and Voil in albuminates, but exceeds all the others 
in this ingredient ; it is less than all the others in fats, 
but much larger in carbo-hydrates. 
The ration given as typical for the United States Army, 
increased by the vegetable allowance, is much larger 
than any of the others in albuminates, fats, and carbo- 
hydrates. 
In a paper on the best ration for the soldier, published 
in the " Transactions of the Ninth International Medical 
Congress," is found a table giving the mean proportion 
of the components of seven different rations, which mean 
is as follows: Albuminates, 4.37 ounces ; fatty material, 
2.74 ounces ; carbo-hydrates, 13.4 ounces. Let us compare 
with these amounts, the amounts given for what I have 
termed the typical ration of the United States Army, 
when increased by one pound of vegetables. The com- 
position of this ration thus increased is as follows : 
Com pari- 
so n with 
other r a- 
tions ; Unit- 
ed States Ar- 
my ration in- 
creased b y 
addition of 
one pound 
potatoes. 
Diet.-To the ration of the soldier as described, page 
120, third volume of this Handbook, Con- 
gress in 1890 added one pound of vegetables, 
which by .decision of the War Department 
were to be issued as : 1, One hundred per cent, in fresh 
potatoes ; or, 2, eighty per cent, in fresh potatoes, and 
twenty per cent, in fresh onions ; or, 3, seventy per cent, 
in fresh potatoes, and thirty per cent, in canned toma- 
toes, or in such fresh vegetables as can be procured in 
the vicinity of the station, or which it may be practicable 
to furnish from a distance in wholesome conditions ; such 
as onions, cabbages, beets, turnips, carrots, and squash. 
It was further directed that in preparing requisitions for 
these things, the preferences of the troops will be consid- 
ered as far as climate, resources of the vicinity, transpor- 
tation facilities, and season may render practicable. 
Under these instructions the food supplied the soldier 
has been increased by the amount of one pound of vege- 
tables per man, and the Subsistence Department, in issu- 
ing, has been guided by the expressed preferences of the 
troops as to what particular vegetables were supplied, by 
far the greater proportion being Irish potatoes. 
The Irish potato is one of the most abundant of the 
vegetable foods raised in this country, and it is also one 
that can be readily transported, and with 
small danger of injury or loss, as compared 
with most other vegetables. It is, therefore, 
to be presumed that it will be largely selected 
and supplied as food ; and concerning it as the vegetable 
component of the ration, I will principally make comment. 
According to the Tables found in Parke's " Hygiene," 
about three-fourths of the potato consists of water, and one- 
fifth of carbo-hydrates. One-tiftieth consists of albumin- 
ates ; one-sixth of one per cent, of fatty material; and one 
per cent, of salts ; so that one pound of potatoes added to 
the ration adds 0.32 oz. of albuminates ; 0.0256 of fatty ma- 
terial ; 3.36 oz. of carbo-hydrates, and 0.16 of salts. Add- 
ing these amounts to the ration given on page 121-2, Vol. 
III.,of the Handbook, these rations will foot up as follows: 
Vegetable 
ration. 
Albumi- 
nates. 
Fatty 
material. 
Carbo- 
hydrates. 
Meat, half beef 
Ounces. 
1.245 
Ounces. 
0.6972 
Ounces. 
Meat, half bacon 
0.53 
4.40 
Bread, half flour 
Bread, half hard bread 
Beans ... 
1.314 
1.248 
0.54 
0.108 
0.104 
0.05 
6.174 
5.822 
1.20 
Sugar 
2.316 
Potatoes 
0.32 
0.0256 
3.36 
Total 
5.197 
5.3848 
18.872 
The Irish 
potato as 
vegetable ra- 
tion. 
The increase of albuminates in this ration (5.197 
ounces) over the amount contained in the mean of several 
rations before given (4.37 ounces), equals 0.827 ounce, 
or nineteen per cent. 
The increase in the fatty matter (5.3848 ounces) over 
that of the mean ration as above (2.74 ounces), equals 
2.6448 ounces, or ninety-six per cent., almost double. 
The increase in the carbo-hydrates (18.872 ounces) over 
the carbo-hydrates of the mean ration (13.4 ounces) equals 
5.472 ounces, or forty per cent. Certainly there can be 
no doubt of the sufficiency of this last-named ration. 
Considering the figures of the ration called the 
" Largest ration of the United States Army in weight,'' 
and the "United States Army Salt Beef Ration," on page 
121, Vol. III., Reference Handbook, we find that, when 
added to the pound of potatoes as above, both of these 
rations much exceed the " Mean Ration " in the amounts 
of albuminates and carbo-hydrates, but are less in fats. 
But the addition or substitution of bacon or salt pork, 
for fresh or salt meat in almost any proportion that would 
presumably, or probably, be issued, would bring up the 
fatty constituents, and still leave the albuminates and 
carbo-hydrates largely in excess. It is quite certain that 
in actual service the contingency can never occur when 
Composition of IT. S. Ration when Increased by One Pound 
Potatoes. 
Albumi- 
nates. 
Fatty 
material. 
Carbo- 
hydrates. 
Largest ration of U. S. Armv in 
Ounces. 
Ounces. 
Ounces. 
weight 
5 966 
1.684 
19.296 
U. S. Army salt beef ration 
4.72117 
1.2685 
18.7512 
Typical ration of U. S. Army ... 
5.197 
5.3848 
18.872 
320 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Field Surgeons. 
Field Surgeons. 
bacon or salt pork will be wanting as part of the ration, 
for any length of time. 
If, then, the experiments of all students and observers 
in regard to diet are worth anything whatever, if the 
experience of feeding armies and large bodies 
of men teaches aught worthy of reliance, it 
may be affirmed that the present ration of the 
United States soldier is larger than is neces- 
sary. Manifestly the sin of excess in the ra- 
tion is less to the disadvantage of the soldier 
than that of insufficiency ; but the same can- 
not be affirmed as to its advantage to the tax-payer. 
The first cost to the United States of a pound of pota- 
toes will not average less than a cent. This alone, to an 
army of one hundred thousand men, will equal $1,000 
per day. To this must be added the cost of transporta- 
tion to and with the army, and the expenses due to loss. 
In time of war each of the above items of cost will be 
largely increased over time of peace, and the cost of trans- 
portation is one of the heaviest expenses of the campaign. 
Unless it can be shown that the supplying or the eating 
of unnecessary food possesses certain advantages not due 
to the final consumption of the food in the processes of 
nutrition, it may well be doubted whether the legislation 
which added to each ration one pound of vegetables was 
wise legislation, even though liberal to the soldier. 
Certainly, those who have accompanied an army 
through a campaign will appreciate the immense addi- 
tional labor and expense which will be entailed on the 
Quartermaster and Subsistence Departments if the at- 
tempt be made to carry out the law in time of war and 
supply the vegetables which have been added to the ra- 
tion. The title of the act giving a vegetable ration is, 
" An act to prevent desertions from the army and for 
other purposes." 
The foregoing considerations are entirely independent 
of the question of the desirability and necessity of fresh 
vegetables as an article of diet. This desirability is undis- 
puted. 
On p. 103, Vol. III., Reference Handbook, it is 
stated that the "surgeon must insist that fresh vegeta- 
bles be supplied." Although it is said that 
people have lived, and do live, on animal food 
alone, or animal food with the addition of 
food of vegetable origin, but not ordinarily considered 
as fresh vegetables (flour, etc.), it will not here be denied 
that green, fresh vegetables are, if not necessary, cer- 
tainly very desirable as an article of diet. 
Vegetarians claim that they live on vegetable food, to 
the exclusion of animal food, with the maintenance of 
better health than belongs to the consumer of animal food; 
and green vegetables are beyond doubt often a luxury. 
But in the study of the soldier's ration, economy is an- 
important consideration, certainly when its practice can- 
not be shown to conflict with aught more important. 
The nutritive power of vegetables is small in propor- 
tion to weight, and the large amount of water they con- 
tain (which in the cabbage is nine-tenths or over) will 
always interfere with their general use as a constituent 
of the ration of an army in the field. 
In time of peace, by company and post gardens, and 
by the barter' or exchange of other portions of the sol- 
dier's ration, as has been heretofore shown in this Hand- 
book, the soldier may always have, and does in general 
have, an abundance of vegetables. 
In time of war I believe the regular daily issue of a 
fresh vegetable ration to be almost, if not quite, imprac- 
ticable ; but vegetables may and must be purchased, and 
issued from time to time, on the recommendation of the 
medical authorities, as the circumstances may favor 
their procurement, or as the need may become impera- 
tive. This issue should be a special issue to replace 
other articles of food or in addition thereto. 
Drink.-Not much on the subject of drink need be 
added to what was said on that subject, p. 123, Vol. III. 
of this Handbook. It is proper to em- 
phasize the importance of boiling as a puri- 
fying process for suspected water. A temper- 
ature of 212° F. and upward will destroy the life of the 
(SUPPLEMENT.; 
bacillus of cholera and of microbes generally, and this 
mode of purification is cheap and handy. 
. Ice Machines.-Since the Reference Handbook 
was published the Medical Department has supplied ice 
machines to such Southern posts as were unable to ob 
tain, by purchase, ice for the use of the sick. 
The Surgeon-General has announced that these ma- 
chines "are furnished by the Medical Department to 
supply ice for the use of the sick in hospital, and not for 
the comfort or convenience of the garrison at large," 
and this because such supply for the well belongs to an- 
other supply department. Under the regulations issued 
by the Surgeon-General June 13, 1891, the ice machines 
are operated under the immediate direction of medical 
officers. 
After the sick were furnished with the needed ice the 
surplus manufactured was sold to officers, soldiers, and 
civilians at prices fixed by the officer in 
charge, with the approval of the Medical 
Director, these prices being sufficiently high to create a 
fund from which were met the expenses of the ice man- 
ufacture, viz., such expenses as repairs, fuel, oil, am- 
monia and salt, wages, freight on supplies, etc. 
No action of the Medical Bureau has been more grate- 
ful or beneficent to the army than this issue of ice ma- 
chines and the supply of ice which it has been found 
practicable to issue to the garrisons at an expense gener- 
ally of half a cent or less per pound. 
A description of the ice machine used will be found 
under the heading Supply Table in this paper. 
Clothing.-The soldier's clothing allowance, accord- 
ing to the latest orders of the War Department, is as fol- 
lows : 
P re s e n t 
United 
States Army 
ration larger 
than needed 
for purposes 
of n u t r i - 
tion. 
Ice supply. 
Allowance of Clothing. 
Articles. 
Year. 
Total for five 
years. 
First. 
Second. 
Third. 
Fourth. 
fa 
1st 
6 
mos. 
2d 
fi 
mos. 
Helmets and trimmings, complete, 
number 
1 
1 
2 
Forage-cap and trimmings, number. 
1 
1 
1 
1 
1 
1 
fi 
Campaign hats, number 
1 
1 
1 
1 
1 
5 
Uniform coats, number . 
1 
1 
2 
Trousers, pairs 
2 
1 
2 
2 
2 
1 
10 
Canvas fatigue coat, number 
1 
1 
1 
1 
1 
5 
Canvas fatigue trousers, pairs 
1 
1 
1 
1 
1 
5 
Linen collars, number 
4 
2 
6 
6 
6 
fi 
30 
Dark-blue flannel shirts, number .. 
2 
1 
2 
2 
2 
2 
11 
Knit undershirts, number 
2 
1 
3 
3 
3 
3 
15 
Drawers, pairs 
2 
1 
3 
3 
3 
3 
15 
Boots, for mounted troops, pairs... 
1 
1 
1 
3 
Shoes, for mounted troops. pairs... 
1 
1 
1 
2 
1 
1 
7 
Shoes, for foot troops, pairs 
2 
1 
2 
3 
2 
2 
12 
Barrack shoes, pairs 
1 
1 
1 
1 
1 
5 
Stockings, woollen, pairs 
3 
1 
4 
4 
4 
4 
20 
Stockings, cotton, pairs 
3 
3 
fi 
fi 
fi 
30 
Blouses, number 
1 
1 
1 
1 
1 
5 
Overcoats, number 
1 
1 
Chevrons, cloth, pairs 
2 
1 
1 
1 
1 
fi 
Chevrons, gold lace, pairs 
1 
1 
2 
Stripes for trousers, pairs 
2 
1 
2 
2 
2 
1 
10 
Stable-frock, for mounted troops, 
number 
1 
1 
2 
Overalls, for engineers and mount- 
ed troops, pairs 
1 
1 
1 
1 
1 
5 
Blankets, woollen, number 
1 
1 
2 
Berlin gloves, for mounted troops, 
2 
2 
4 
4 
4 
4 
20 
Berlin gloves, for foot troops, pairs. 
4 
4 
8 
8 
8 
8 
40 
Leather gauntlets, pairs 
1 
1 
1 
3 
Suspenders, pairs 
1 
1 
1 
1 
1 
5 
Band musicians authorized by law 
are entitled to mounted helmets, 
and, in addition to the forego- 
ing. to the following articles : 
Troupers, white, pairs 
2 
1 
2 
2 
2 
1 
10 
Aiguillette and shoulder - knots, 
number 
1 
1 
2 
Music pouch 
1 
1 
Vegetables 
needed a s 
food. 
Boiling to 
purify water. 
To this allowance must be added canvas mittens and 
canvas lined caps, and also leggings and cravats. 
Cork helmets are supplied to troops, in the first and 
321 Field Surgeons. 
Field Surgeons. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
third years of their enlistment, in lieu of the campaign 
hats. 
Arctic overshoes and woollen mittens, when issued, 
will be charged to the enlisted men at cost prices. The 
necessity for their issue must, however, be certified to 
by the department commanders. The allowance for 
these articles is as follows : 
Arctic overshoes, one pair in each of the first and 
third years of enlistment, and woollen mittens, two pairs 
per annum. 
Overcoats made of fur or other suitable material will 
be issued and accounted for in the manner prescribed by 
paragraph 1301 of the regulations. 
One fur cap and one pair of fur gauntlets will also be 
issued annually to all enlisted men in the Departments of 
the Platte, Dakota, and the Columbia, and in other de- 
partments, when specially authorized by the department 
commander, at the prices established for such articles in 
the annual price-list. 
Rubber blankets and ponchos may be issued gratui- 
tously at the rate of one per annum to each enlisted man, 
until the stock on hand shall have become exhausted. 
Enlisted men may draw, whenever in the opinion of 
the proper officer it may be necessary, during their first 
year's enlistment, the two woollen blankets to which 
they are entitled during their service of five years. 
The full amount of the allowance as given in the above 
table the soldier is not obliged to draw, and 
of what he does not draw, the money value 
is placed to his credit, and paid to him in 
money at date of his discharge from the ser- 
vice or at other stated settlement. 
Reports and Records Required of the 
Military Surgeon.-Of the reports and 
records named, page 128, Vol. III., Reference Hand- 
book, the case, diet, and prescription book, No. 10; 
the register of patient's effects, No. 12 ; and meteoro- 
logical reports, No. 13, are no longer required of the 
surgeon. 
Tlie form called " Consolidated Reports of the Medical 
Department," No. 18, has been done away with and a 
new form substituted, called a " Report of Sick and 
Wounded." In certain respects the latter is an improve- 
ment upon the former, but retains some of its defects. 
To the author it seems that the effort is made to com- 
prise. in this report too much, and it is to be 
hoped that some day a simpler form of re- 
port of sick and wounded may be adopted 
for the army. The writer of this paper has 
had occasion during the past thirty years to pay very 
much attention to this especial report. 
Since the remarks were printed concerning said re- 
port (page 127, Vol. III., of this Handbook), a paper 
was read on the subject before the Section of Military 
and Naval Medicine and Surgery of the Ninth Interna- 
tional Medical Congress, and published in its "Trans- 
actions." For more detailed arguments on the subject 
the reader is referred to that paper. 
The report of sick and wounded of an army should be 
as brief as possible, consistently with its useful purpose, 
because the officer making it must be often, if not al- 
ways, without the clerical help or the time needful to 
prepare an elaborate paper. 
It is an army report, and not a paper specially pre- 
pared for the Census Bureau, for the Pension Bureau, or 
the general statistician, to the aid of all of whom, how- 
ever, it should come, but solely within its own sphere ; 
not pretending to give information so special in its kind 
as to be almost certainly inaccurate and unreliable when 
reported by any other than a skilled observer or student 
of the specialty. 
No one can well do amateur work which interferes 
with his proper legitimate work if he is interested in 
that legitimate work and if that work occupies his time. 
Accordingly it seems wisest to require from the mili- 
tary surgeon, as part of his military duty, such reports 
only as grow out of and belong to his place as a military 
surgeon. 
The following propositions, which were adopted, and 
(SUPPLEMENT.) 
reported by the Section of Military and Naval Medicine 
and Surgery of the Ninth International Medical Con- 
gress to the Congress itself are here again enumerated : 
1. The main object of a report of sick and wounded 
for an army is to give the diseases and injuries, their 
number, their proportion occurring among the troops 
and the results thereof, all other objects being inci- 
dental and secondary, or better effected in certain cases 
by special reports. 
2. For purposes of convenience this report should be 
monthly. 
3. It is desirable that, for comparison and study, the 
form of this report should be uniform for all armies and 
as simple as maybe. 
4. No nosological arrangement can now be made which 
commends itself to everyone, and which all will agree 
on as the only one compatible with scientific knowledge ; 
and, therefore, that nomenclature and arrangement of 
diseases should be adopted which is most convenient for 
use in the exigencies of military service. 
5. In view of the great desirability of an uniform 
" report of sick and wounded " by all armies, and in the 
absence of any other form better fitted to fulfil the ends 
for which this report is made, this Section recommends 
the adoption of the subjoined " form " in the medical 
departments of all armies. 
The "form" which followed contained the date, 
place, and mean strength ; a list of diseases, by name, 
occurring, with their result, cure, death, etc. ; a report 
of vaccinations ; of discharges on certificate of surgeon, 
and of deaths, by name ; and " directions" how to make 
out the report. 
The nosological table recommended was that of the 
Prussian army, arranged in fourteen divisions, as fol- 
lows : 
First Division.-General diseases (poisoning). 
Second Division.-Diseases of the nervous system. 
Third Division.-Diseases of respiratory organs. 
Fourth Division.-Diseases of circulatory organs. 
Fifth Division.-Diseases of organs of assimilation. 
Sixth Division.-Diseases of urinary and sexual organs 
(excluding venereal). 
Seventh Division.-Venereal diseases. 
Eighth Division.-Diseases of the eye. 
Ninth Division.-Diseases of the ear. 
Tenth Division.-Diseases of integument. 
Eleventh Division.-Diseases of organs of locomotion. 
Twelfth Division.-Mechanical injuries. 
Thirteenth Division.-Other diseases, including in the 
order here named, self-mutilation, attempted suicide, sim- 
ulation, general debility of body, debility from old age. 
Fourteenth Division.-Under observation. 
Concerning this form the author remarked that "it is 
not claimed that this ' form ' is perfect, but it is simple, 
compact, easily understood, easier to make out than any 
form known to the writer, and contains all the data neces- 
sary to determine the proportion of cases of disease or 
injury occurring in an army, and the results thereof, be- 
sides all the data needed to enable proper conclusions to 
be reached in regard to pensionsand similar allowances." 
I add that no questions regarding doubtful pathology 
are involved, and that careful reconsideration leads me 
to here urge this form upon the favorable consideration 
of the military surgeon. 
In addition to the new Report of Sick and Wounded a 
few stated reports and records have also been added, to 
wit: a Monthly Statement of Ice Fund from surgeons 
in charge of ice machines (to the Surgeon-General); a 
Semi-annual Return of Record Books (to the Surgeon- 
General); a Morning Report Book of the Hospital Corps 
(to the commanding officer); a Monthly Return of Hos- 
pital Corps (to the Surgeon-General); a Clothing Ac- 
count Book of the Hospital Corps; a Descriptive Book 
of the Hospital Corps. 
The last four books and reports have been rendered 
necessary by the organization of a separate Hospital 
Corps, under the command of the surgeon. Concerning 
this corps and its necessity to the field-surgeon further 
remarks will be made. 
The mon- 
ey value 
of clothing 
not drawn 
placed to 
s o 1 <1 i e r s' 
credit. 
Report of 
sick and 
wounded. 
322 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Field Surgeons. 
Field Surgeons. 
Hospital Corps.-On pages 132 to 139 inclusive, Vol. 
III., Reference Handbook, under the heading " Care 
and Removal of the Wounded in Battle," a somewhat ex- 
tended notice is given of the ambulance corps of various 
armies, including that of the United States Army. 
The ambulance corps of the United States Army as 
described, loc. cit., had done good service during the 
great War of the Rebellion, and its operations were a 
great improvement upon the modes of caring for the 
wounded and sick in the field in previous wars. Still it 
had manifest imperfections, the most vital being that it 
really only existed during war, and that its organiza- 
tion only included, besides its officers, the litter-bearers 
and drivers. 
The most progressive military surgeons of our army, 
and those whom they could influence to co-operate, did 
not fail, during the years following the war, to represent 
to those whom they thought could and would aid them, 
the necessity of a more comprehensive and permanent 
organization of a body of men whose sole duty should 
be the care of the sick and wounded at all tinies, and 
particularly their first aid when wounded, and their 
transportation after injury. Finally, March 1, 1887, an 
act passed by Congress was apprbved by the President 
and became a law. 
This law establishing the Hospital Corps is the most 
important legislation for the Medical Department which 
has taken place since the Medical Department was re- 
organized. Upon page 222, Vol. VII., Reference 
Handbook, appears quite a full article by Pilcher upon 
the transportation of the disabled on land. This article 
is mostly devoted to the handling of the wounded in a 
systematic manner, and the drill of the organized body 
by whom the wounded must be handled. Incidentally 
a few words are said concerning the Hospital Corps, in- 
dependent of its drill, and a few words only, and it 
seems proper to here treat more fully of that corps, its 
organization, and its duties other than that of transport- 
ing the wounded. The law organizing the Hospital 
Corps, is textually as follows: 
An act to organize the Hospital Corps of the Army 
of the United States, to define its duty and fix its pay. 
Be it enacted by the Senate and House of Representatives 
of the United States of America in Congress assembled. 
That the Hospital Corps of the United States Army 
shall consist of hospital stewards, acting hospital stew- 
ards, and privates ; and all necessary hospital services in 
garrison, camp, or field (including ambulance service) 
shall be performed by the members thereof, who shall be 
regularly enlisted in the military service ; said corps shall 
be permanently attached to the Medical Department, and 
shall not be included in the effective strength of the army 
nor counted as a part of the enlisted force provided by law. 
Sec. 2. That the Secretary of War is empowered to 
appoint as many hospital stewards as, in his judgment, 
the service may require; but not more than one hospital 
steward shall be stationed at any post or place without 
special authority of the Secretary of War. 
Sec. 3. That the pay of hospital stewards shall be forty- 
five dollars per month, with the increase on account of 
length of service as is now or may hereafter be allowed 
by law to other enlisted men. They shall have rank 
with ordnance-sergeants and be entitled to all the allow- 
ances appertaining to that grade. 
Sec. 4. That no person shall be appointed a hospital 
steward unless he shall have passed a satisfactory exami- 
nation before a board of one or more medical officers as 
to his qualifications for the position, and demonstrated his 
fitness therefor by service of not less than twelve months 
as acting hospital steward; and no person shall be desig- 
nated for such examination except by written authority 
of the Surgeon-General. 
Sec. 5. That the Secretary of War is empowered to 
enlist, or cause to be enlisted, as many privates of the 
Hospital Corps as the service may require, and to limit 
or fix the number, and make such regulations for their 
government as may be necessary; and any enlisted man 
in the army shall be eligible for transfer to the Hospital 
Corps as a private. They shall perform duty as ward- 
(SUPPLEMENT.) 
masters, cooks, nurses and attendants in hospitals, and 
as stretcher-bearers, litter-bearers, and ambulance attend- 
ants in the field, and such other duties as may by proper 
authority be required of them. 
Sec. 6. That the pay of privates of the Hospital Corps 
shall be thirteen dollars per month, with the increase on 
account of length of service as is now or may hereafter 
be allowed by law to other enlisted men; they shall be 
entitled to the same allowances as a corporal of the arm 
of service with which on duty. 
Sec. 7. That privates of the Hospital Corps may be 
detailed as acting hospital stewards by the Secretary of 
War, upon the recommendation of the Surgeon-General, 
whenever the necessities of the service require it; and 
while so detailed their pay shall be twenty-five dollars 
per month, with increase as above stated. Acting hos- 
pital stewards, when educated in the duties of the posi- 
tion, may be eligible for examination for appointment as 
hospital stewards as above provided. 
Sec. 8. That all acts and parts of acts in so far as they 
contravene the provisions of this act are hereby repealed. 
This law remains unchanged to the present time, with 
the one exception that the pay of the private, Hospital 
Corps, has been increased from thirteen dollars to eigh- 
teen dollars per month, because it was found difficult to 
procure for the first named pay men of the acquirements 
demanded. Immediately after the passage of the law it 
became necessary to establish the regulations provided 
for in its fifth paragraph, and the Secretary of War or- 
dered for that purpose a Board consisting of the late 
Adjutant-General of the army, and three army medical 
officers, of whom the writer was the senior. 
The Board, after a month's consideration, reported a 
system of regulations which were approved by the Secre- 
tary of War, and published to the army. They were 
incorporated in the new Army Regulations with such 
changes as from time to time were demanded to facilitate 
their operation. 
Condensed, the points of these regulations important 
to be here made known are as follows : 
Privates of the Hospital Corps may be enlisted from 
civilians, or transferred from soldiers of the line of the 
army. The latter will be the chief source of 
supply. The transfer will be made on the 
application of the post-surgeon, which ap- 
plication must show : 1st, That the man must 
desire to transfer ; 2d, that he has served 
already one year or more ; 3d, that he is 
not married ; 4th, his age, and if over forty, his special 
qualifications as nurse or cook ; 5th, his character ; 6th, 
his physical condition ; 7th, his habits as to temperance ; 
8th, whether for existing or prospective vacancy ; 9th, the 
date of expiration of his present enlistment; 10th, his abil- 
ity to read and write ; 11th, his general intelligence and 
aptitude for the duties of a private of the Hospital Corps. 
Neither artificers nor musicians must be recommended 
for transfer. 
In time of peace recruits for the Hospital Corps who 
have not previously received at least one year's military 
instruction in the army shall be attached to a company 
stationed at Fort Monroe, Virginia; Fort Leavenworth, 
Kansas ; or Fort Riley, Kansas, and shall perform all the 
duties and be subject to all the drill and discipline re- 
quired of privates in the organizations to which they are 
attached. After one year's service in the line they may 
be assigned to duty in the Hospital Corps. The number 
of privates so enlisted and undergoing instruction shall 
at no time exceed ten, unless otherwise specially author- 
ized by the Secretary of War. 
Privates who have served one year or more in the Hos- 
pital Corps, afid have displayed particular merit, will be 
recommended to the Surgeon-General for 
promotion, by the senior medical officer of 
the command ; from those thus recom- 
mended acting hospital stewards will be ap- 
pointed. The candidate for promotion as 
acting hospital steward must pass a satisfac- 
tory examination as to his physical condition, moral 
character, and general aptitude, and in the general prin- 
Qualifica- 
tions neces- 
sary for pri- 
vates of the 
Hospital 
Corps. 
Qualifica- 
tions for ap- 
poin t m e n t 
as acting 
hospital 
stewards. 
323 Field Surgeons, 
Field Surgeons. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
ciples of arithmetic, including decimal fractions and the 
rules of proportion ; in orthography and penmanship ; 
the Articles of War and the regulations affecting en- 
listed men ; pharmacy ; care and use of meteorological 
instruments and hospital and field appliances furnished 
by the Medical Department ; the methods of rendering 
first aid to the sick and wounded ; the ordinary modes of 
cooking. 
To be appointed hospital steward the candidate must 
have served at least one year as acting hospital steward. 
He must then pass an examination, oral and 
written, on the branches named above, and 
also in the elementary principles of hygiene, 
including ventilation, heating, and disinfect- 
ing ; the principles of materia medica, thera- 
peutics, and minor surgery ; the administration of anaes- 
thetics. He must also possess a thorough knowledge 
of the regulations of the Medical Department. 
These examinations must be conducted by commis- 
sioned medical officers. 
Hospital stewards cannot be reduced to the ranks, but 
acting hospital stewards may. Their duties are, under 
the direction of the medical officer, to look 
after and distribute hospital stores and sup- 
plies ; to care for hospital property ; to com- 
pound and administer medicines ; to supervise the prepa- 
ration and serving of food ; to maintain discipline in 
hospitals and watch over their general police ; to prepare 
the hospital reports and returns ; to supervise the duties 
of the members of the Hospital Corps in hospital and in 
the field ; and to perform such other duties connected 
with their positions as may, by proper authority, be re- 
quired of them. 
From each company in the army four men shall be se- 
lected as litter-bearers, to be known as company bearers. 
These men, together with all available men of 
the Hospital Corps, are to be instructed at 
least four hours in each month under super- 
vision of the medical officer, in the duties of 
litter-bearers and the method of rendering first aid to 
the sick and wounded. 
During an engagement, or in an emergency, the com- 
pany bearers shall, under the orders of their commanding 
officers, and the supervision of the regimental surgeons, 
if any are present, give first aid to the wounded or carry 
them to the rear until relieved by members of the Hospi- 
tal Corps ; when so relieved they shall immediately join 
their companies. In active service company bearers shall 
wear as a distinguishing mark a red brassard around the 
left arm. 
Members of the Hospital Corps will be instructed by 
the senior medical officer of the post at such times (in ad- 
dition to those previously prescribed) as he 
may deem necessary. This instruction shall 
consist of lectures and demonstrations in the 
methods of rendering first aid to sick and 
wounded, and of drills in the ambulance ser- 
vice, and as litter-bearers, in accordance with the pre- 
scribed manual. 
Members of the Hospital Corps shall not be required to 
perform any military duties other than those pertaining 
to their corps. They shall not be required to attend re- 
views, parades, or other military ceremonies. 
Hospital stewards will be assigned in the proportion 
of one to every post; two, if the post equals six com- 
panies ; and an additional steward for each 
additional six companies. An acting hospital 
steward is allowed also to every post save the 
smallest. Privates of the Hospital Corps are 
allowed in the proportion of three to every post ; four, if 
the garrison consists of two companies, and an additional 
private for each additional two companies. 
In the field troops shall be accompanied by such num- 
ber of men of the Hospital Corps as may be 
determined by the post commander on the 
recommendation of the post surgeon. 
Upon the march or in battle medical officers shall, 
habitually, be attended by a mounted private of the 
Hospital Corps, carrying a medical officer's orderly pouch. 
Hospital stewards, acting hospital stewards, and at least 
one private of the Hospital Corps in each separate com- 
pany shall be mounted when serving in the held ; and all 
privates of the Hospital Corps shall be mounted when 
serving with mounted commands. The Quartermaster's 
Department will furnish the necessary mounts. 
Each private of the Hospital Corps shall carry a can- 
teen of water, a knife of approved pattern, and a simple 
package of dressings ; and, except when serving as an 
orderly, a Hospital Corps pouch. 
In time of war ambulance and field hospital services 
will be performed by members of the Hospital Corps. 
The privates of the corps, to perform the du- 
ties of litter-bearers, service with the ambu- 
lances, and at dressing and ambulance sta- 
tions, should number at least two per cent, 
of the aggregate strength of the command. To every 
ten privates there should be an acting hospital steward, 
and to every thirty privates a hospital steward. 
The allowance of ambulances, stretchers, and horse and 
mule litters are the same as fixed in the law published, 
p. 137, Vol. HI., Reference Handbook, 
and the medical director of the army and 
each army corps is also given the control in 
the terms of that law'. The wording of that 
law is also used in prohibiting the use of ambulances 
save for the transportation of sick and wounded, and 
in urgent cases for medical supplies, and all persons save 
the proper medical officers, the officers, non-commis- 
sioned officers, and privates of the ambulance service, 
or others specially assigned by competent authority, are 
prohibited from taking or accompanying the sick and 
wounded to the rear. 
The medical director or (chief medical officer is also 
again directed, previous to a march or battle, to cause the 
ambulances to be distributed and managed 
for the collecting the sick and wounded and 
conveying them to their destination, and to 
provide, under the general instructions of the 
commanding general, for the care of the 
wounded at dressing and hospital stations, 
when taken possession of by the enemy, by 
deciding in advance what medical officers and members 
of the Hospital Corps shall remain with a dressing or 
hospital station in case it is abandoned or captured by 
the enemy. 
Privates of the Hospital Corps in the field in time of 
war will be organized into a company for each brigade, 
with their hospital stewards and acting hos- 
pital stewards, under command of an officer 
of the ambulance service or a medical officer 
detailed for that purpose, and will habitually 
camp near the division hospital, or, if there 
be none, the brigade or field hospital, to give such as- 
sistance as may be needed. 
They will be assigned, by order of the commanding 
general or the senior medical officer, to such duties con- 
nected with their corps elsewhere as may be required ; 
but on the completion of such duty, or after an action, 
they w ill rendezvous at their camp, unless otherwise or- 
dered. In time of action, in the absence of specific 
orders from the commanding general or proper medical 
officer, the officer in charge of the company will, under 
the general instructions which he may have received, 
himself issue the necessary orders to proceed to the dress- 
ing stations, or to the relief and care of the wounded. 
For the care and treatment of the sick while in hospi- 
tal or in transport, members of the Hospital Corps should 
be allowed as follows : 
To general and division hospitals, six privates to every 
thirty beds, with such number of hospital stewards and 
acting hospital stewards as the Surgeon-Gen- 
eral. with the approval of the Secretary of 
War, may direct. To a railway hospital 
train of tw'enty cars, carrying six hundred 
sick and w'ounded, twro hospital stewards, six acting 
hospital stewards, and one hundred privates ; and to 
trains of a greater or less capacity the number should be 
in the same proportion, to vary, however, at the discre- 
Qualifica- 
tions for the 
position o f 
h o s p it a 1 
steward. 
Hos p i t a 1 
and ambu- 
lance service 
in war. 
Duties o f 
hospita 1 
stewards. 
Ambulances, 
st re t ch ers, 
horse and 
mule litters. 
Litter- 
bear ers, or 
company 
bearers. 
Medical di- 
rector man- 
ages ambu- 
lances a n d 
provides for 
care of 
wounded af- 
ter battle. 
P r i v ates 
of Hospital 
Corps organ- 
ization in 
field. 
Litter drill 
and instruc- 
tion in first 
aid to wound- 
ed. 
Memb ers 
of Hospital 
Cor^s. how 
assigned. 
Allowance 
of Hospital 
Corps in the 
field or war. 
Field Ser- 
vice. 
324 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Field Surgeons. 
Field Surgeons. 
tion of the medical director, according to the distance to 
be travelled and the character of the cases to be trans- 
ported. To a hospital boat of three hundred beds, three 
hospital stewards, six acting hospital stewards, and sixty- 
five privates ; or in like proportion to hospital boats of a 
greater or less capacity. 
Definition of Terms.-Treating of the terms used 
in connection with the Hospital Corps, the Surgeon-Gen- 
eral defines them as follows : 
Wardmaster.-A private in charge of a ward or wards, 
wherein are other privates of the Hospital Corps on duty 
as nurses. This term is usually employed only in general 
hospitals. 
Nurse.-A private who is in charge of patients in a 
ward. In the ordinary post hospital where but one 
private is on such duty he may also be in charge of the 
ward. 
Cook.-A private who is in charge of the kitchen and 
preparation and cooking of the food. 
Attendant.-A private who performs other duties than 
those heretofore enumerated. 
Orderly.-A mounted private who habitually attends 
a medical officer " upon the march or in battle." The 
employment of an orderly in garrison is not contemplated 
by existing regulations, and the use of the term must be 
restricted to service in the field. 
A description will here be given of certain articles 
which are either a part of the outfit of the soldier of the 
Hospital Corps or ordinarily used by him, and of which 
the Field Surgeon should have knowledge. 
Uniform, and Dress.-The uniform is Io be almost the 
same as that of an infantry soldier, with modifications as 
hereunder. 
Trousers for all Enlisted Men of the Hospital Corps.-Of 
dark-blue kersey, same quality as for non-commissioned 
officers of the other arms of the service. 
Stripes for Trousers for Enlisted Men of the Hospital 
Corps.-Of emerald green piped with white. Hospital 
steward's to be one and one-quarter inch wide ; acting 
hospital steward, one inch wide ; privates, to be one-half 
inch wide. 
Forage-cap Ornament for Hospital Stewards.-A cross 
in white metal, inclosed by a wreath in white metal; for 
acting hospital stewards and privates of the hospital 
corps, a cross in white metal. 
Helmets for Enlisted Men of the Hospital Corps.-Same 
as for infantry, save that the side buttons shall be of 
yellow metal with a Geneva cross of white metal. De- 
vice, a Geneva cross. 
Uniform Coats.-Same as for enlisted men of infantry 
except that the facing shall be of emerald green piped 
with white ; that for acting Hospital Stewards to have a 
red cross on each side of the collar in front. The uniform 
dress-coats for all non-commissioned officers shall be 
made of dark blue cloth of finer quality than for pri- 
vates. 
Chevrons for Uniform Coats.-For a hospital steward, 
three bars and an arc of gold lace; for an acting hos- 
pital steward, same as for a hospital steward, omitting 
the arc. 
Cloth Chevrons for Overcoats and Blouses.-For a hos- 
pital steward, three bars and an arc of one bar of 
emerald green cloth, inclosing a red cross ; for an act- 
ing hospital steward, the same as for a hospital steward, 
omitting the arc. 
For a Private of the Hospital Corps and for all Persons 
Neutralized by the Terms of the Geneva Convention.-A 
brassard of white cloth, sixteen inches long and three 
inches wide, with a cross of red cloth, two inches long 
and two inches wide in centre, to be worn on the left 
arm, above the elbow. 
For a Company Litter-bearer.-A brassard of red cloth, 
to be worn on the left arm above the elbow. 
Equipment for a Private of the Hospital Corps.-A 
blanket-bag, blanket-bag shoulder-straps (pair), blanket- 
bag coat-straps (pair), canteen, canteen-strap, haversack, 
haversack-strap, waist-belt, waist-belt plate, meat-can, 
tin cup, knife, fork, spoon, knife and scabbard (Hospital 
Corps), package of dressings, and Hospital Corps pouch. 
(SUPPLEMENT.) 
Brassards. -The brassard of the red cross was adopted 
by the Geneva convention as a badge of neutrality, to be 
worn by all persons authoritatively serving with the medi- 
cal department of belligerents. It is therefore of no use 
in time of peace. It was adopted by the War Depart- 
ment as the distinctive badge for privates of the Hospital 
Corps, and being a part of their uniform is to be worn at 
all times. 
The duty of the company bearer is defined in Army 
Regulations, par. 1575, and is limited, except for purposes 
of drill, to " active service," during which he should wear 
the badge of his special duty. 
As the company bearer is merely an official emergency 
man, he should, when serving in the field, be equipped as 
is any other soldier of the line, plus a field tourniquet 
and a package of dressings. 
Arms for Hospital Corps.-The Surgeon-General 
informs medical officers that when on service in an In- 
dian country they should take steps to arm members of 
the hospital corps for self-protection against a savage 
enemy. 
The Acting Chief of Ordnance concurs "in the views 
of the Surgeon-General as to the necessity of arming the 
members of the Hospital Corps for self-protection when 
on field service in an Indian country. Post commanders 
will arm the medical enlisted men when necessary. This 
will meet the case and relieve the medical officers from 
making returns for fire-arms when use by their men will 
only be occasional." 
Contents of Knapsack.-One rubber blanket, one woollen 
blanket, one undershirt, one pair of trousers, two pairs 
of socks, two pairs of Berlin gloves, one pair of drawers, 
one blue flannel shirt, one towel, one pair of shoes, toilet 
articles, tin cup (suspended underneath). 
Litter and Sling.-The regulation hand-litter consists 
of a canvas bed, six feet long and twenty-two inches 
wide, made fast to two poles seven and a half feet long, 
and stretched by two jointed braces. The ends of the 
poles form the handles, nine inches long, by which the 
litter is carried. The fixed iron legs are loop-shaped, 
four inches high and one and three-quarter inches wide. 
On the left front and right rear handles a half round 
iron ring is fixed, four and a half inches from the end ; 
between this and the canvas plays the movable ring of the 
sling. 
A cross strap with ring and snap is permanently fas- 
tened to the bottom of each pole near the handles, the 
free (ring) end passing through a staple undef the oppo- 
site pole. When the litter is open the straps lie trans- 
versely under the canvas ; when the litter is closed they 
are passed around it through the free loop of the sling 
and fastened to the snaps, thus securely closing the litter. 
One pair of regulation slings is permanently attached 
to each litter. They are made of gray woollen webbing, 
two and one-half inches wide, with a leather-lined loop 
at one end and a leather strap (with buckle) at the other, 
the strap passing through a steel swivel, itself attached 
to the movable ring on the handle. 
Hospital and Ambulance Flag.-In November, 1889, it 
was published to the army in regulations, that: 
The hospital and ambulance flags of the army are as 
follows : For general hospitals, white bunting 9x5 feet, 
with a cross of red bunting 4 feet high and 4 feet wide 
in the centre ; arms of cross to be 16 inches wide. 
For field hospitals, white bunting, 6x4 feet, with a 
red cross of bunting, 3 feet high and 3 feet wide in the 
centre ; arms of cross to be 12 inches wide. 
For ambulances and guidons to mark the way to field 
hospitals, white bunting, 16 x 28 inches, with a red cross 
of bunting 12 inches high and 12 inches wide in the 
centre ; arms of cross to be 4 inches wide. 
It will be remembered that Article VII. of the Geneva 
Convention declares that the flag adopted for hospitals, 
ambulances, and evacuations shall be distinctive and uni- 
form. 
Travois.-The travail or travois was briefly treated but 
not described, page 142, Vol. III., Reference Hand- 
book, and is spoken of by Pilcher in his article on the 
transportation of the wounded, Vol. VII. As adopted 
325 Field Surgeons. 
Field Surgeons. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
by the United States Army Medical Department the 
travois consists of two jointed side-poles seventeen feet 
long (when extended) connected by two cross-bars, one 
. . . feet long, placed . . . feet from the front 
ends, the other . . . feet long, placed six feet behind 
the first, and of a regulation litter, suspended from the 
cross-bars by straps provided for the purpose. For trans- 
portation, the litter and cross-bars being removed, the 
poles are closed, the bars laid alongside them and the 
whole secured by the bar-straps into a package nine feet 
long which may be carried upon the brackets of the am- 
bulance. A breast-strap and traces accompany the tra- 
vois. It is drawn by one animal, the rear ends of the 
poles trailing on the ground. 
The service of the travois requires three men, one to 
lead the animal, the others to watch the litter and be 
ready to lift its rear poles when passing over obstacles, 
crossing streams, or going up hill. 
Field Hospital.-As adopted by the United States 
Army Medical Department the canvas of a regimental 
field hospital consists of two hospital tents, and three 
hospital tent flies, three conical wall tents, one common 
tent. The hospital tents to be used as a ward ; the coni- 
cal wall tents as dispensary, squad, and mess tents re- 
spectively ; and the common tent as latrine cover. The 
tents are most conveniently pitched in cross-shfipe as per 
following diagram : 
(SUPPLEMENT.) 
and eleven feet to ridge, the wall being four and a half 
feet high ; it furnishes comfortable accommodations for 
six patients, and requires to pitch it a ridge pole and two 
upright poles, seven long tent pins on each side for the 
guy ropes, and two on each side for the long guys, eigh- 
teen in all. Twenty-four small pins are needed for the 
front, rear, and walls. The hospital tent should always 
be pitched first in the field hospital. 
Geneva Convention.-Reference to the Geneva Con- 
vention has been made in the foregoing, and it partic- 
ularly behooves the field surgeon to be familiar with its 
provisions. 
During the War of the Rebellion the War Department 
published to the army " Instructions for the Government 
of Armies of the United States in the Field," prepared by 
Francis Lieber, LL.D., and revised by a board of officers. 
Therein were contained the following paragraphs par- 
ticularly interesting to the field surgeon : 
35. Classical works of art ... as well as hospital, 
must be secured against all avoidable injury, even when 
they are contained in fortified places while besieged or 
bombarded. 
49. A prisoner of Var is a public enemy, armed or at- 
tached to the hostile army for active aid, who has fallen 
into the hands of the captor,.either fighting or wounded, 
on the field or in the hospital, by individual surrender or 
by capitulation. . . . 
All soldiers, of whatever species of arms ; . . . all 
disabled men ... if captured . . . are prisoners 
of war, and as such exposed to the inconveniences, as 
well as entitled to the privileges, of.a prisoner of war. 
53. The enemy's chaplains, officers of the medical staff, 
apothecaries, hospital nurses, and servants, if they fall 
into the hands of the American army, are not prisoners 
of war, unless the commander has reasons to retain them. 
In this latter case, or if, at their own desire, they are 
allowed to remain with their captured companions, they 
are treated as prisoners of war, and may be exchanged if 
the commander sees fit. 
79. Every captured wounded enemy shall be medically 
treated according to the ability of the medical staff. 
115. It is customary to designate by certain flags (usu- 
ally yellow), the hospitals in places which are sheltered, 
so that the besieging enemy may avoid firing on them. 
The same has been done in battles when hospitals are 
situated within the field of engagement. 
116. Honorable belligerents often request that the hos- 
pitals within the territory of the enemy may be desig- 
nated, so that they may be spared. 
An honorable belligerent allows himself to be guided 
by flags or signals of protection as much as the contin- 
gencies and the necessities of the fight will permit. 
117. It is justly considered an act of bad faith, of in- 
famy, or fiendishness, to deceive the enemy by flags of 
protection. Such act of bad faith may be good cause for 
refusing to respect such flags. 
Early in the war, in 1861, and for sometime thereafter, 
captured medical officers were considered prisoners of 
war the same as the combatants, but later action in re- 
gard to captured medical officers was in accordance with 
the above paragraphs. 
The Geneva Convention modifies the above quoted 
paragraphs slightly in certain directions, which will be 
patent on reading the original Convention with the articles 
additional thereto to which it appears the United States 
have acceded. The importance of this Convention is 
such as to demand its appearance in this place. 
General Orders, No. 3. 
Headquarters of the Army, 
Adjutant-General's Office, 
Washington, January 14, 1892. 
The Convention between the United States, Baden, 
Switzerland, Belgium, Denmark, Spain, France, Hesse, 
Italy, Netherlands, Portugal, Prussia, Wiirtemberg, 
Sweden, Greece, Great Britain, Mecklenburg-Schwerin, 
Turkey, Bavaria, Austria, Russia, Persia, Roumania, 
Salvador, Montenegro, Servia, Bolivia, Chili, Argentine 
Republic, and Peru ; with additional articles : For the 
8 ft. 
Rear. 
I 
15 ft. 
16 ft. 8 in. 
Squad. 
Hospital. 
1G ft. 8 in. 
Mess and 
Cook. 
20 ft. 
20 ft. 
1G ft. 8 in. 
Dispensary 
When desired, a fly is pitched over the space between 
the dispensary and ward, thus affording shelter for those 
reporting at " Surgeon's Call." 
A regimental detachment of the Hospital Corps consists 
of two non-commissioned officers and eight privates. 
One army wagon is required to transport a regimental 
field-hospital complete. 
Canvas for a battalion field hospital consists of one 
hospital tent and two hospital tent flies ; two conical wall 
tents ; one common tent. 
The battalion detachment of the Hospital Corps consists 
of one non-commissioned officer and four privates. One 
escort wagon is required to transport a battalion field- 
hospital complete. 
Tentage for medical officers is not included in that for 
the field hospital. Each medical officer is allowed one 
wall tent complete. 
A hospital tent is fourteen feet long, fifteen feet wide, 
326 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Field Surgeons, 
Field Surgeons. 
amelioration of the wounded in armies in the field ; con- 
cluded August 22, 1864 ; acceded to by the President 
March 1, 1882 ; accession concurred in by the Senate 
March 16, 1882 ; proclaimed as to the original conven- 
tion, but with reserve as to the additional articles, July 
26, 1882 ; commonly known as the Geneva Convention, is 
as follows : 
ORIGINAL CONVENTION. 
Article 1. Ambulances and military hospitals shall be 
acknowledged to be neuter, and, as such, shall be pro- 
tected and respected by belligerents so long as any sick 
or wounded may be therein. 
Such neutrality shall cease if the ambulances or hospi- 
tals should be held by a military force. 
Art. 2. Persons employed in hospitals and ambulances, 
comprising the staff for superintendence, medical ser- 
vice, administration, transport of wounded, as well as 
chaplains, shall participate in the benefit of neutrality, 
while so employed, and so long as there remain any 
wounded to bring in or to succor. 
Art. 3. The persons designated in the preceding article 
may, even after occupation by the enemy, continue to 
fulfil their duties in the hospital or ambulance which they 
serve, or may withdraw in order to rejoin the corps to 
which they belong. 
Under such circumstances, when these persons shall 
cease from their functions, they shall be delivered by the 
occupying army to the outposts of the enemy. 
Art. 4. As the equipment of military hospitals remains 
subject to the laws of war, persons attached to such hos- 
pitals cannot, in withdrawing, carry away any articles 
but such as are their private property. 
Under the same circumstances an ambulance shall, on 
the contrary, retain its equipment. 
Art. 5. Inhabitants of the country who may bring help 
to the wounded shall be respected, and shall remain free. 
The generals of the belligerent powers shall make it their 
care to inform the inhabitants of the appeal addressed to 
their humanity, and of the neutrality which will be the 
consequence of it. 
Any wounded man entertained and taken care of in a 
house shall be considered as a protection thereto. Any 
inhabitant who shall have entertained wounded men in 
his house shall be exempted from the quartering of troops, 
as well as from a part of the contributions of war which 
may be imposed. 
Art. 6. Wounded or sick soldiers shall be entertained 
and taken care of, to whatever nation they belong. 
Commanders-in-chief shall have the power to deliver im- 
mediately to the outposts of the enemy soldiers who have 
been wounded in an engagement, when circumstances per- 
mit this to be done, and with the consent of both parties. 
Those who are recognized, after their wounds are 
healed, as incapable of serving, shall be sent back to 
their country. 
The others may also be sent back, on condition of not 
again bearing arms during the continuance of the war. 
Evacuations, together with the persons under whose 
directions they take place, shall be protected by an abso- 
lute neutrality. 
Art. 7. A distinctive and uniform flag shall be adopted 
for hospitals, ambulances, and evacuations. It must, on 
every occasion, be accompanied by the national flag. An 
arm-badge (brassard) shall also be allowed for individuals 
neutralized, but the delivery thereof shall be left to mili- 
tary authority. 
The flag and the arm-badge shall bear a red cross on a 
•white ground. 
Art. 8. The details of execution of the present conven- 
tion shall be regulated by the commanders-in-chief of bel- 
ligerent armies, according to the instructions of their 
respective governments, and in confonpity with the gene- 
ral principles laid down in this convention. 
ADDITIONAL ARTICLES. 
Article 1. The persons designated in Article 2 of the 
Convention shall, after the occupation by the enemy, 
(SUPPLEMENT. 
continue to fulfil their duties, according to their wants, to 
the sick and wounded in the ambulance or the hospital 
which they serve. When they request to withdraw, the 
commander of the occupying troops shall fix the time of 
departure, which he shall only be allowed to delay for a 
short time in case of military necessity. 
Art. 2. Arrangements will have to be made by the bel- 
ligerent powers to insure to the neutralized person fallen 
into the hands of the army of the enemy the entire enjoy- 
ment of his salary. 
Art. 3. Under the conditions provided for in Articles 
1 and 4 of the Convention, the name "ambulance" 
applies to field hospitals and other temporary establish- 
ments, which follow the troops on the field of battle to 
receive the sick and wounded. 
Art. 4. In conformity with the spirit of Article 5 of 
the Convention, and to the reservations contained in the 
protocol of 1864, it is explained that for the appointment 
of the charges relative to the quartering of troops, and of 
the contributions of war, account only shall be taken in 
an equitable manner of the charitable zeal displayed by 
the inhabitants. 
Art. 5. In addition to Article 6 of the Convention, it 
is stipulated that, with the reservation of officers whose 
detention might be important to the fate of arms and 
within the limits fixed by the second paragraph of that 
article, the wounded fallen into the hands of the enemy 
shall be sent back to their country, after they are cured, 
or sooner if possible, on condition, nevertheless, of not 
again bearing arms during the continuance of the war. 
[Articles concerning the Marine.} 
Art. 6. The boats which, at their own risk and peril, 
during and after an engagement pick up the shipwrecked 
or w'ounded, or which, having picked them up, convey 
them on board a neutral or hospital ship, shall enjoy, 
until the accomplishment of their mission, the character 
of neutrality, as far as the circumstances of the engage- 
ment and the position of the ships engaged will permit. 
The appreciation of these circumstances is entrusted to 
the humanity of all the combatants. The wrecked and 
wounded thus picked up and saved must not serve again 
during the continuance of the war. 
Art. 7. The religious, medical, and hospital staff of any 
captured vessel are declared neutral, and, on leaving the 
ship, may remove the articles and surgical instruments 
which are their private property. 
Art. 8. The staff designated in the preceding article 
must continue to fulfil their functions in the captured 
ship, assisting in the removal of the wounded made by 
the victorious party : they will then be at liberty to return 
to their country, in conformity with the second para- 
graph of the first additional article. 
The stipulations of the second additional article are 
applicable to the pay and allowance of the staff. 
Art. 9. The military hospital ships remain under mar- 
tial law in all that concerns their stores ; they become the 
property of the captor, but the latter must not divert 
them from their special appropriation during the contin- 
uance of the war. 
Art. 10. Any merchantman, to whatever nation she may 
belong, charged exclusively with removal of sick and 
wounded, is protected by neutrality, but the mere fact, 
noted on the ship's books, of the vessel having been 
visited by an enemy's cruiser, renders the sick and 
wounded incapable of serving during the continuance of 
the war. The cruiser shall even have the right of put- 
ting on board an officer in order to accompany the con- 
voy, and thus verify the good faith of the operation. 
If the merchant ship also carries a cargo, her neutrality 
will still protect it, provided that such cargo is not of a 
nature to.be confiscated by the belligerents. 
The belligerents retain the right to interdict neutralized 
vessels from all communication, and from any course 
which they may deem prejudicial to the secrecy of their 
operations. In urgent cases special conventions may be 
entered into between commanders-in-chief, in order to 
neutralize temporarily and in a special manner the ves- 
sels intended for the removal of the sick and wounded. 
327 Field Surgeons, 
Food Inspection. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Art. 11. Wounded or sick sailors and soldiers, when 
embarked, to whatever nation they may belong, shall be 
protected and taken care of by their captors. 
Their return to their own country is subject to the 
provisions of Article 6 of the Convention, and of the 
additional Article 5. 
Art. 12. The distinctive flag to be used with the na- 
tional flag, in order to indicate any vessel or boat which 
may claim the benefits of neutrality, in virtue of the 
principles of this Convention, is a white flag with a red 
cross. The belligerents may exercise in this respect any 
mode of verification which they may deem necessary. 
Military hospital ships shall be distinguished by being 
painted white outside, with green strake. 
Art. 13. The hospital ships, which are equipped at the 
expense of the aid societies, recognized by the govern 
meats signing this Convention, and which are furnished 
with a commission emanating from the sovereign who 
shall have given express authority for their being fitted 
out, and with a certificate from the proper naval author- 
ity that they have been placed under his control during 
their fitting out and on their final departure, and that 
they were then appropriated solely to the purpose of 
their mission, shall be considered neutral, as wrell as the 
whole of their staff. They shall be recognized and pro- 
tected by the belligerents. 
They shall make themselves known by hoisting, to- 
gether with their national flag, the white flag with a red 
cross. The distinctive mark of their staff while per- 
forming their duties shall be an armlet of the same colors. 
The outer painting of these hospital ships shall be white, 
with red strake. • 
These ships shall bear aid and assistance to the 
wounded and wrecked belligerents without distinction 
of nationality. 
They must take care not to interfere in any way with 
the movements of the combatants. During and after 
the battle they must do their duty at their own risk and 
peril. 
The belligerents shall have the right of controlling 
and visiting them ; they will be at liberty to refuse their 
assistance, to order them to depart, and to detain them 
if the exigencies of the case require such a step. 
The wounded and wrecked picked up by these ships 
cannot be reclaimed by either of the combatants, and 
they will be required not to serve during the continuance 
of the war. 
Art. 14. In naval wars any strong presumption that 
either belligerent takes advantage of the benefits of neu- 
trality, with any other view than the interest of tlie sick 
and wounded, gives to the other belligerent, until proof 
to the contrary, the right of suspending the Convention, 
as regards such belligerent. 
Should this presumption become a certainty, notice 
may be given to such belligerent that the Convention is 
suspended with regard to him during the whole con- 
tinuance of the war. 
Art. 15. The present act shall be drawn up in a single 
original copy, which shall be deposited in the archives 
of the Swiss Confederation. 
The additional articles have been acceded to by the 
United States, and signed on behalf of Great Britain, 
Austria, Baden, Bavaria, Belgium, Denmark, France, 
Netherlands, North Germany, Sweden and Norway, 
Switzerland, Turkey, and Wurtemberg, but will not 
acquire full force and effect as an international treaty 
until the exchange of the ratifications thereof between 
the several contracting states shall have been effected. 
II. The foregoing Convention and additional articles 
are published by the order of the President, who com- 
mands that the original Convention and the first five of 
the additional articles shall form part of the " Instruc- 
tions for the Government of Armies of the United States 
in the Field," as published in General Orders, No. 100, 
1863, from this office. 
III. By direction of the Secretary of War the provis- 
ions of the Geneva Convention incorporated into the 
" Instructions for the Government of Armies of the 
United States in the Field " in the preceding paragraph 
will form part of the examination of captains of the line, 
Quartermaster's and Subsistence Departments, as pre- 
scribed under the head of " Military Law " in the Mem- 
orandum from this office dated October 5, 1891. 
By command of Major-General Schofield : 
Official. J. C. Kelton, Adjutant-General. 
Drill of the Hospital Corps.-In the past six 
years much attention has been given to the drill of the 
hospital corps. Several systems and manuals of drill 
have been prepared by different military surgeons, and 
more than one has been adopted by the medical depart- 
ment of the army, to be in its turn discarded, so that the 
whole subject may be considered as yet undecided and 
in a state of transition. The composite of all these 
efforts of individuals, as well as those of a Board con- 
vened by the War Department for the purpose of pre- 
paring a manual of drill for adoption in the United 
States Army, is about to appear in a new manual to be 
prescribed to the army as its official hospital corps drill. 
The writer has examined carefully every one of these 
systems of drill, and has found each to possess merit. 
I propose to present some remarks pertinent to one 
phase of the subject, and that is the effect of drill on 
separate individual action. In so far as regards those 
duties of the hospital corps .relating to the handling and 
first aid to wounded, the drill has acted unfavorably. 
Since the presentation to the Hospital Corps of our 
army of its first manual of drill, the writer of this paper, 
in the discharge of his official duties as Medical Director, 
has made many formal inspections of the Hospital Corps 
and its drill, at between thirty and forty different mili- 
tary posts, extending from Pembina to San Diego, Cal. 
At these inspections a supposititious case has been pre- 
sented at the drill to a set of " fours," in which a great 
emergency had occurred, a wounded man bleeding rap- 
idly, or some other case demanding prompt and rapid 
action, and this view of the case was emphatically pre- 
sented to the "fours" in words. In nearly every case 
the action of the "four" has been slow and deliberate, 
precisely as they had been drilled, while in the mean- 
time the wounded man might have perished from lack 
of aid. In all these cases the officers under whom the 
men had been drilled informed me that they had not 
failed to impress, previously, on the men drilled the ne- 
cessity of promptness of action in such emergencies, and 
further expressed surprise at the inappropriate action of 
their men of which I speak. 
Now, it is quite apparent that nothing will account for 
the display of the want of judgment, and for the im- 
proper action in these cases but the drill. The men had 
been "drilled into" a certain routine, and so "drilled " 
that they were unable to depart therefrom when circum- 
stances required that they should. 
This view of the case acquires additional force when 
we consider what a drill is. and what for. 
Drill seems to be the systematic instruction in certain 
acts which can be effected in different ways, but which 
Drill in gen- should be always done in the same way, 
erai; what it and in the one particular manner taught at 
is for- the drill; or else acts that are performed by 
a number of persons together, and in harmony, and 
therefore best performed in a methodical, systematic 
manner. 
Drill does not include the very large number of acts 
which are seldom best performed in one single way, or 
by a single person, but whose best manner of perform- 
ance, in different cases, will vary widely, according to 
circumstances, and this best manner be selected by the 
exercise of individual judgment. This distinction 
clearly appears in early definitions of drill, though not 
made so prominent in some later definitions. 
Wilhelm speaks of drill as in general the "exercises 
through which soldiers and sailors are passed to qualify 
them for their duties." 
Webster's Dictionary gives the military meaning as 
" the act or exercise of training soldiers in the military 
art, as in the manual of arms, in the execution of evolu- 
tions and the like." Worcester's definition is, " the 
instruction of officers and soldiers in the exercise of 
328 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Field Surgeons. 
Food Inspection. 
the firelock, and in the first principles of field move- 
ments." 
Where men perform military exercises in masses, such 
as companies, platoons, or sets of fours, these exercises 
are best taught by drill and performed in an undeviating 
manner. Where the exercise, however, is to be per- 
formed individually, and demands individual judgment, 
as in sharp-shooting, or giving the first aid to a wounded 
soldier, it is best done independently of drill. 
There is something very attractive about the drilling 
of men in a military manner-the giving them orders 
and watching them move in obedience thereto,-and any 
drill manual for the Hospital Corps must, of course, treat 
of the marching movements of the men and their hand- 
ling of the litter, as well as of the first aid to the wounded, 
unless, as would be proper, the two subjects are em- 
braced in different handbooks. Hence the danger, and 
Military move- the tendency which really has manifested 
ments made too itself, of making the military movements 
conspicuous by of uie members of the Hospital Corps too 
important and conspicuous a part of their 
education, to the neglect of the most important part of 
their duty when in the field, viz.: the first care of the 
wounded, the carriage of whom, on a litter, does not con- 
stitute the greatest part of such first care, though one 
necessary portion. 
A certain amount of drill is necessary to a soldier of 
the Hospital Corps ; but one of the qualifications for a 
private of the corps has already been stated to be service 
in the line of the army long enough for the acquirement 
of knowledge of the drill. Any subsequent drill can 
only serve to familiarize the man with concerted manage- 
ment of the litter, the ambulance, and the dummy, while 
in these directions it accustoms and prepares the squad 
of litter-bearers to act intelligently together. 
But the first aid of the wounded is a very important 
part of the duty of the private of the Hospital Corps, and 
importance of the drill is only one and not the most effec- 
" first aid to sick tive mode of teaching him any part of 
ami wounded," jj^g Tile regulations have attempted to 
which Hospital guard against the promotion to undue im- 
Corps men portance of drill over teaching by their 
should be in- very terms. They say that the company- 
bearers, and men of the Hospital Corps, 
shall be "instructed" in "the duties of litter-bearers 
and the methods of rendering first aid to the sick and 
wounded.'' And "the instruction," in further terms, 
is directed to consist of " lectures and demonstrations 
in the methods of rendering first aid to the sick and 
wounded, and of drills in the ambulance service, and 
as litter-bearers, in accordance with the prescribed man- 
ual." 
As, however, it became manifest that undue promi- 
nence was given to drill as compared with other instruc- 
tion, the Surgeon-General last year issued the following 
judicious directions : 
" As the object of this drill is the instruction of mem- 
bers of the Hospital Corps and company-bearers in the 
methods of moving, carrying, and otherwise handling 
the disabled, it should be conducted personally by a 
medical officer, who will combine with it instruction for 
rendering first aid in emergencies. While the military 
element in litter drill is desirable-and indeed essential- 
a knowledge of methods in rendering first aid is indis- 
pensable to practical efficiency in the corps. For this 
reason the hour devoted to drill should be largely given 
to object-lessons and demonstrations, especially in the 
methods to be used for the arrest of hemorrhage, the 
application of temporary dressings to fractures and 
wounds, methods of artificial respiration, etc., a dummy 
being used for this purpose whenever practicable. 
" The object of instruction to company-bearers is ' to 
insure the constant presence, in each company, of a num- 
ber of men who can, in emergencies, render temporary 
aid to the sick or wounded of their organizations ; ' and 
' their duty during an engagement ' . . . is to ' carry 
them to the rear until relieved by the members of the 
Hospital Corps.' They should, therefore, be instructed 
primarily and by object-lessons, as far as practicable, in 
(SUPPLEMENT.) 
first aid, litter-drill being subordinate to this important 
knowledge." 
I have thus endeavored to impress upon the reader the 
view that, while instruction of the litter-bearer and pri- 
vate of the Hospital Corps, in all the subjects named in 
the regulations is of the utmost importance, yet the drill 
in military movements is of less importance than, and 
should be subordinated to, instruction in succor and first 
aid to the sick and wounded. Joseph II. Smith. 
FLUORESCEIN (Resorcin-phthalein Anhydride). This 
is one of the numerous coal-tar products. It results 
from the union of resorcin and phthalein when heated to 
the melting-point in equal parts by weight. The chemi- 
cal formula is (CelLXOHLCCOL. It is a yellowish-red 
crystalline powder, sparingly soluble in water, more sol- 
uble in an alkaline solution, showing a beautiful green 
fluorescence. 
It possesses the property of adhering to the tissue be- 
neath the epithelium of mucous membranes and impart- 
ing to it a deep green color, while the epithelial covering 
is in no way affected. Advantage was taken of this by 
Dr. Straub, a Netherlands army surgeon, to detect lesions 
of the eye, who found that the most minute destruction of 
tissue could be clearly defined. The value of this discov- 
ery was made known to the profession by Dr. Thomalla, 
of Friedland, Centralblatt f. prak. Augenheilk., Novem- 
ber, 1889. Dr. R. L. Randolph {Johns Hopkins Bulletin, 
April, 1890) reports his experience with it, for this pur- 
pose, with favorable results. A solution of ten grains of 
fluorescein, with fifteen grains of bicarbonate of sodium to 
the ounce of distilled water is prepared, and a few drops 
placed in the eye on the cornea. Where the membrane 
is intact no trace of the coloring matter is left, but where 
the slightest abrasion exists, the parts are impregnated 
with the stain and the injury distinctly mapped out. 
After washing the eye with water, whenever a discolora- 
tion exists, some lesion is present, and if any foreign body 
is present its size and extent is quite evident by a green 
ring formed around the substance. In ulcers of the cor- 
nea the same positive results were always obtained by 
Dr. Randolph. In simple superficial keratitis the color 
was made less distinct ; in parenchymatous keratitis the 
results were negative. Dr. Thomalla had found that in 
acute glaucoma the disturbances of the cornea that 
attend this affection could be detected and the diagnosis 
confirmed. Dr. Randolph did not succeed in detecting 
any changes in two cases in which he used the solution. 
The depth of the coloration depends upon the extent of 
the wound. When superficial, only the exposed tissue is 
affected, but when the destruction of tissue is deeper the 
coloring fluid is absorbed by the open vessels, and the 
staining radiates from the wound. In ulcers and minute 
abscesses the coloring matter is restricted by the walls of 
the diseased spots. Cicatricial tissue is not affected, and 
the opaque spots of old lesions may be distinguished 
from those of recent origin. Some experience is required 
to detect the slighter abrasions and estimate the various 
degrees of discoloration. Other observers have obtained 
the same satisfactory action without any unfavorable re- 
sults. The application is perfectly unirritating, and may 
be used when the most acute inflammation exists. A pot- 
ash solution may be prepared, and is preferred by some 
to that of soda. Beaumont Small. 
FOOD AND DRUG INSPECTION. Modern Legis- 
lation Relative to Food and Drug Inspection.-In 
the third volume of the Reference Handbook articles 
were published on the subject of " Adulteration of Food 
and Drink," and upon " Legislation respecting Food and 
Drug Adulteration," which fully set forth the inspection 
upon those topics up to the date of their publication. 
The present article will, therefore, be chiefly devoted to 
the subject of the efficiency of such legislation to pro- 
vide protection against this species of crime, and to the 
amount of work accomplished under such laws. 
Popular knowledge upon the subject of food adultera- 
tion is undoubtedly derived to a great extent from the 
occasional publications of the daily press, which are 
329 Food and Drug 
Inspection. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
too often of a very sensational character, exaggerating 
not only the extent of adulteration, but also the com- 
parative ratio of harmful adulteration to that which is 
merely fraudulent in its character. Fortunately these 
publications are not so common as they were a few 
years ago. It is but ten years since a public document, 
in commenting upon this subject, stated that " fraudulent 
adulteration is but little more common than injurious 
adulteration." An examination of the food supply of 
almost any community at the present day would un- 
doubtedly show the incorrectness of this statement. 
England.-The following statement from the Twenty- 
first Annual Report of the Local Government Board for 
1891-92 shows the advantages of food and drug inspec- 
tion in England and Wales since the beginning of opera- 
tions under the Food and Drug Acts in 1876 : 
The total number of analyses of food and drug sam- 
ples made in 1891 was 29,028, or about 1,600 more 
than in the previous year. The increase has been quite 
constant during the past twelve years. In the five years 
1877-81 the average number of samples examined was 
16.688, or one to every 1,520 of the population ; in 1882- 
86 it rose to 21,772, or one in 1,237 ; in 1887-91 it was 
26,846, or one in 1,060 ; while in 1891 it was 29,028, or 
one in 999. In London one sample was examined for 
every 580 persons, and in the provinces one for every 
1,140. But in some quite populous districts the pro- 
visions of the Acts were not carried out, and in com- 
menting upon the neglect of the authorities in these dis- 
tricts the Board says : " It is surprising that the local 
authorities in these and many other cases are content 
to leave the inhabitants without that protection against 
fraud by the sale of adulterated food, which the exercise 
of the statutory powers conferred on the authority would 
be likely to insure." 
The following table shows that a decided improvement 
has taken place in England since the Food and Drug 
Acts went into operation : 
(SUPPLEMENT.) 
21.5, ranging from Oin St. James, Westminster, and other 
districts, up to 47.2 per cent, in Lambeth. In other 
large cities the results of analysis were more favorable, 
Manchester having but 4.7 per cent., Leeds 4.2, and 
Salford 1.3 ; while Liverpool and Birmingham had, re- 
spectively, 17.6 and 17.9 per cent. 
Part of this difference undoubtedly may be accounted 
for by diversities in the practice of the inspectors, for 
while one takes samples only from those retailers whom 
he suspects of adulteration, another may buy from all 
dealers in his district. Some, again, are not sufficiently 
careful to conceal their official character, and it is evi- 
dent that an inspector who makes purchases himself, in 
a place where he is known, is much less likely to be 
supplied with adulterated milk than one who employs a 
deputy for the purpose. 
Out of the 1,633 samples of milk reported as adulter- 
ated, 989 were the subjects of legal proceedings. In 866, 
lines were imposed amounting to £1,443 (about $7,025). 
The percentage of samples of adulterated butter in- 
creased from 11.5 per cent, in 1890 to 15.5 in 1891, not- 
withstanding the existence of stringent laws similar to 
those in force in the United States. 
The number of samples found to be adulterated was 
551, and 394 penalties were inflicted, amounting to £630. 
Of the 1,684 samples of coffee examined, 287, or 17 per 
cent., were adulterated, and of these the Board says: 
" The proportion of genuine coffee was in some instances 
as little as 30.15, or even 5 per cent. It is possible that, 
as is often asserted in defence of the practice of selling 
these mixtures, some persons consider that the flavor of 
chicory improves the coffee. But as no special skill is 
required to mix the two articles, it would certainly be 
more economical for the consumer to buy his chicory 
separately, at its market value of about twopence a pound, 
rather than to pay about six times that price for it under 
the name of coffee. The penalties were generally very 
low, occasionally as little as five shillings." 
The use of poisonous pigments in England, as else- 
where, appears to have nearly or quite disappeared under 
the protective action of the Food and Drug Laws. The 
principal adulterant found in lard was cotton-seed oil. 
About one-fifth of the samples of spirits examined 
were found diluted, but in very few instances had any- 
thing but water been added. 
The amount of drug adulteration found was 16.4 per 
cent. (121 samples out of of 740), of which the Board 
says: "Considering that the difference between pure 
and adulterated medicine may conceivably be a matter 
of life or death to the patient, it is desirable that still 
more should be done in this direction." 
The articles not specified were oatmeal, vinegar, ar- 
row-root, cheese, cocoa, olive-oil, yeast, canned peas, gin- 
ger, etc. 
Of 412 samples of tea examined, not one was found 
adulterated. 
The report of the Public Analyst of Kent for 1891 is 
worthy of notice. He says : " The steady going prac- 
tice of diluting milk and spirits by the addition of 
water probably will always continue more or less, as the 
law is put in force ; but there are other often most in- 
genious forms of adulterations, introduced as special 
branches of industry, which arise anew, for a time flour- 
ish, and then gradually die"out. This was the case with 
the addition of cotton-seed oil to lard, and the substitu- 
tion of margarine for butter, of powdered olive-stones 
for pepper, the fact being that the practice of adultera- 
tion has become a fine art, scientific knowledge and 
technical skill being applied to the subject as persever- 
ingly, and, indeed, as successfully, as the same things are 
being employed in other more legitimate connections. 
'Works chemists' of the highest skill in each special 
department of the food trade are continually engaged in 
the endeavor to produce articles that can be sold at a 
greater profit than the things they resemble, at perhaps a 
less price. This gives rise to a perpetual conflict be- 
tween the falsifier on the one hand, and the public ana- 
lyst on the other, in which the latter, in some respects is 
placed at a great disadvantage, for whereas every move 
Results of Examinations Made in England and Wales by the 
Public Analysts, under the Food and Drug Acts, 1877-91. 
Character of 
samples. 
Number of 
samples exam- 
ined in 1891. 
Percentages of adulteration. 
Total. 
Adul- 
tera- 
ted. 
1891. 
1890. 
Five-year periods. 
1877-81. 
1882-86. 
1887-91. 
Milk 
12,151 
1,633 
13.4 
12.8 
21.1 
16.7 
13.2 
Bread 
799 
8 
1.0 
0.7 
6.6 
3.4 
1.4 
Flour 
437 
1 
0.2 
0.6 
2.5 
0.5 
3.0 
Butter 
3,558 
551 
15.5 
11.5 
13.9 
17.9 
13.4 
Coffee 
1,(184 
287 
17.0 
15.3 
18.6 
17.8 
14.8 
Sugar 
111 
8 
4.7 
13.8 
1.2 
14.5 
4.6 
Mustard 
683 
60 
8.7 
7.1 
17.4 
9.2 
Confectionery, 
11 
41 
2.8 
etc 
Pepper 
403 
1,452 
18 
' Ki 
2.7 
3.2 
7.5 
Tea 
412 
'' 26 
.... 
'4.6 
0.1 
Lard 
1,107 
2.3 
14.2 
4.4 
7.9 
Wine 
51 
2 
3.9 
7.7 
4.7 
Beer 
268 
11 
4.1 
2.0 
5.4 
3.0 
2.6 
Spirits 
3,139 
600 
19.1 
18.1 
34.9 
22.3 
18.5 
Drugs 
740 
121 
16.4 
14.5 
22.0 
13.6 
13.1 
Other articles. 
1.967 
180 
9.2 
5.6 
7.5 
- 
■ 
- 
- 
- 
Total 
29,028 
3,540 
12.2 
11.2 
16.2 
13.9 
11.7 
The foregoing table shows a slight retrogression since 
1890. But the three five-year periods show a decided 
improvement, comparing the earlier with the latter. 
The comments of the Local Government Board show 
that the practice of milk adulteration in the cities of 
England differs but little from that which prevails in 
large cities of the United States. 
The whole number of samples of milk examined in 
England in 1891 was 12,151, or about two-fifths of all 
samples of food examined. Of these 1,633, or 13.4 per 
cent., proved to be adulterated. As might be expected, 
the samples from cities were much more adulterated than 
those from the country districts. 
In London the percentage of adulterated samples was 
330 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Food and Drug 
Inspection. 
(SUPPLEMENT.) 
of 985 samples of butter, 241, or 24 per cent., were adul- 
terated by the addition or substitution of other fats ; of 
260 samples of salad oil, 111, or 42 per cent., were adulter- 
ated ; of 372 samples of flour, only 11, or 3 per cent., 
were adulterated ; of 134 samples of bread and cake, 44 
were condemned on account of being mouldy or badly 
baked ; of 253 samples of sugar and confectionery, 26 
were adulterated ; of 24 samples of honey and preserves, 
10 were adulterated with coloring matters ; of 262 samples 
of chocolate and cocoa, 99 were adulterated with foreign 
fats and other substances; of 268 samples of coffee, 
chicory, and tea, 42 were adulterated ; of 1,344 samples 
of spices, 83, or 6 per cent., only were adulterated ; of 
185 samples of preserved meats, 63 were adulterated ; 
three children's toys, out of 13 examined, were condemned 
on account of dangerous coloring matter ; of 346 cook- 
ing utensils, 110, or nearly one-third, contained lead; of 
737 samples of illuminating oil, 88 were below the stand- 
ard. Only 2 samples of drugs were examined and both 
were found good. 
The chief difference in the experience of the Paris in- 
spection and that of Massachusetts consists in the low 
ratio of adulteration in milk and in spices in Paris. The 
former is probably partially due to the existence of a 
lower standard of milk solids in Paris. 
Hamburg.-The International Review of Food Adul- 
terations (published at Amsterdam) reports that at Ham- 
burg, in 1890, of 758 samples of butter examined, 282 
were adulterated ; 25 samples of milk out of 44, and 17 
samples of coffee out of 27 were adulterated. Of the 
cases of butter adulteration 185 were convicted, 9 were 
acquitted, and the remainder were under consideration. 
The chemist characterizes the extent of butter falsifica- 
tion as "deplorable." 
Liege.-M. de Molinari, Director of the Laboratory of 
Li&ge, Belgium, reports 2 samples of coffee adulterated 
from thirty to fifty per cent. ; 7 samples of milk, 8 of 
butter, 2 of pepper, 4 of mustard, 2 of fruit syrup, 4 of 
liquors, and 4 of beer were adulterated. Fines were im- 
posed from 5 to 100 francs each. 
Constantinople.-M. P. Apery, Government Chemist at 
Constantinople, reports, as the result of examinations 
from March to December, 1891 : 4 samples of meat, dam- 
aged ; 4 of fat, rancid and old ; 8 of butter, mixed with 
foreign fats ; 25 of coffee, mixed w ith roasted cereals; 1 
of olive-oil, old and rancid ; 13 of milk, watered ; 2 of 
cheese, 1 of drinking-water, polluted and unfit to drink ; 
1 of vinegar, containing w ood spirit; 2 of flour, mixed 
with bean flour ; 1 each of cream of tartar, saffron, and 
glycerine, adulterated. 
Strasburg.-Dr. Amthor, of Strasburg, reports for the 
year ending April 1, 1891 : Of 27 samples of suspected 
milk, 16 were adulterated ; of 32 samples of butter, 8 were 
spurious ; of 26 samples of confectionery and chocolate, 
8 were adulterated ; of 37 samples of canned food, 19 
were adulterated, chiefly with copper. In two of these 
fines amounting to thirty marks were imposed ($7.50). 
Of 12 samples of vinegar, all were good. No trichinae 
were found in the hams. Of 59 fruit syrups, 18 were 
adulterated, the adulterants being.chiefly coloring matter 
and glucose ; some were entirely artificial. Four fines of 
145 marks wrere imposed ($35). Of 92 samples of spices, 
11 w'ere adulterated ; all samples of honey and of cheese 
were good ; of 9 samples of olive-oil, one was adulter- 
ated, and a fine of 10 marks imposed. Of 58 samples of 
lard, 18 wrere adulterated with cotton-seed oil and stea- 
rine. Seven fines wTere imposed, amounting to 263 marks. 
Of 356 samples of wrine, 32 were bad and 14 suspicious ; 
the adulterants were mainly water and alcohol. Two 
fines were imposed, amounting to 2.600 marks ! also six 
months in jail ! Of 98 samples of sausages, 18 were 
adulterated with flour, for which 6 fines were imposed of 
160 marks in all. For having the fittings of beer-pumps 
in bad condition, 13 fines were imposed of 50 marks. 
All samples of petroleum were found to be of good 
standard quality. Cooking utensils, examined under a 
law of 1887, were found to contain lead and zinc. 
Other articles examined were coloring matters injurious 
to health, cosmetics containing lead, tubes for conduct- 
and method on his part that is devised to advance the art 
of detection of adulteration is done openly in the face of 
the scientific world, the arts of the adulterator are prac- 
tised and perfected in secret. In point of fact, the most 
refined and successful processes that have been introduced 
for the falsification of food have been devised in view of, 
and with the express design to elude, those means of de- 
tection which from time to time are discussed and pub- 
lished in the "Transactions" of our scientific societies. 
This will explain how it comes about that, from time to 
time, new methods of adulteration are sprung upon us, 
and for a while a new fashion in adulteration sets in, until 
in turn, by the invention of new processes or by the per- 
fecting of old ones, detection of the new-fashioned mode 
of adulteration is made possible, and a check thereby 
put upon the evil practice, which in course of time 
dying out is followed by other perhaps more cunning 
devices, and so it goes on, year by year, an everlasting 
see-saw of attack and defence, from all of which it 
naturally follows that the pursuit of the public analyst, 
day by day, becomes more onerous and more exact- 
ing." 
Paris.-The work of examining the food supply of 
Paris has been conducted at the Municipal Laboratory, 
on the north bank of the Seine, during the past twelve 
years. When the writer visited this establishment in 
1891 it presented the appearance of a busy workshop in 
which is employed a large force of skilled chemists. Pro- 
fessor C. Girard is the chief chemist in charge. Two 
printed reports of this laboratory have been published, 
dated 1882 and 1885. 
By decision of the Municipal Council gratuitous quali- 
tative analyses are made at this laboratory of such articles 
of food and drink as are deposited at the laboratory for 
this purpose. The greater part of the articles examined 
is collected by inspectors authorized to visit shops and 
markets where food is sold, for the purpose of making 
collection of such samples. These inspectors also have 
authority to destroy unsound food. Their collections are 
generally made from such kinds of food preparations as 
are suspected of adulteration or are especially liable to 
this species of fraud. Hence the monthly bulletins is- 
sued from the laboratory do not represent the actual con- 
dition of the markets, since many articles of food are not 
liable to adulteration. The number of articles examined 
in each year amounts at present to more than 20,000 an- 
nually. The scope of the analyses embraces several 
articles in common use besides food, such as children's 
toys, wall-paper, cooking utensils, preparations used in 
embalming, coloring matter, cosmetics, and illuminating 
oils. 
The following condensed statement, compiled from the 
monthly bulletins for the eleven months ending May 31, 
1892, will give a fair illustration of the work accom- 
plished in Paris during that period: Number of visits 
made to markets and shops, 45,394 ; amount of meat and 
fish destroyed, 327,025 kilogrammes, or about 360 tons ; 
amount of vegetables and fruits destroyed, about 1,000 
tons; amount of mushrooms, tomatoes, etc., destroyed, 
about 295 tons ; amount of butter and cheese destroyed, 
about 14 t°n ; complaints before justice. 200 ; number of 
articles submitted to examination, 19,928; of these 7,015 
were samples of wine, more than half of which were 
found to be adulterated by the addition of water, alcohol, 
sugar, coloring matters, plaster, salicylic acid, or other 
articles. 
The other articles were chiefly the following: 97 
samples of vinegar, of which 36 were adulterated ; 688 
samples of beer, of which only 1 was adulterated ; 109 
samples of cider, of which 45 were adulterated, either by 
dilution, coloring matter, or other means ; 410 of dis- 
tilled liquors, of which 240, or 585 per cent., were 
adulterated in various modes ; 639 samples of drinking- 
water, of which 173 were unfit for use, either in conse- 
quence of pollution by organic or mineral ingredients ; 
4,315 samples of milk, of which only 279, or but little 
more than six per cent., were found adulterated by skim- 
ming or watering ; of 156 samples of syrup, 74, or nearly 
half, were adulterated with glucose or coloring matters ; 
331 Food and Drug 
Inspection. 
REFERENCE HANDBOOK OF THE AIEDICAL SCIENCES. 
ing beer and wine, nipples of nursing-bottles, etc. The 
total number of samples examined was 1,322. 
Austria.-The Director of the Laboratory at Vienna, 
Dr. AI. Alansfeld, reports, for the year ending August 24, 
1891, out of 447 specimens that 160, or 35 per cent., were 
adulterated. The samples examined were bread, milk, 
butter, liquors, tallow, cocoa-butter, vinegar, preserves, 
coloring matters, fruit-juice, spices, compressed yeast, 
honey, coffee, Hour, and olive-oil. 
Dr. AL T. Lecco, Official Government Chemist of Bel- 
grade, reports upon the following analyses of food and 
other articles for the year ending October, 1892 : 
(SUPPLEMENT.) 
from the cow, as such, I should have decided that it had 
been both skimmed and watered. Such milk should not 
be considered as an article of sale, but as a pathological 
secretion." 
In commenting upon the use of poisonous salts of 
copper as a coloring matter for preserved peas and other 
vegetables, he says, "Food should not be made to as- 
sume a good appearance to the injury of health." 
The Canton Chemist of Geneva, in his quarterly report 
for the last three months of 1891, reports upon the anal- 
yses of 274 samples, 215 of which were of wine-165 red 
and 50 white ; 49 were plastered and 147 not plastered. 
They were further classified as 87 good, 108 medium, and 
20 inferior ; 20 were reported as injurious to health. Of 
10 samples of butter, 7 were good and 3 adulterated ; of 
14 samples of water, 7 were potable and 7 unfit for use ; 
of 4 samples of milk, 2 were pure and 2 adulterated ; of 
13 samples of sausage-meat, 10 were good and 3 bad ; 
of 6 samples of spices, all were pure. 
Dr. Schaffer, Canton Chemist of Berne, Switzerland, 
reported upon the following articles in 1890 and 1891, 
from which it appears that the scope of the Canton 
chemist's authority extends to nearly all articles in do- 
mestic use as well as to food and drugs. 
N u m b e 
r of 
Adulterated or 
samples 
ex- 
of bad qual- 
amined. 
ity. 
Bread 
21 
1 
Milk 
571 
39 
Cream 
42 
20 
Butter .... 
8 
1 
Lard 
23 
1 
Wa er 
23 
9 
2 
Salad oil 
68 
28 
S.uisages .... 
15 
4 
('ake 
4 
1 
Wine 
138 
10 
Brandy 
77 
9 
Vinegar 
28 
16 
Ground coffee 
5 
5 
Whole coffee 
Y 
3 
Pepper(ground) 
85 
29 
Pepper (whole) 
1 
Cinnamon 
47 
28 
Sugar 
28 
1 
Crockery ware 
8 
6 
Metallic faucets 
4 
2 
Cosmetics 
18 
9 
Miscellaneous 
135 
16 
Articles examined. 
Number exam- 
ined. 
Number found 
adulterated. 
1890. 
1891. 
1890. 
1891. 
Ammoniac 
2 
Apples, dried 
Axle-oil 
2 
9 
1 
Azurin 
2 
2 
Beer 
8 
3 
2 
Beer faucets 
1 
Brandy and spirits 
26 
16 
3 
10 
2 
Bread and cake 
8 
2 
Butter 
7 
9 
3 
2 
Cloth and fabrics 
4 
1 
Cloves 
2 
Coal 
7 
1 
Cocoa 
6 
12 
5 
5 
Coffee and coffee substitutes 
15 
2 
2 
Coloring matters 
25 
6 
17 
Confectionery 
90 
61 
Cooking utensils 
2 
Cordials 
7 
14 
2 
8 
Cotton yarn 
Fertilizers 
62 
52 
3 
3 
Fireworks 
4 
4 
Fodder (for cattle) 
16 
28 
1 
1 
Fruit 
12 
16 
Hat linings 
Maize 
5 
3 
4 
Meal 
6 
7 
1 
2 
Milk 
193 
260 
61 
99 
Paper 
3 
2 
1 
Peat 
1 
Pepper 
37 
33 
16 
17 
Petroleum 
4 
2 
Rum 
13 
32 
6 
11 
Saffron 
32 
38 
29 
20 
Sal ammoniac 
2 
3 
Sausages 
3 
1 
1 
Soap 
3 
6 
Soda 
1 
Stomach bitters 
4 
Sugar 
2 
7 
Sulphate of copper 
6 
4 
Sulphosteatite 
1 
1 
Syrup 
Tallow 
3' 
i 
Tea 
11 
3 
Vaseline 
3 
4 
Water, including mineral waters 
123 
110 
24 
28 
Wine 
353 
388 
78 
74 
Wool 
3 
3 
The chemist states that the greater part of these arti- 
cles were falsified by the addition of substances which 
cheapened their value. 
The articles which were harmful to health were adul- 
terated wines, cake colored with chrome yellow, brandy 
containing an excess of amylic alcohol, cosmetics con- 
taining corrosive sublimate and compounds of lead ; 
metal faucets containing twenty-five to thirty-three per 
cent, of lead. 
Amsterdam.-Drs. Coster and Mazure, Government In- 
spectors at Amsterdam, reported, in 1890, that out of 31 
specimens of dried apples examined, 24 contained zinc in 
variable proportions ; dried pears also were found to con- 
tain the same ; the supposed cause being the drying of 
these fruits in galvanized (zinc-coated) vessels. In min- 
eral waters they found minute traces of metals, chiefly 
copper. Out of 804 samples, 577 had no metallic poi- 
son. 
They examined 1,781 specimens of pork, and none of 
them contained trichina?. Of this number 1,090 were 
from America. 
Sicitzerland.-In Switzerland the work of examining 
articles of food and drink is well organized by the ap- 
pointment of a competent chemist in each Canton, whose 
duties embrace the analysis of all articles in domestic 
use wherein a chemical analysis may be required. 
In the summer of 1891, the writer visited the labora- 
tories of the Cantons of Berne and Lucerne, and found 
them well equipped and intelligently conducted. The 
Swiss method of work would form a good model for 
conducting a laboratory for food analysis in any Amer- 
ican city. 
Dr. Ambuhl, Canton Chemist of St. Gall, examined, 
in 1890, 1,269 samples of all sorts. Out of 96 samples 
of milk, 9 were diluted with water from 10 to 35 per 
cent. In his examinations of samples taken direct from 
the cow, he found one which contained only 0.45 per 
cent, of fat instead of 3 or 3.5, and 8.9 of total solids in 
place of 12.5, or 13 per cent., and says of this sample : 
" If I had not known that this milk was drawn directly 
In addition to the foregoing the chemist reports upon 
several proprietary articles, such as Putzwasser for clean- 
ing brass; hair-dye, containing nitrate of silver; salve 
for burns ; mixture for erasing writing ; powder for re- 
moving acid taste from wine (carbonate of lime), and an- 
tidotes for erysipelas. 
332 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Food and Drug 
Inspection. 
Massachusetts.-The following summary presents in 
a condensed form some of the results of the w'ork of food 
and drug inspection in Massachusetts by the State Board 
of Health during the past nine years of its work in this 
direction : 
Summary. 
Years. 
Total. 
1883. 
1884. 
1885. 
1886. 
1887. 
1888. 
1889. 
1890. 
1891. 
Number of samples of food examined 
695 
1,962 
3.771 
3,438 
4,870 
4.904 
4,854 
5,585 
4,870 
34.949 
Number of samples found to be pure 
Number of samples found to be adulterated, 
363 
779 
2,180 
2,186 
3,163 
3,385 
3,213 
3,771 
3,206 
22,246 
or not conforming to the statutes 
332 
1,183 
1.591 
1,252 
1,707 
1,519 
30.9 
1,641 
1,814 
1,664 
12,703 
Percentage of adulteration. 
Number of samples of milk examined (in- 
47.8 
60.3 
40.3 
36.4 
35.1 
33.8 
32.5 
34.2 
36.3 
eluded above) 
218 
1,123 
2,219 
2,085 
3,081 
2,825 
3,219 
3,236 
2,726 
20,732 
Number of samples above standard 
35 
347 
1,297 
1,323 
1,900 
1,705 
1,120 
1 971 
1,858 
1,629 
12,065 
Number of samples below standard 
183 
776 
922 
762 
1,181 
1,248 
1,378 
1,097 
8.667 
Percentage of adulteration 
83.9 
69.1 
41.7 
36.5 
38.3 
39.6 
38.7 
42.6 
40.2 
41.8 
Number of samples of drugs examined... 
603 
682 
1,007 
888 
550 
862 
600 
400 
424 
6.016 
Number of samples of good quality 
Number of samples adulterated, as defined 
357 
431 
571 
463 
400 
634 
503 
325 
352 
4,036 
by the statutes 
246 
251 
436 
425 
150 
228 
97 
75 
72 
1.980 
Percentage of adulteration 
40.8 
36.8 
43.3 
47.8 
27.3 
26.4 
16.2 
18.7 
17.0 
32.9 
Total examinations of food and drugs 
1,298 
2.644 
4,778 
4.326 
5.420 
5,766 
5.454 
5,985 
5,294 
40.965 
Total examinations of good quality 
Total examinations not conforming to the 
720 
1,210 
2,751 
2,649 
3.563 
4,019 
3,716 
4,096 
3,558 
26,282 
statutes 
578 
1.434 
2,027 
1.677 
1,857 
1,747 
1,738 
1,889 
1,736 
14.683 
Percentage of adulteration 
Expense of collection, examination, and 
44.5 
54.2 
42.4 
38.7 
34.3 
30.3 
31.9 
31.5 
32.8 
35.8 
prosecution 
Expense of collection, and examination per 
§2,931 56 
$5,529 60 
$8,557 43 
$8,025 34 
$8,803 62 
$8,915 41 
$10,356 28 
$10,013 04 $10,019 41 
$73,151 69 
sample 
2 26 
2 09 
1 79 
1 85 
1 62 
1 54 
1 89 
1 67 
1 89 
1 79 
As is customary under the operation of all new laws of 
similar character, the first few months of work are 
usually devoted to an examination of the different sorts 
of food, in order to determine the extent and the charac- 
ter of adulteration. This preliminary examination es- 
tablished the fact that many staple products are not 
subject to adulteration, except in rare and exceptional 
instances. This applies, so far as Massachusetts is con- 
cerned, to sugar, Hour, and the various other cereal prod- 
ucts, so that it has not been deemed necessary to give 
much attention to these articles of food. Hence the fig- 
ures in the foregoing table should not be understood as 
representing the actual amount of adulteration existing 
in the general food-supply, nor even in articles liable to 
adulteration, since special pains are taken at times to 
obtain only such articles as are known to be adulterated. 
Experience often shows an inspector where to find adul- 
terated articles of food. The difference in the percent- 
ages of the first two years (1883 and 1884) and the last 
two (1890 and 1891) in the foregoing table may be taken 
as representing quite fairly the improvement, not in the 
general food-supply under the present inspection, but in 
those articles which are found to be liable to adultera- 
tion. Upon this point the Board published the follow- 
ing general statement in its Annual Report of 1884 : 
" There can be no question as to the beneficial results 
of the law, as executed by the officers of the Board, in im- 
proving the quality of the food and drug supply of the 
State, especially in regard to milk and butter-in the 
former case as relates to the quality of the supply, and 
in the latter as relating to the proper branding and mark- 
ing of spurious goods. The extensive correspondence of 
the Health Department with wholesale houses outside of 
Massachusetts also confirms their appreciation of the 
value of the work done in this State, and also thb neces- 
sity of furnishing articles of undoubted purity for this 
market. This is especially true of all classes of drugs 
sold at wholesale by parties outside the State. 
" The actual economic results obtained by the enforce- 
ment of the statutes relative to food and drug inspection 
cannot be stated exactly. The law is comprehensive and 
its provisions cover a great variety of articles. Its re- 
straining influence extends outside of Massachusetts to 
manufacturers sending goods to this market. Such par- 
ties appreciate the value of the work done in this State, 
and also the necessity of furnishing articles of undoubted 
purity for this market. It is specially provided by the 
statute that at least three-fifths of the amount appropri- 
ated shall be expended in the enforcement of the laws 
relating to the adulteration of milk and its products. 
This provision has been carefully observed." 
It was found convenient, after a year's work, to adopt 
a code of regulations for the government of its analysts 
and inspectors in the performance of their duties under 
the Food and Drug Acts. The following is a copy of 
these regulations. It is not thought necessary to repeat 
the laws in force in Massachusetts here, since the sub- 
stance of them has been presented in the third volume of 
the Reference Handbook : 
Rules and Regulations of the State Board of Health of 
Massachusetts Relative to the Inspection and Analysis of 
Food and Drugs.-1. The State Board of Health shall 
appoint analysts and inspectors, as provided in section 5 
of chapter 263, Acts of 1882. 
2. It shall be the duty of the inspectors to procure 
samples of drugs and articles of food at such times and 
places as the secretary shall direct, in the manner pro- 
vided in section 6 of chapter 263 of the Acts of 1882, and 
in section 3 of chapter 289 of the Acts of 1884, and in 
all acts amendatory of said provisions. 
3. Under the direction of the secretary, the inspectors 
shall, for the identification of samples, affix a number 
to each sample of food or drugs obtained by them, in 
such manner as may be prescribed. Under no circum- 
stances shall an inspector convey any information to an 
analyst as to the source from which any sample was ob- 
tained. 
4. The inspectors shall keep records of each sample, 
each record to include the following items : (a) The in- 
spector's number ; (b) the date of purchase or receipt of 
sample ; (c) the character of the sample ; (d) the name of 
the vendor ; (e) the name of the city or town, and street 
and number where the sample is obtained, and in the case 
of a licensed milk pedler, the number of his license ; (/) 
as far as possible the names of manufacturers, producers, 
or wholesalers, with marks, brands, or labels stamped or 
printed upon goods. 
5. It shall be the duty of the analysts so appointed to 
determine, under the direction of the secretary, by proper 
examination and analysis, whether articles of food and 
333 Food and Drug 
Inspection. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
drugs, manufactured for sale, offered for sale, or sold 
within this Commonwealth, are adulterated within the 
meaning of chapter 263 of the Acts and Resolves passed 
by the General Court of Massachusetts in 1882, and all 
acts amendatory thereof, adulteration being defined as 
follows, viz. : 
In the case of drugs, (1) If sold under or by a name 
recognized in the United States Pharmacopoeia, it differs 
from the standard of strength, quality, or purity laid 
down therein, unless the order calls for an article inferior 
to such standard, or unless such difference is made known 
or so appears to the purchaser at the time of such sale. 
(2) If when sold under or by a name not recognized in 
the United States Pharmacopoeia, but which is found 
in some other pharmacopoeia or standard work on Mate- 
ria Medica, it differs materially from the standard of 
strength, quality, or purity laid down in such work. (3) 
If its strength or purity falls below the professed stand- 
ard under which it is sold. 
In case of food: (1) If any substance or substances 
have been mixed with it, so as to reduce or lower or in- 
juriously affect its quality or strength. (2) If any inferior 
or cheaper substance or substances have been substituted 
wholly or in part for it. (3) If any valuable constituent 
has been wholly or in part abstracted from it. (4) If it 
is an imitation of or is sold under the name of another ar- 
ticle. (5) If it consists wholly or in part of a diseased, 
decomposed, putrid, or rotten animal or vegetable sub- 
stance, whether manufactured or not, or in the case of 
milk, if it is the produce of a diseased animal. (6) If it 
is colored, coated, polished, or powdered, whereby dam- 
age is concealed, or if it is made to appear of better or of 
greater value than it really is. (7) If it contains any 
added poisonous ingredient, or any ingredient which 
may render it injurious to the health of the person con- 
suming it. 
6. It shall also be the duty of the analysts to receive 
such specimens of food and drugs for analysis as may 
be delivered to them by the secretary, or by the inspec- 
tors, and to examine the same. To avoid, as far as pos- 
sible, all suggestion or danger of specimens having been 
tampered with, each analyst shall keep each specimen in 
his possession in a suitable and secure place, labelled in 
such a manner as to prevent any person from having 
access to the same without the knowledge and presence 
of the analyst. 
Analyses of perishable articles should be made 
promptly after they are received. 
7. An analyst shall give no information, under any 
circumstances, regarding the result of any analysis,, to any 
person except to the secretary of the Board, prior to any 
trial in court in reference to such analysis. 
The analysts shall carefully avoid any error regarding 
the inspector's number attached to each sample, and 
shall report the results of their work in detail to the sec- 
retary. 
In the case of all articles having a numerical standard 
provided by statute, the result of the analysis should 
show their relation to such standard. 
8. Before beginning the analysis of any sample, the 
analyst shall reserve a portion, which shall be sealed, and 
in the event of finding the portion analyzed to be adul- 
terated, he shall preserve the sealed portion, so that in 
case of a complaint against any person the last-named 
portion may, on application, be delivered by the secretary 
to the defendant or to his attorney. 
9. Each analyst shall present to the secretary, on the 
Monday before the first Thursday of each month, a 
summary of the analyses made by him during the previ- 
ous month. 
Each analyst shall also present, on or before the first 
of January of each year, an annual report of the work 
done for the year ending on the 30th of September pre- 
ceding. 
10. The secretary shall have charge of the reports of 
analyses, and shall cause cases founded on such reports 
to be submitted to the courts for prosecution. 
In each case of a retailer, and of every dealer not a 
manufacturer or producer, he may, if the party has not 
been previously complained of in court, issue a notice or 
warning of any violation of the law relative to the adul- 
teration of food and drugs, and of the offender's liability 
to prosecution on a repetition of the sale. 
11. Should the result obtained by any analyst be ques- 
tioned in any given case, another analyst shall repeat the 
analysis, unless otherwise instructed by the Board, pro- 
vided a sufficient sum to meet the expense of the analysis 
be deposited with the secretary by any interested party 
feeling aggrieved, which sum will not be returned unless 
the second analysis fails to confirm the first in essential 
particulars. 
12. Any appeal from the decision of an analyst shall be 
filed with the secretary, who shall report it, and any 
matter in controversy to the Board, giving his judgment 
thereon, and the Board shall supervise and control the 
action of its officers in executing the law. 
13. Where standards of strength, quality, or purity are 
not fixed by the act, the analysts shall present to the sec- 
retary such standard as in their judgment should be 
fixed, and the secretary shall report the same to the 
Board for its action. The standards set by the British 
Society of Public Analysts will be followed, as nearly as 
practicable, until otherwise ordered. 
14. Whenever a drug or preparation, not prescribed in 
a national pharmacopoeia or other standard work on Ma- 
teria Medica, shall be manufactured, offered for sale, or 
used in this State, the standard of such drug, and the 
standard and proportion of the ingredients of such prepa- 
ration, and the range of variability from such standard 
or standards, shall be ascertained by the analysts, who 
shall report the same through the secretary to the 
Board. 
15. The analysts shall occupy such time in the per- 
formance of their respective duties as a reasonable com- 
pliance with the terms of the statute shall require, and 
shall be present one hour of each day, at such time of the 
day and at such place as shall be designated by the Board, 
to meet the convenience of interested parties and the 
public. 
The following classified list embraces most of the ex- 
aminations of articles of food examined in Massachusetts 
under the Food and Drug Acts up to October 1, 1891: 
Articles examined. 
Number 
examined. 
Number adnl- „ . . 
terated or be- P«cent of 
low standard. ^"Iteratrnn. 
Milk 
20,732 
8,667 
41.8 
Condensed milk 
20 
2 
10 
Butter 
1,195 
338 
28 
Cheese 
130 
1 
0.8 
Vinegar 
1.140 
052 
57 
Lard 
173 
74 
43 
Olive-oil 
313 
200 
66 
Spices find Condiments: 
Black pepper 
997 
331 
33 
White pepper 
582 
239 
41 
Cayenne pepper 
140 
33 
23 
Mustard 
784 
379 
47 
Cloves 
737 
154 
21 
Cassia and cinnamon 
789 
103 
13 
Pimento 
18 
2 
11 
Ginger 
663 
73 
11 
Nutmeg 
18 
1 
6 
Mace 
179 
69 
39 
Allspice 
340 
27 
8 
Curry powder 
21 
0 
0 
Coffee 
290 
97 
33 
Tea 
352 
5 
1 
Cocoa and chocolate 
4 y 
9 
12.5 
Wheat flour 
22 
0 
0 
Bread 
24 
1 
4 
Cake 
3 
0 
0 
Corn-meal, rye-meal, oat-meal, 
barley-meal 
15 
0 
0 
Sago, tapioca, and corn-starch. 
21 
0 
0 
Buckwheat and cerealin 
3 
0 
0 
Cream of tartar 
1.877 
370 
20 
Baking powders 
150 
115* 
74 
Soda and saieratus 
100 
2 
Molasses 
1,105 
212 
18 
Syrups 
39 
13 
33 
Maple syrup 
210 
89 
42 
Sugar 
151 
5 
Maple sugar 
118 
44 
37 
* Containing alum. 
334 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Food and Drug 
Inspection. 
Artificial Coloring-matter in Food.-The practice of 
employing coloring-matters in connection with different 
articles of food is very common. The following may be 
named as very common examples : 
Certain condiments, such as mustard, ginger and other 
spices, sugar, confectionery, preserved and canned goods 
(especially peas and beans), milk, butter, oleomargarine, 
pickles, cake, syrups, and various sorts of beverages. 
The coloring-matters employed in connection with 
these articles of food may be classified as follows : 
1. Harmless Colors.- These are usually made from 
some comparatively harmless organic products, such as 
annatto, caramel, turmeric, and cochineal. 
2. Injurious Colors.-These are usually some of the 
metallic compounds, such as lead, copper, and tin. 
It cannot be urged in regard to any of these colors, 
whether harmless or otherwise, that they have any true 
value as articles of food, and the demand for their use 
comes mainly from the trader, and not from the actual 
consumer, excepting, so far as the latter has been er- 
roneously educated by the former as to color-standards 
in the matter of food. No good and useful end is 
attained by their use, so far as the question of nutriment 
is concerned, and not only may harm ensue, but also 
even fatal consequences, as in recent cases which occurred 
in Philadelphia from the use of poisonous compounds of 
The true use of artificial-food colors is usually a fraud- 
ulent one, and they are consequently employed mainly 
for the purpose of giving to an inferior article of food a 
fictitious value, and thus to imitate other articles of a 
similar character, but of better quality, at least so far as 
their actual cost is concerned. The difference in actual 
nutritive value as articles of food may, however, be but 
little or nothing. 
When examinations of milk were made in Massachu- 
setts soon after the enactment of the law of 1882, it was 
found that the addition of coloring-matter to milk was a 
very common practice in the cities. From the fact that 
colored samples of milk were almost invariably found to 
be adulterated in other ways, it was inferred that artifi- 
cial coloring was practised for the purpose of concealing 
fraud, and of giving to milk which had been skimmed and 
watered the appearance of milk of good standard quality. 
Hence a vigorous warfare was made against the practice 
until it disappeared. 
The question of the sale of preserved vegetables colored 
bright green by sulphate of copper came to the attention 
of the Board, and the safe ground was taken that the 
introduction of poisonous metallic colors in any amount 
whatever, should have no legitimate place in the food- 
supply of the people. 
Trichinae in Pork.-Among the many questions re- 
lating to the food-supply in Massachusetts the quality 
of the pork offered for sale has not been overlooked. 
Nearly thirteen thousand hogs have been examined un- 
der the direction of the Board for the presence of tri- 
chinae. Of this number seven hundred and ninety-one, 
or 6.3 per cent., were found to be trichinous. Western 
hogs were found to contain less than Eastern, and of 
those raised in Massachusetts, those reared in public insti- 
tutions and upon the refuse of cities were found to suffer 
the most. An examination was also made of sausages, 
and only one out of 365 was found to contain trichinae. 
Baking-powders. - No class of substances employed 
in the preparation of food has been the subject of so 
much discussion as these ; and this is true notwithstand- 
ing the fact that, as elements in the matter of food econ- 
omy, or as nutritive constituents of the necessary food 
of mankind, they have absolutely no value. Their use 
in the preparation of food was unknown until the early 
part of the present century, and for ages the human race 
lias thrived without them. Whenever bread was desired 
which should possess the properties of porosity and light- 
ness of texture, in early times, some sort of leaven or 
yeast was employed for the purpose. 
The use of baking-powders at the present day is due, 
undoubtedly, to several causes, prominent among which 
is a demand for rapid and convenient methods of pre- 
Articles examined. 
Number 
examined. 
Number adul- 
terated or be- 
low standard. 
Per cent, of 
adulteration. 
Glucose 
4 
9 
50 
Honey 
266 
118 
44 
Confectionery 
285 
52 
18 
Milk sugar 
1 
0 
1 
Pickles 
29 
2 
7 
Lime-juice 
7 
0 
0 
Lemon juice 
21 
21 
100 
Horse-radish 
20 
8 
40 
Arrow-root 
21 
4 
19 
Gelatine 
34 
3 
9 
Salt 
21 
1 
5 
Canned foods t 
203 
133 
66 
Flavoring extracts 
39 
5 
13 
Sardines 
5 
4 
80 
Jellies and jams 
61 
12 
20 
Fig paste 
2 
1 
50 
Whiskey, wine, ale, beer, and 
cider £ 
17 
7 
41 
Miscellaneous § 
79 
0 
0 
Drugs 
6,016 
1,980 
33 
t A considerable portion of these were French vegetables, which were 
examined for the presence of copper as a coloring agent. 
f A large number of examinations of spirits and wines is included in 
the item of drugs. 
§ Under this head are included samples of sage, marjoram, macaroni, 
vermicelli, poultry dressing, desiccated cocoa-nut, citron, compressed 
yeast, meat-extracts, etc. 
A broad view of the subject of food inspection would 
include the examination of water as one of the neces- 
saries of life, since it is essential to the preparation of 
most articles of food, and also a convenient vehicle for 
the administration of very many of them. It is also 
absolutely necessary to the healthy growth of the human 
organism. 
The important work of water analysis has been con- 
ducted by the Engineering Department of the State 
Board of Health since 1887, and this work has been ex- 
tended to the examination of the waters of the ponds, 
streams, springs, reservoirs, and wells used as public 
supplies by about one hundred and fifty cities and towns 
in the State. The total number of such examinations 
has been about ten thousand five hundred. Full reports 
upon this subject may be found in the reports of the 
Board for the years 1887 to 1892. 
In addition to the regular routine mode of food and 
drug inspection in Massachusetts, much has been ac- 
complished by work in special directions during the nine 
years since the work was begun. These may be enumer- 
ated as follows : 
Investigations relating to the quality of milk as pro- 
duced by the cow. 
Analysis of injurious and other empirical preparations: 
Hair-dyes, cosmetics, bitters, and tonics ; alleged cures 
for the opium and alcohol habits, etc. 
Coloring-matters in food : Milk, butter, oleomargarine, 
preserved vegetables, salts of tin in molasses, etc. 
Food Preservatives. - The quality of wines and 
liquors; report upon oleomargarine ; the uses of glucose 
in food ; the presence of trichinae in pork products ; the 
standard of vinegar ; baking-powders ; the use of the word 
" compound. " 
The Standard of Milk.-For the purpose of determining 
the consistency of the existing standard of milk in Mas- 
sachusetts, analyses were made in 1884 of the milk of 
six hundred cows, the samples being collected in differ- 
ent parts of the State, and from different herds of ani- 
mals, of different ages, and in different seasons of the 
year. The average total solids of the entire number was 
found to be very nearly thirteen and one-third per cent, 
(the legal standard is thirteen per cent.). In later years 
these figures have been confirmed by further examina- 
tions upon the same point. 
With reference to breeds of cows the results of anal- 
yses were as follows : 
The average milk of 11 Jerseys had 14.02 total solids and 4.34 fat. 
" " " " 92 native cows " 13.09 " " " 3.31 " 
" " " " 30 Ayrshires " 12.97 " 11 " 3.35 " 
" " " " 51 Durhams " 12.73 " " " 3.28 " 
" " " " 47 Holsteins " 12.51 " " " 3.29 " 
335 Food and Drug 
Inspection. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
paring bread and pastry for cooking ; and, also, to the 
stimulus of trade produced by excessive advertising. 
If the statements of rival manufacturers as to the poi- 
sonous qualities of all other baking-powders except their 
own were to be credited, the use of these preparations 
would soon cease. Such false teaching does harm in 
misleading the community and creating a distrust. The 
fallacy lies in the want of discrimination between large 
and small doses of the ingredients of such powders. For 
example, common salt and mustard act as poisons in large 
doses and produce vomiting. In small doses, on the con- 
trary, neither of them is harmful. 
The same is also true, to a certain extent, of cream of 
tartar, alum, and other ingredients of baking-powders. 
Another property which is common to this class of arti- 
cles is that of chemical reaction, which takes place when 
the different ingredients of these powders are brought in 
contact, and also into solution, in the process of prepara- 
tion of bread. The resulting salts which follow7 this 
union may, and often do, have very different properties 
from those which were characteristic of the different 
ingredients of which such powders were originally com- 
posed. In one instance hydrate of alumina is the result- 
ing salt; in another, a salt quite similar to Rochelle 
salts; and in another, the phosphate of alumina. It is 
therefore a misleading statement to call alum " a corro- 
sive poison," or to assert the same property of cream of 
tartar or the acid phosphate of lime, since it is not in 
either of these forms that the baking-powder is ingested 
by the consumer. For the same reason it is also mani- 
festly wrong to state that cream of tartar or phosphate 
of lime is healthful. Both of these are drugs, and as 
such have their proper uses. Their constant daily use 
is another question. 
The singular claim has been made in behalf of the 
phosphate of lime that it "restores the phosphates lost 
by the removal of the bran." It may reasonably be 
asked whether, in the interest of public health, as well 
as economy, it would not be better to retain this valuable 
portion of the grain in preference to the attempt to sub- 
stitute for the natural constituent an artificial representa- 
tive. Flour made from the whole wheat, or other grains, 
while it may be less pleasing to the eye and possibly to 
the taste, has the advantage of producing w'holesome 
bread. 
Claims are made by the makers of baking-powders of 
purity for their own products, and also of impurity for 
the products of others. In whatever sense these terms 
may be regarded by the community at large, it should be 
remembered that the introduction of these articles is of 
comparatively recent date; that they are compounded of 
several ingredients ; that different manufacturers employ 
different ingredients to attain the same object or end. 
No standard has ever been adopted by any government 
authority, so far as we can learn, for this class of prepa- 
rations ; hence the use of the terms purity and impurity, 
as applied to them, must be considered as arbitrary, or 
at least merely conventional. Experiments have been 
undertaken with the view of settling the question as to 
whether the ingredients of certain baking-powders were 
injurious to health ; and, while positively harmful results 
have in some instances been reached by the ingestion of 
considerable doses of such ingredients, when taken sin- 
gly, still, the question of actual injury to health, on the 
one hand, or of freedom from harm on the other, from 
the use of baking-powders in food, cannot be regarded 
as settled. 
Mixtures or Compounds.-The work of inspection in- 
cludes a careful examination of the methods in which 
food is offered for sale, especially with reference to the 
question of labelling and the agreement of the label with 
the actual contents of the package to which it is affixed, 
since the statute of Massachusetts provides that "mixt- 
ures or compounds " are not to be treated as adulterated 
in the eye of the law, "provided that the same are not in- 
jurious to health and are distinctly labelled as mixtures 
or compounds." 
This provision of the law is frequently disregarded, 
especially in the case of spices; and while the term 
" compound " is to be found after prolonged search upon 
the label, it often occupies an obscure position, or is 
printed in extremely small type, so that the term " dis- 
tinctly labelled " does not apply. 
It is not always safe to infer that all parts or packages 
in a lot of spices or similar articles of food are pure, be- 
cause a single sample or package proves to be pure. The 
following case is an illustration: Two packages of pow- 
dered cloves were obtained at a grocery. The packages 
were in unbroken tin boxes of one-quarter pound each, 
and were purchased at an interval of three weeks ; each 
package was of the same size, and each had exactly the 
same brand or label. On inquiry of the retailer it was 
found that both of the packages came from the same lot. 
It appeared on examination that the first package was 
considerably adulterated and the second was pure. A 
notice of this fact was therefore sent as usual to the re 
tailer, who transmitted the notice to the manufacturer, 
who lives outside the limits of the State ; he denied the 
charge, and hence, as is customary in cases of disputed 
analysis, samples were sent to a second analyst, who con- 
firmed the statement of the first; and finally, four analy- 
ses were made with the same result, neither chemist 
knowing anything of the source of the samples, nor did 
either know that a previous analysis had been made. 
This circumstance shows that it is not always safe to 
judge of the character of any group or lot of articles from 
the examination of a single sample. 
Gross Appearances.-It is evident that very little reli- 
ance can be placed upon the mere external inspection of 
articles of food, such as may be made by the employment 
of the senses of taste, touch, smell, and sight, since the 
principal object of the falsifier of food preparations is to 
deceive the senses of the consumer by every possible re- 
source of his art. It is a common experience in this de- 
partment of work to receive articles of food from various 
sources, which are believed by the persons presenting 
them for examination to be adulterated, but which the 
analyst finds to be pure. This experience is true in the 
case of many of the articles of food which are liable to 
adulteration, and also of some articles which are scarcely 
ever found to be adulterated. The same experience has 
been met by other authorities who have had charge of 
similar work (" Report of Commissioner of Internal Rev- 
enue, Washington, 1887," p. exliii.). Among the vari- 
ous articles which have been thus submitted to the Board 
for examination (under the impression of the person sub- 
mitting them that they were adulterated) were the fol- 
lowing : Flour, sugar, molasses, vinegar, cream of tartar, 
honey, milk, butter, cheese, lard, salt, and several kinds 
of spices or condiments. 
The reasons for these false notions with reference to 
the quality of articles of food are mainly the following : 
1. A liability to mistake the deterioration of an article, or 
an inferiority in grade or quality, for an actual falsifica- 
tion or substitution. 2. A lack of familiarity with the 
true physical characteristics of the article in question. 
Notices to Retailers.-It has been the custom of the 
Board to issue a w aiming notice to retailers selling arti- 
cles found to be adulterated, in cases where there was 
a reasonable probability that the retailer was not, aware 
that such articles were adulterated. 
In certain articles of food which have been specially 
liable to fraud, such as the various sorts of spices, condi- 
ments, cream of tartar, etc., adulteration has been greatly 
diminished, and is in many instances limited to parties 
whose business is conducted outside of the State, and 
cannot therefore be easily reached except through the 
customary notice sent to the retailer who buys of such 
outside parties. 
These notices have proved to be a very efficient mode 
of diminishing adulteration. It is not the retailer who 
is seriously affected by the receipt of such a notice, but 
the wholesale dealer or manufacturer to whom it is 
speedily forwarded by the retailer, and who finds that he 
cannot afford to continue a wholesale imposition. 
Drugs.-The term "drugs" in the Massachusetts 
Act of 1882 embraces "all medicines for internal and 
external use, antiseptics, disinfectants, and cosmetics. 
336 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Food and Drug 
(SUPPLEMENT.) 
Inspection, 
Hence the work of the State Board of Health, in this di- 
rection, has not been confined to the remedies defined in 
the United States Pharmacopoeia, but has embraced many 
other articles, and especially empirical preparations of a 
more or less harmful character. 
Of the drugs found to be of a specially inferior quality 
during the earlier investigations of the analysts in 1883' 
and 1884 were the following : 
Tincture of opium (U. S. P., 1.20 to 1.60 parts per 
100 of morphine), 144 samples out of 197 fell below the 
required limit of 1.2, and some had as little as .01, 
.14, .17, or a mere fraction only of the minimum require- 
ment. Citrate of iron and quinine (legal requirement 
twelve per cent, of quinine), eighty-five per cent, of the 
samples had less than the required amount, and several 
had as little as three and 3.5 per cent., or but little more 
than a quarter of the requirement. Of powdered jalap 
only one sample out of twelve conformed to the phar- 
macopoeial standard. Of 192 samples of powdered drugs, 
39 were found to be adulterated in various forms. Of 19 
samples of compound spirits of ether, 2 only contained 
the required amount of the ethereal oil required by the 
statutes. Of 23 samples of spirit of nitrous ether, scarcely 
any had the required amount of ethyl nitrite. 
Twenty-two samples or lots of the quinine pills made 
by different manufacturers were examined. These 
were examined in two groups, at an interval of several 
months, during which time the manufacturers had be- 
come aware of the work of the Board in this direction. 
The analysis of the second group showed in nearly 
every instance an improvement. The following figures 
indicate the percentages of the required weight of the 
pills made by nine manufacturers, in the.two series of 
analyses: 
Percentage of Adulteration as Given in the Reports of Each 
Year. 
England and Wales. 
Massachusetts 
Ratio of 
Ratio o 
Average 
Year. 
adulteration. 5 years. 
adulteration. 
Per cent. Per cent. 
Per cent. 
1877 .... 
19.2' 
1878 
17.2 
1879 
14.8 
• 16.2 
1880 
15.7 
1881 
14.7, 
1882 
1883 .... 
15.0 
44.5 
1884 .. .. 
14.4 
13.9 
54.2 
1885 
13.2 
42.4 
1886 
11.9 
38.7 
1887 
12.8 
34.3 
1888 
10.8 
30.3 
1889 
11-5 
12.7 
31.9 
18^0 
11.2 
31.5 
1891 
32.8 
First Series. Second Series. 
1. 93.5 97.9 
2. 86.6 97.3 
3. 93.3 99.6 
4. 93.8 100.7 
5. 107.6 76.5 
First Series. Second Series. 
6. 84.7 89.5 
7. 93.8 101.1 
8. 104.4 100.5 
9. 97.0 97.1 
The foregoing list shows an improvement in each case 
except two. Of 106 samples of pharmacopoeial spirits 
and wines, only 10, or 9.4 per cent., conformed to the le- 
gal requirements. 
In proof of the improvement under the action of the 
statutes, very marked changes for the better have been 
found to have taken place in many of the foregoing ar- 
ticles. 
Among the non-pharmacopoeial preparations exam- 
ined in 1885, were eleven hair-dyes, all of which con- 
tained lead in large amounts ; also twenty different fraud- 
ulent nostrums advertised for the cure of the opium- 
habit, most of which were solutions of morphine. One 
of them was the so-called " Keeley gold cure," which was 
found to contain no gold whatever. In 1887 about fifty 
proprietary articles, sold as tonics and bitters (some of 
which were advocated as temperance drinks), were ex- 
amined chiefiy for their alcoholic contents. All -were 
found to contain alcohol in the proportion of six to 
forty-eight per cent, by volume. One of these, which 
was advertised as a remedy for inebriety and the opium- 
habit, was the celebrated " Scotch Oats Essence," con- 
taining alcohol and morphine, the latter in varying pro- 
portions. This nostrum very soon disappeared after its 
analysis had been published. 
Cosmetics for the complexion, termed face-bleaches, 
freckle-lotions, skin-tonics, have been examined and 
found to consist of strong solutions of corrosive subli- 
mate. It was required that these, if sold at all, should 
be labelled as poisons, and sold under careful restrictions 
only. Seventeen complaints were made against parties 
selling these articles in violation of the statutes. 
In the following brief table the ratio of adulteration 
found in articles of food and drugs in England and in 
Massachusetts, during the period of inspection and en- 
forcement of the laws, is presented : 
Fig. 160.-Diagram showing the Ratio of 1 
1877-91, and in Massachusetts, 
Adulteration in England, 
s, 1883-91. 
As a comment upon the foregoing table and diagram 
the following observations may be made : 
First. The gradual lessening of adulteration under the 
action of judicious legislation. 
Second. The much greater ratio presented in the col- 
umn headed Massachusetts than in that of England and 
Wales. 
The reason for this great difference may be found, 
first, in the fact that in conformity to the requirements of 
the statutes in Massachusetts more than half the samples 
examined were milk. The standard of milk in the State 
is unusually high as compared with that of other coun- 
tries (thirteen per cent, of solids, except in May and 
June, when it is twelve per cent.). Hence it is the cus- 
tom to report all samples as adulterated which are found 
to be below the foregoing limits. Now, there are many 
animals, especially those of the Holstein breed, which 
habitually produce milk having less than thirteen per 
cent, of solids. Hence it has not been deemed prudent 
to enter complaints at court to the full extent of the legal 
requirements. In the case of milk, therefore, the ratio 
of adulteration as reported is partially an apparent and 
not an actual adulteration. Secondly, the samples se- 
lected under the Massachusetts law are mainly such as 
are known or suspected to be adulterated, while in Eng- 
land many samples of such staple articles as bread, flour, 
sugar, and tea are annually examined, which are prac- 
tically free from adulteration. 
In the following table and diagram the articles exani- 
337 Food and Drug 
I nspection. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
ined are classified in three groups, by means of which 
this element of apparent adulteration in milk is separ- 
ated: 
(SUPPLEMENT.) 
The first group is subject to the following subdivision, 
(a) Additions have been made to the food products either 
of a commercial or fraudulent nature, and of substances 
more or less harmful. (6) The vessel in which the food 
has been prepared or preserved renders the food poison- 
ous. (c) The manipulation of food, or its surroundings, 
may expose it to harmful contamination, (d) It may be 
mixed accidentally with foreign substances. 
The second group is subject to the following divisions •. 
(a) An animal designed for food has been fed with food 
of a harmful or poisonous character ; the poisons ab- 
sorbed appear in the milk, or, not having had time to be- 
come eliminated, either the whole animal or some of its 
organs have become poisonous, (b) Recognizes the pos- 
sibility of the formation of poisonous ptomaines in meat, 
under certain conditions, (c) In consequence of certain 
unknown conditions wholesome vegetable food occa- 
sionally becomes harmful. 
Third group: (a) Animal, vegetable, and mineral 
food products may be invaded by parasites of the larger 
kinds, (b) Food may become the prey of micro-organ- 
isms of a parasitic nature, involving the processes of (1) 
fermentation, (2) putrefaction and (3) the development of 
infectious diseases, either of which may render the food 
harmful, either by infection, by ptomaine poisoning or 
by the combined action of both, (c) Food contaminated 
by its surroundings, or by infectious contact, becomes 
the carrier of pathogenic germs. 
This list is sufficiently ample to show that the food 
analyst has a wide field of investigation. 
The following special regulations regarding food in- 
spection were published by Dr. Schumacher Kopp, Can- 
ton Chemist of Lucerne, and also a member of the Inter- 
national Jury of Award at the Paris Exposition of 1889. 
The following extract is taken from his report: 
Collection of Food.-In collecting food the greatest 
cleanliness should be observed. Clean bottles, and, if 
possible, new ones, should be used in collecting fluids. 
Bottles should be closed only with new corks. 
In collecting drinks, the local experts must be present, 
and the beverages should be drawn from the regular 
source of supply. 
In collecting milk, fill the bottle to the cork ; seal 
every bottle at once after corking it. If milk is collected 
in a stable, the cows must be milked quite dry, by a dis- 
interested person, and in the presence of the local magis- 
trate, or a policeman. 
Strong glass, or porcelain, or crockery vessels should 
be used for the collection of butter. 
For coffee, tea, and meal, boxes of clean wood or paste- 
board should be used. 
The use of paper bags for collecting samples is forbid- 
den. 
Bread and sausages should be wrapped in clean wdiite 
paper ; if possible, parchment paper. 
The use of printed or colored paper for this purpose is 
forbidden. 
Quantity of Food Necessary for Examination.-1. For 
the local health authority : Beer, one litre ; bread, one 
whole loaf ; brandy, 0.3 litre ; butter, 50 grammes ; vine- 
gar, 0.2 litre ; coffee, 30 grammes ; meal, 200 grammes ; 
milk, 0.5 litre ; cider, 0.5 litre ; tea, 10 grammes ; drink- 
ing-water, 1 litre; wine, 0.5 litre; small sausages, one 
whole sausage ; large sausages, 100 grammes ; honey, 
50 grammes. 
For the Canton Chemist the quantities are nearly the 
same as the foregoing, but in most instances two samples 
are taken. When two samples are taken, for example, 
of water, two litres in one bottle are not meant, but twro 
bottles each containing one litre. 
Sealing.-The samples collected must be sealed at once 
upon the spot, with an official seal. This seal must 
cover the whole head of the bottle, in order to keep the 
air out, and to avoid leakage. 
Marking.-The samples should be plainly marked in 
two different places immediately after collection, one on 
the neck of the bottle, and the other on the opposite side 
of the body of the bottle. Each marking must contain : 
1, The number and name of the article collected; 2, 
Percentage of Adulteration in Milk, other Articles of Food, 
and Drugs in Massachusetts. 
Years. 
Milk. 
Other articles 
of food. 
Drugs. 
1883 
83.9 
35.4 
40 8 
1884 
69.1 
48.5 
36.8 
188$ 
41.7 
43.1 
43.3 
J 886 
36.5 
36.2 
47.8 
1887 
38.3 
29.4 
27.3 
1888 
39.6 
19.2 
26.4 
1889 
38 7 
24 0 
16 2 
189(1 
4'2.6 
18.6 
18.7 
1891 
40.2 
26.4 
17.0 
Fig. 161.-Diagram showing the Ratio'of Adulteration of Drugs and 
Different Articles of Food in Massachusetts in the Years 1883-91. 
Milk, ; other articles of food, ; drugs 
The ratio of samples of food collected for examination 
to the whole population for the past five years has been 
about as follows : In England and Wales, 1 to each 1,000 
of the population ; in the city of Paris, 1 to each 120 
of the population ; in Massachusetts, 1 to each 375 of the 
population. 
The work of a food analyst embraces a variety of 
branches. In a recent monograph by two French army 
surgeons, Polin and Labit, the following classification of 
such work is presented. Three principal groups, as fol- 
lows : 1. Examination of articles in which the alterations 
in character are either of a chemical or of a mechanical 
kind. 2. Those which are biological. 3. Those which 
are parasitic. 
338 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Food and Drug 
Inspection. 
name of the jurisdiction authorizing the collection, and 
of the collector. 
Provision is made for the collection of two samples 
when necessary, so that, in case of a dispute, the second 
may be examined under the auspices of a superior au- 
thority. The samples sent to the Canton chemist must 
contain no information as to their source. A report 
must also be sent to the Health Officer, stating the arti- 
cles collected, the date of their collection, name of the 
dealer, his source of supply, and in every case his re- 
marks upon the character of his goods. This report 
must be signed by the local expert and by the police as- 
sisting in the collection. All samples sent to the Canton 
chemist must be so packed with sawdust, paper, or wad- 
ding, that they may be transmitted without injury. The 
name of the sender must accompany all packages, letters, 
etc., and they must be prepaid ; otherwise they will not 
be received. 
In sending milk to the Canton chemist, observe espe- 
cially : 1. That the milk is thoroughly cooled in cold 
water before it is forwarded. 2. (a) In the accompany- 
ing report mention must be made first of the number of 
cows from which a sample of mixed milk is taken ; (b) 
how many cows, if any, are in the stable which have 
•calved within fourteen days of collection of the milk ; 
(c) how many cows, if any, are near the time of calving. 
Food Standards.-Bread.-The water in a freshly 
baked loaf of bread should not be more than thirty per 
cent, of its weight, and the ash, after deducting the com- 
mon salt, should not be more than one per cent. 
Butter.-This name should only be associated with the 
fat which is made from milk only. Artificial butter 
must be properly marked as such, being designated as 
margarine, and packed in separate parcels. Such names 
as " cheap butter," " tub butter," and " Alpine butter," 
are forbidden, except as applied to pure butter. 
Vinegar must contain- four per cent, of acetic acid. 
The addition of other acids, flavoring matter, and ani- 
line colors, is forbidden. 
Honey must be called honey only when it is free from 
adulteration. Such terms as "table honey," "Swiss 
honey," and " Appenzell honey," etc., are forbidden, 
except when applied to pure honey. Substitutes for 
honey, such as syrups, etc., and also mixtures of these 
with pure honey, must be plainly marked as such. 
Coffee must not yield more than four per cent, of ash 
(Mocha, eight per cent.). Artificial coloring is to be re- 
garded as adulteration. Mixtures of coffee with other 
substances are not to be called coffee. 
Rye-meal should not yield more than two per cent, of 
ash. 
Wheat meal should not yield more than one and a half 
per cent, of ash. The water of rye- and wheat-meal 
should not be more than fifteen per cent, of its weight, 
and that of other meals eighteen per cent. 
Milk.-Milk must be sold as drawn from the cow. Its 
specific gravity at a temperature of 15° C. (60° F.) before 
skimming should not be less than 1.029 nor more than 
1.033, and when skimmed after twenty-four hours it 
should not be less than 1.033 nor more than 1.037. The 
chemical examination should show at least 11.5 percent, 
of solid residue, and at least three per cent, of fat.* 
When taking milk at dairies for comparison, it is desira- 
ble to have examinations made within the shortest possi- 
ble time, three days at the longest, and the cows should 
be milked dry by disinterested persons. " Centrifugal " 
milk should be marked as such, and when inspected at a 
temperature of 15° C. should have a specific gravity of 
from 1.034 to 1.037, and should have at least 8.4 per 
cent, of solids. The sale of the milk of sick cows is for- 
bidden, as well as that of cows within eight days before 
and after the time of calvipg. 
Cider, after fermentation, must not- have less than 
three per cent, by weight, and 3.76 per cent, by volume 
(SUPPLEMENT 
of alcohol, and not less than 1.5 per cent, of solids, nor 
less than .15 of one per cent, of ash. 
Tea must not have more than seven per cent; of ash. 
Water for domestic use must neither have color nor 
sediment. Nor should it have smell or bad taste. 
Water containing infusoria and bacteria should be 
avoided. 
Sausages should be made only of healthy, fresh meat, 
fat, and spices in general use. Any additions of starches 
are considered as adulterants. 
Propriety of International Laws on the Sub- 
ject of Food Inspection.-Dr. Von Hamel Koss ex- 
pressed his opinion, at the International Congress of Hy- 
giene at London, in 1891, that a codex alimentarius should 
be adopted for civilized nations, as agreed upon by a 
competent commission for general use. He commented 
upon the different standards of different countries, and 
as an example quoted the milk standard of Massachu- 
setts, which is thirteen per cent, of solids (twelve per 
cent, in May and June), while milk having 11.5 per cent, 
solids is deemed to be pure in Holland. 
At the International Congress of Agriculture at The 
Hague, in the following month (September, 1891), con- 
clusions were formulated as to the need of uniform laws 
relative to food adulteration and the protection of food 
products. It was then voted " that each State should 
establish a commission of competent men, who should be 
charged with the duty of investigating the methods of 
analysis in use, and of determining the proper methods 
of such analysis, and that each State should publish an 
annual report of its proceedings and exchange reports 
with other States." 
United States.-Recent attempts have been made to se- 
cure national legislation for the general prevention of food 
and drug adulteration in the United States, but thus far 
the only articles which have become the subjects of such 
legislation are butter and lard. 
The following bill, usually known as the Paddock Bill, 
was reported to Congress in 1890, and in many respects 
resembles that which was reported in 1880. Its pro- 
visions are reasonable, and not as stringent as those 
which are in force in some of the States, since knowl- 
edge of the fact of adulteration on the part of the vendor 
must first be proven to secure conviction under this 
Act. 
A Bill for Preventing Adulteration and Misbranding of 
Food and Drugs, and for other Purposes.-Be it en- 
acted, etc. Section 1. That, for the purpose of pro- 
tecting the commerce in food-products and drugs be- 
tween the several States and Territories of this Union 
and foreign countries, the Secretary of Agriculture shall 
organize in the Department of Agriculture a division to 
be known as the food division, and make necessary rules 
governing the same to carry out the provisions of this 
act, and appoint a chief thereof, at a salary of $3,000 
per annum, whose duty it shall be to procure from time 
to time, under rules and regulations to be prescribed by 
the Secretary of Agriculture, and cause to be analyzed 
or examined samples of food and drugs sold or offered 
for sale in any State or Territory other than where manu- 
factured. The Secretary of Agriculture is hereby au- 
thorized to employ such chemists, inspectors, clerks, 
laborers, and other employees as may be necessary to 
carry out the provisions of this act. 
Sec. 2. That the introduction into any State or Terri- 
tory from any other State or Territory or foreign country 
of any article of food or drugs which is adulterated 
within the meaning of this Act is hereby prohibited, and 
any person who shall wilfully and knowingly ship, or 
deliver for shipment, from any State or Territory or 
foreign country, to any State or Territory, or who shall 
knowingly receive in any State or Territory from any 
other State or Territory or foreign country, or who, 
having so received, shall deliver, for pay or otherwise, 
or offer to deliver to any other person, any such article 
so adulterated within the meaning of this Act, shall be 
guilty of a misdemeanor, and for such offence be fined 
not exceeding $200 for the first offence, and for each sub- 
sequent offence not exceeding $300, or be imprisoned not 
* The standard of whole milk in Paris is a minimum of 11.5 per cent, 
of solids and 2.7 fat. That of the British Society of Public Analysts is 
11.5 total solids and 2.5 fat. That of the State of New York is 12 per 
cent, of solids and 3 per cent, of fat. Of New Jersey 12 per cent, of sol- 
ids. Of Massachusetts and New Hampshire, 13 per cent, of solids. 
339 Food Inspection. 
Friedrichroda. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
exceeding one year, or both, in the discretion of the 
court. 
Sec. 3. That the chief of said food division shall 
make, or cause to be made, under rules and regulations 
to be prescribed by the Secretary of Agriculture, ex- 
aminations of specimens of food and drugs which may 
be collecteel from time to time, under rules and regula- 
tions to be prescribed by the Secretary of Agriculture 
under its direction in various parts of the country, and 
publish in bulletins the result of such analyses. But 
the names of manufacturers or vendors of such foods 
or drugs analyzed shall in no case be published in such 
bulletins until after conviction in the courts of violation 
of this Act. If it shall appear from such examination 
that any other provisions of this Act have been violated, 
the Secretary of Agriculture shall at once cause a report 
of the fact to be made to the proper United States Dis- 
trict Attorney, with a copy of the results of the analysis 
duly authenticated by the analyst under oath. 
Sec. 4. That it shall be the duty of every district 
attorney to whom the food division shall report any 
violation of this Act to cause proceedings to be com- 
menced and prosecuted without delay for the fines and 
penalties in such case provided, unless, upon inquiry 
and examination, he shall decide that such proceedings 
cannot probably be sustained, in which case he shall re- 
port the facts to the food division. 
Sec. 5. That the term " drug," as used in this Act, 
shall include all medicines for internal or external use. 
The term " food," as used herein, shall include all 
articles used for food or drink by man, whether simple, 
mixed, or compound. 
Sec. 6. That for the purposes of this Act an article 
shall be deemed to be adulterated- 
In case of drugs : 
First. If, when sold under or by a name recognized 
in the United States Pharmacopoeia, it differs within the 
knowledge of the seller from the standard of strength, 
quality, or purity according, to the tests laid down 
therein. 
Second. If, when sold under or by a name not recog- 
nized in the United States Pharmacopoeia, but which 
is found in some other pharmacopoeia or other standard 
work on materia medica, it differs within the knowledge 
of the seller materially from the standard of strength, 
quality, or purity, according to the tests laid down in 
said work. 
Third. If its strength or purity fall below the pro- 
fessed standard under which it is sold. 
In the case of food or drink : 
First. If any substance or substances has or have been 
knowingly mixed and packed with it so as to reduce or 
lower' or injuriously affect its quality or strength, so that 
such product, when offered for sale, shall be calculated 
and shall tend to deceive the purchaser. 
Second. If any inferior substance or substances has 
or have been knowingly substituted wholly or in part 
for the article, so that the product, when sold, shall be 
calculated and shall tend to deceive the purchaser. 
Third. If any valuable constituent of the article has 
been knowingly wholly or in part abstracted, so that the 
product, when sold, shall be calculated and shall tend to 
deceive the purchaser. 
Fourth. If it be an imitation of and knowingly sold 
under the specific name of another article. 
Fifth. If it be knowingly mjxed, colored, powdered, 
or stained in a manner whereby damage is concealed, so 
that such product, when sold, shall be calculated to de- 
ceive the purchaser. 
Sixth. If it contain within the knowledge of the seller 
any added poisonous ingredient or any ingredient which 
may render such article injurious to the health of the 
person consuming it. 
Seventh. If it consist within the knowledge of the 
seller of the whole or any part of a diseased, filthy, 
decomposed, or putrid animal or vegetable substance, 
or any portion of an animal unfit for food, whether 
manufactured or not, or if it is the product of a dis- 
eased animal, or of an animal that has died otherwise 
(SUPPLEMENT.) 
than by slaughter : Provided, That an article of food 
or drug which, does not contain within the knowledge 
of the seller any added poisonous ingredient shall not 
be deemed to be adulterated- 
First, in the case of mixtures or compounds which 
may be now or from time to time hereafter known as 
articles of food under their own distinctive names, and 
not included in definition fourth of this section ; 
Second, in the case of articles labelled, branded, or 
tagged so as to plainly indicate that they are mixtures, 
compounds, combinations or blends ; 
Third, when any matter or ingredient has been added 
to the food or drug because the same is required for the 
production or preparation thereof as an article of com- 
merce in a state fit for carriage or consumption, and not 
fraudulently to increase the bulk, weight, or measure of 
the food or drug, or conceal the inferior quality thereof ; 
Fourth, where the food or drug is unavoidably mixed 
with some extraneous matter in the process of collection 
or preparation. 
Sec. 7. That every person manufacturing, offering, 
or exposing for sale, or delivering to a purchaser any 
drug or article of food included in the provisions of this 
Act shall furnish such drugs or article of food to any per- 
son interested or demanding the same, who shall apply 
to him for the purpose, and shall tender him its value, 
of a sample sufficient for the analysis of any such article 
of food which is in his possession. And upon the pres- 
entation of such drug or article of food to the proper 
officer of the food division by a responsible person, with 
a request from such person for an official analysis of the 
same, the chief of such division shall make, or cause to 
be made, such analysis of the drug or article of food so 
presented, under rules and regulations to be prescribed 
by the Secretary of Agriculture. 
Sec. 8. That whoever refuses to comply, upon de- 
mand, with the requirements of section seven of this Act 
shall be guilty of a misdemeanor, and, upon conviction, 
shall be fined not exceeding $100 nor less than $10, or 
imprisoned not exceeding one hundred nor less than 
thirty days, or both. And any person found guilty of 
manufacturing, offering for sale, or selling an adulter- 
ated article of food or drug under the provisions of this 
Act shall be adjudged to pay, in addition to the penalties 
heretofore provided, for all the necessary costs and ex- 
penses incurred in inspecting and analyzing such adul- 
terated articles of which said person may have been 
found guilty of manufacturing, selling, or offering for sale. 
Sec. 9. That in prosecutions for violations of this Act 
proof of the act done shall be held to imply knowledge 
and intent on the part of the accused, unless such knowl- 
edge and intent shall be disproved on the trial. 
Sec. 10. That this Act shall not be construed to inter- 
fere with commerce wholly internal in any State, nor 
with the exercise of their police powers by the several 
States. 
The English Food and Drug Act was quoted with 
sufficient fulness in the third volume of the Reference 
Handbook ; hence it is not repeated here. 
Germany.-After the enactment of the English law, a 
demand arose in Germany for similar legislation, and a 
bill was introduced early in 1879, which became a law in 
May of that year. 
A very complete inquiry had already been made, in 
anticipation of this Act, in the year 1878, embracing the 
examination of 231,478 samples of food, drink, and other 
articles coming under the proposed law. Of these, 3,508 
proved to be adulterated, or 1.5 per cent, only ; 1,538 
articles of food were decomposed and unfit for consump- 
tion, and 3,332 convictions of offenders were secured. 
Of the whole number, there were 152,043 samples of 
milk ; 17,628 of beer ; 21,380 of sausages and meat ; 
17,203 of flour and bread, etc. A few glaring instances 
of the use of harmful ingredients were detected. 
The following is the text of the Act in question : 
Section 1. The sale of food and articles of consump- 
tion, as well as the trade in toys, paper-hangings, colors, 
eating, drinking, and cooking utensils, and petroleum, is 
to be regulated by this Act. 
340 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Food Inspection* 
Friedrichroda. 
Sec. 2. The officers of the sanitary police are em- 
powered to enter any rooms in which the articles com- 
ing under Section 1 are kept for sale, during the usual 
business hours, or while the rooms are kept open for sale. 
They are authorized to take, according to their choice, 
for the purpose of analysis, samples of the articles com- 
ing under Section 1, and which are kept in the sale-rooms, 
or which are sold in public places, upon market-places, 
squares, streets, or which are hawked about. • If request- 
ed, part of the sample must be left with the vendor, 
properly secured or sealed. For the sample the usual 
price is to be paid to the seller. 
Sec. 3. The sanitary officers are empowered to make 
inspections of the premises of persons who have, accord- 
ing to Sections 10, 12, 13 of this Act, been sentenced to 
imprisonment, or of rooms in which articles specified in 
Section 1 are kept for sale, or in which such articles 
intended for sale are stored. 
This power of inspection begins with the date at which 
the sentence takes force, and ceases after three years 
from the date on which the term of imprisonment ceases, 
or is remitted. 
Sec. 4. Sanitary officers, in the meaning of this Act, 
are the medical sanitary officers, as well as those officers 
which are nominated as such by the Superior Court of 
Administration. The central authority of the empire will 
decide which court has to act as Superior Court of Ad- 
ministration. 
Sec. 5. By imperial decree, with assent of the Federal 
Council, regulations for the protection of health may be 
framed to prohibit: 1. Certain modes of preparing, 
storing, or packing articles of food or consumption in- 
tended for sale. 2. The trade and offering for sale of 
articles of food or consumption, of certain conditions, or 
under a name not corresponding to their real condition. 
3. The sale and offering for sale for slaughter of animals 
suffering from certain diseases, as well as the sale and 
offering for sale of the flesh of animals which are affected 
with certain diseases. 4. The use of certain substances 
and colors for the manufacture of wearing apparel, toys, 
paper-hangings, eating, drinking, and cooking utensils, 
as well as the sale and offering for sale of articles manu- 
factured contrary to this regulation. 5. The sale and 
offering for sale of petroleum of a certain nature. 
Sec. 6. By imperial decree, with assent of the Federal 
Council, the manufacture, sale, or offering for sale, of 
articles intended for adulterating articles of food or 
consumption may be prohibited or limited. 
Sec. 7. The imperial decrees, issued under Section 6, 
are to be laid before the next following session of Par- 
liament. They are to be put out of force as soon as 
Parliament so requires it. 
Sec. 8. Whoever acts contrary to the regulations of 
Sections 5, 6, is punishable with a fine up to 150 marks 
(about $35), or with imprisonment. 
Sec. 9. Whoever, contrary to regulations of Sections 2 
to 4, refuses entry to the rooms, the taking of samples, 
or inspection, is punishable with a fine from 50 to 150 
marks, or with imprisonment. 
Sec. 10. Liable to imprisonment up to six months, and 
to a fine up to 1,500 marks, or to either of these, is : 1. 
Whoever, for the purpose of fraud in commerce, imi- 
tates articles of food or consumption, or adulterates the 
same by deteriorating them by the subtraction or addi- 
tion of substances, or gives them the appearance of a 
better quality. 2. Whoever knowingly sells articles of 
food or consumption, which are spoiled or imitated, or 
adulterated according to Section 1, without giving notice 
of these circumstances, or offers them for sale under a 
name liable to lead to deception. 
Sec. 11. If offences mentioned in Section 10 have been 
committed by negligence, a fine up to 150 marks or im- 
prisonment is to be inflicted. 
Sec. 12. Liable to imprisonment, and to loss of civil 
rights, is : 1. Whoever prepares articles intended for the 
food of others in such a manner that their consumption 
is calculated to injure health, also, who knowingly sells, 
offers for sale, or otherwise brings into circulation as 
articles of food or consumption such articles which are 
injurious to health. 2. Whoever intentionally manufact- 
ures wearing apparel, toys, paper-hangings, eating, 
drinking, and cooking utensils, or petroleum, so that the 
probable use of these articles proves injurious to health ; 
also, who knowingly sells such articles, offers them for 
sale, or otherwise brings them into circulation. 
The attempt is punishable- 
If, through the action, grievous bodily injury,, or the 
death of any person has been caused, penal servitude up 
to five years is to be inflicted. 
Sec. 13. If, in the cases of Section 12, the consumption 
or use of the articles was liable to destroy health, and if 
that circumstance was known to the vendor or manufact- 
urer, penal servitude up to ten years, or, if the death of 
any person was caused, penal servitude not under ten 
years, or for life, is to be adjudged. Besides the punish- 
ment, supervision by the police may be ordered. 
Sec. 14. If any of the actions indicated in Sections 12 
and 13 has been committed through negligence, a fine up 
to 1,000 marks is to be imposed, or imprisonment up to 
six months ; and if, by the action, the health of any per- 
son shall have been injured, imprisonment up to one 
year; but if the death of any person shall have been 
caused, imprisonment from one month to three years. 
Sec. 15. In the cases of Sections 12 and 14, besides the 
punishment, the confiscation of the- articles which were 
made, sold, offered for sale, or otherwise brought into 
circulation, is to be caused, no matter whether the arti- 
cles belong to the defendant or not; in the cases of Sec- 
tions 8, 10, and 11, the confiscation may be caused. 
If in cases of Sections 12 and 14 the prosecution or 
punishment of any person is not practicable, confiscation 
of the articles alone may be caused. 
Sec. 16. In the judgment it may be ordered that the 
sentence be made public, at the expense of the defendant. 
On the motion of any defendant who has been found 
not guilty, the Court has to order the publication of the 
acquittal; the costs to be paid by the State, unless they 
are to be paid by the prosecutor. 
In the order the mode of publication is to be stated. 
Sec. 17. If, for the place where the offence was com- 
mitted, a public institution for the examination of arti- 
cles of food or consumption be in existence, the fines im- 
posed by authority of this law, and as far as the State can 
dispose of them, go to the fund which provides the cost 
of maintaining that institution. 
Bibliogbaphy. 
The following list contains only The titles of such works upon Food and 
Drug Adulteration and Inspection as have been recently published : 
Reports of the Local Government Board of England, 1877-91. 
Reports of the Paris Municipal Laboratory, 1882 and 1885. 
Reports of the Canton Chemists of Switzerland, 1890-92. 
The Analyst, London, vols. 1 to 16, 1877-92. 
Polin and Labit : Examen des Aliments suspects, Paris. 1892. 
J. P. Battershall: Food Adulteration and its Detection. New York, 1887. 
Revue Internationale des Falsifications, six vols. Amsterdam, 1888-92. 
Bulletins of the Department of Agriculture, Washington, D. C. (Depart- 
ment of Chemistry). 
Food and Drink (weekly), London. England, 1892. 
F. Vacher : The Food Inspector's Handbook. London, 1893. 
Dr. F. Meyer and Dr. C. Finklenburg : Gesetz betref. den Verkehr mit 
Nahrungsm., Genussm. und Gebrauchsgegenstanden vom 14. Mai, 1879. 
Berlin, 1880 ; Verfiilschung der Nahrungs- u. Genussmittel, in Petten- 
kofer's Handbuch d. Hygiene, 1882. 
Dr. A. J. Wedderburn : Special Report on the Extent and Character of 
Food Adulterations, including State and other Laws Relating to Foods 
and Beverages. Washington, 1892. 
Samuel W. Abbott. 
FRIEDRICHRODA. A popular watering-place and 
climatic resort in Thuringia, Germany. 
Location.-Friedrichroda is charmingly situated in 
the " Thunngerwald" near the city of Gotha, and at an 
elevation of 1,300 feet above sea-level. The pure moun- 
tain-air, the attractive scenery, the saline waters, and fa- 
cilities for brine, pine-needle, and other baths all contrib- 
ute to make it a favorite resort in that section of the 
country. 
Access.-The place is now a station on the railroad 
running from Gotha to Eisenach. 
Indications.-Friedrichroda is much frequented dur- 
ing the summer season (May to October) by those af- 
341 Friedrichroda. 
Gall-Bladder. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT). 
dieted with minor neuroses, anaemia, bronchial and slight 
pulmonary affections, and scrofula. There are several 
bathing establishments, with facilities for massage, 
hydrotherapy, inhalations, etc. The place is also made 
use of as " Terrainkurort," for the Oertel system. Milk 
and whey cures are much employed there. 
Accommodation. - There are hotels and numerous 
boarding-houses ; also a Kurhaus where music and the 
usual entertainments are provided. 
Edmund C. Wendt. 
FRONTAL SINUSES, DISEASES AND INJURIES OF 
THE. Osteoma of the Frontal Sinus.-The statis- 
tics of operations for the removal of these growths con- 
tinue to show a very high mortality. Thus out of fifty- 
four cases in which interference to the extent of the re- 
moval of the bone was carried out, thirty-three per cent, 
died of meningitis.1 The serious nature of the operative 
procedure seems to be in direct proportion to the size of 
the tumor. Hence it is suggested that early interference 
should be practised.2 
Empyema of the Frontal Sinuses.-Intense catar- 
rhal inflammation of the frontal sinus may give rise to an 
empyema of the cavity. This may be due to a primary 
inflammation, in which an acute or chronic obstruction of 
the infundibulum occurs, and consequent retention of 
pus. Of forty-eight cases collected and analyzed, in three 
acute obstruction occurred.3 In four cases hypertrophied 
turbinated bodies and polypi were found. In fourteen 
cases injuries by blows, falls, etc., were the primary 
cause of the affection.4 In one-half the entire number of 
forty-eight cases there was nothing in either the history 
or the condition to suggest the origin of the disease, al- 
though there are strong reasons for believing that it had 
its origin in some intra-nasal affection which blocked up 
the infundibulum. 
The course of the disease may be exceedingly rapid or 
very slow. In the first instance the empyema is due di- 
rectly to accumulation of* pus. In the more chronic 
cases the distention is first caused by the presence of 
mucus, which afterward becomes changed into muco- 
pus by bacterial infection. Necrosis following periosti- 
tis may be one of the results of the diseased condition of 
the mucous membrane, or it may precede it and act as 
a cause of the disease. 
The orbital plate of the frontal bone first yields to the 
effects of the pressure, and, from its comparative thin- 
ness, may give way. In this way a swelling at 
the root of the nose and at the upper and inner 
margin of the orbit is formed, which may be 
mistaken for an inflammation and distention of 
the lachrymal sac. Where necrosis is either the 
cause or the result of the disease, the swelling may be 
found at some other portion of the sinus wall. The 
swelling is usually one-sided, whatever be the situation 
of the diseased area, for the reason that disease of both 
sinuses is extremely rare. 
The symptoms are-frontal headache, the pain fre- 
quently following the course of distribution of the supra- 
orbital nerve. Chills, rise of temperature, and a general 
malaise are also experienced. To these are to be added 
the symptoms of a severe coryza, with inability to respire 
through the nose, and discharge of mucus or muco-pus. 
Lachrymation may be present. Perforation of the sinus 
may occur posteriorly, in which event circumscribed 
or diffused septic meningitis may occur. The severity 
of these symptoms will vary with the acute or subacute 
character of the case. 
The chronic cases come on insidiously, with moderate 
frontal pain and a feeling of distention in that region, 
and occasional discharge from the nose. As the fluid 
slowly accumulates there is a tendency to protrusion of 
the globe of the eye, due to the pressure from above 
downward and outward. As absorption of the bone 
proceeds, a sense of fluctuation, at first obscure and 
afterward more pronounced, is felt. In both the acute 
and chronic forms, as the contents approach the surface, 
there occurs infection of the structures overlying the 
bone; oedema and swelling, with an erysipelatous blush, 
are observed. In fact these cases may readily be mistaken 
for true infectious erysipelas. The tumor may vary in 
size by reason of an occasional partial emptying of its 
contents through the nose. 
Among the complications of empyema of the frontal 
sinuses may be mentioned disturbances of the visual or- 
gans, brain symptoms, and those referable to the naso- 
pharyngeal cavity. Diplopia and ptosis are sometimes 
present. Variations in visual capacity may result from 
variations in the degree of pressure upon the globe, ac- 
cording as the neighboring swelling increases or decreases 
in size ; even total loss of vision has been reported. 
The empyema, by perforating posteriorly, may give rise 
to secondary abscess of the anterior lobe of the brain. 
Cerebral involvement may be preceded by anosmia and 
symptoms of optic neuritis. As a result of the blocking 
up of the air-passages, mouth-breathing and a very dis- 
tressing dryness of Uie pharyngeal cavity are likely to be 
observed. The sense of smell is lost, and frequently the 
sense of taste as well. 
The treatment of empyema of the frontal sinus consists 
in gaining access to the cavity by making an opening 
into the anterior wall of the sinus, thoroughly cleaning 
the same, and then providing for efficient drainage. An 
exploratory puncture, in case of doubt, may precede the 
formal operation. In exposing the bone, the incision in 
the soft parts should commence at the inner extremity of 
the shaven eyebrow, where no supraorbital notch can be 
felt (a foramen existing instead), and should extend out- 
ward not more than an inch from the median line. By 
this means the vessels and nerves will certainly escape 
injury (Dawbarn). The opening through the bone may 
be made by the dental engine and trephine, but a small 
chisel and wooden mallet will be found to be the mcfet 
generally available instruments for the purpose. The 
drainage through the nose is the most important part of 
the treatment. Soelberg Wells claims to be able to 
accomplish this without external opening by passing an 
instrument upward from the nose into the sinus. Save 
in favorable cases this will be found to be very difficult. 
In opening into the nose from the floor of the sinus, after 
the latter has been opened, the operator's little finger 
should be passed into the nostril of the same side to act 
as a guide. Through and through drainage, by means 
of a perforated drainage-tube of rubber, should then be 
instituted. Mild astringent and antiseptic solutions, such 
as boro-salicylic or Thiersch's, a saturated solution of bo- 
racic acid or pyoktan in (2 to 1,000), should be employed? 
The usual method ol 
drainage is accom- 
plished by crushing 
through into the nasal 
cavity by the aid of f 
pair of closed dressing- 
forceps. It is some 
times necessary to use 
considerable force ir 
effecting this when tht 
floor of the cavity is 
quite thick. In a series 
of experiments upor 
twenty - one cadavers 
Dr. R. II. M. Daw barn 
of New York,6 succeed- 
ed, in all but one, ir 
passing a peculiarly beni 
probe (Fig. 162) dowi 
the natural passage 
through the middle 
meatus, and into the 
nose, and thence out ol 
the nostril. A thread is then to be tied to the end of the 
probe as it projects from the nostril, and the probe is . to 
be withdrawn. The operator now has a thread which 
passes from the nostril and nose through the middle 
Fig. 162. - Dawbarn's Frontal Sinus 
Probe. The distance from a to b is 
about half an inch, and that from b to 
c should be the distance from the in- 
cision in the eyebrow to the nostril. 
The latter distance, therefore, will 
vary much, according to the length 
of the nose. 
342 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Friedrichroda. 
Gall-Bladder. 
meatus and infundibulum into the frontal sinus. To 
this may be attached either a small drainage-tube or a 
strip of iodoform gauze, and by withdrawing the thread 
the drain is brought into position. The plan here sug- 
gested is worth a trial, for if the drainage can be efficient- 
ly applied by Dawbarn's method, it would be a barbar- 
ous procedure, in comparison, to crush through the outer 
plate of bone, as usually taught in the text-books. 
In the series of forty-five cases collected by Richards, 
death occurred in six ; one of these perished through 
albuminuria and another from meningitis. The remain- 
ing four died from secondary cerebral abscess. 
George Ryerson Fowler. 
1 Z. Kikuze : Centralblatt ftir Chimrgie. 1888, No. 36. 
3 J. N. Ischunin : Chirurgitscheski Westmk, Jan., 1890. 
3 Richards : Journal of the American Medical Association, vol. xiv., 
No. 13, 1890. 
4 See also Weinlechner, Wiener klin. Wochenschrift, No. 7, 1889. 
6 Cholewa : Therapent. Monatshefte, 1891. 
* Personal communication. 
GALLACETOPHENONE. This substance has been 
introduced as a substitute for pyrogallic acid in the 
treatment of psoriasis and similar skin diseases. A com- 
mercial name for it is "alizarine-yellow C." Chemi- 
cally it is a tri - hydroxy-benzene, in which a fourth 
hydrogen atom has been replaced by an acetyl group. 
Its formula is CH3CO.C«Ha(OHs). It is prepared by 
treating pyrogallic acid with acetic acid in the presence 
of chloride of zinc. It is a pale yellow powder, almost 
insoluble in cold water, very soluble in hot water, al- 
cohol, ether, and glycerine. The presence of acetate of 
sodium increases its solubility in cold water : one drachm 
may be retained in solution in three and a half ounces 
of w'ater by the addition of one ounce of sodium acetate. 
It is a powerful antiseptic ; a one per cent, solution 
will prevent the putrefaction of chopped meat for twenty- 
one days. 
The chief advantage which is claimed for it, as a sub- 
stitute for pyrogallic acid, is its freedom from irritating 
and toxic properties. Experiments on animals prove it to 
be non-poisonous. It has been shown that dogs will bear 
a dose of one drachm daily for a long time without in- 
convenience. This is due to the fact that it oxidizes 
very slowdy. Pyrogallic acid is too rapid and energetic 
in its action : it has at times caused very serious disturb- 
ances, and fatal results have followed its external use, 
these ill effects being due to its intense reducing power, 
particularly in alkaline solution. Another advantage of 
the new drug is that it does not soil the linen when used. 
The use of gallacetophenone in skin disease was in- 
troduced by Dr. L. von Rekowski, of Professor Nencki's 
Institute, at Berne (Therapeutische Monatshefte, Septem- 
ber, 1891). It was used in psoriasis with very satisfac- 
tory results, the beneficial effects of the treatment being 
noticed within twelve hours. In a short time the 
patches become paler and thinner, and desquamation 
lessens. After ten or twelve days the patches have al- 
most disappeared, and in two or three weeks a perfect 
cure is effected. 
Dr. Hermann Goldenberg, in the New York Medical 
Journal, February 6, 1892, reports his success with it in 
several severe cases of long duration. He considers it 
much superior to pyrogallic acid or chrysarobin, and 
perfectly harmless. It also proved of service in some 
cases of eczema. There is no irritation of the skin, nor 
staining of the skin, hair, or clothing. The drug is 
used in the strength of ten per cent., as an ointment, with 
vaseline, or in solution. Beaumont Small. 
GALL-BLADDER AND DUCTS, SURGERY OF. The 
domain of surgery has been extended during the last de- 
cade so as to include the disorders arising from biliary 
obstructions, which were formerly relegated to the list 
of irremediable cases. While Bobbs did an operation 
upon the gall-bladder incidentally, in seeking to remedy 
a trouble which was not clearly understood, Sims resorted 
to a measure subsequently, with a distinct object in view, 
which led to investigations by others, in connection with 
the gall-bladder, of vast importance. The experiments 
upon inferior animals, which were made by me, looked 
to a different result in the disposition of the bile from 
that which was contemplated, in the external discharge 
of it through a fistulous opening, by Sims. Winiwarter, 
without my knowledge, had sought to convey the bile 
into the intestinal canal, and had thus succeeded in reliev- 
ing the troubles growing out of obstruction of the com- 
mon bile-duct. On this line my efforts were directed to 
clearing up some of the difficulties in the accomplish- 
ment of a communication from the gall-bladder into the 
duodenum or the adjacent small intestines. 
A careful examination of several articles contributed 
to the second volume of the Handbook, entitled 
"Cholecystectomy, Cholecystotomy, and Duodenochole- 
cystostomy," should premise a consideration of the data 
now presented to the profession. It will be learned 
that the principles and processes of the various operative 
procedures were fully elaborated, and the reader will be 
prepared to comprehend what advances have been made 
in the surgery of the gall-bladder and ducts since that 
period. There has been some modification of the differ- 
ent operations originally undertaken, but no material im- 
provement in the steps inculcated for cholecystectomy 
and cholecystotomy ; while new departures are noted 
principally in the excision of gall-stones from the ducts, 
and in the attachment of the gall-bladder to different por- 
tions of the intestinal canal, with a fistulous communica- 
tion between the former and the latter. .The use of gauze 
tamponage in operations involving the integrity of the 
gall-ducts, either around drainage-tubes or without 
them, has been attended with such favorable results as to 
commend this procedure to surgeons. While a case re- 
ported by Lane, and facts occurring in the experience of 
other operators, lead to the conclusion that the presence 
of freshly secreted bile in the peritoneum is not attended 
with any serious consequences, it is certainly very desir- 
able to prevent its entrance into the cavity of the abdo- 
men. It is principally with a view to circumscribe the 
collection of bile from lesions of the ducts, either acci- 
dental or in operations, that gauze packing in the im- 
mediate vicinity of biliary exudation has been resorted 
to of late. When the layers of iodoform gauze are ex- 
tended from the site of an incised or lacerated duct to the 
external abdominal opening, it is claimed that it serves 
to carry out the bile by capillary drainage, even when no 
drainage-tube is employed. It is further held that by 
pressure upon the surrounding parts the extravasation of 
the bile into the structures is obviated, so that in suturing 
the ducts or the gall-bladder, with or without anastomosis 
with the intestinal canal, it is a wise precaution to fill up 
the intervening space with strips of iodoform gauze. 
The operation of cholecystectomy, which was intro- 
duced by Langenbuch, has been practised eight times by 
Terrier, with seven recoveries. Michaux performed this 
operation in two cases, and both resulted in cure. Daw- 
son reports a successful cholecystectomy for impacted 
gall-stones, which were faceted and weighed respectively 
79, 80, and 81 grains. Czerny gives two cures by chole- 
cystectomy, and this process affords highly satisfactory 
results. Other successful operations have been done in 
this country and in Europe, and the fatal results have 
been comparatively small. The number of operations 
reaches in all nearly one hundred, with a mortality of 
less than twenty per cent. This operation is contra-in- 
dicated in cases of obliteration of the ductus communis 
choledochus. But when this is patent, and there is oc- 
clusion of the cystic duct, with greater or less disorgani- 
zation of the gall-bladder, so as to preclude its restoration, 
it is indicated. Biliary fistulae, from the accumulation 
of gall-stones, would also warrant cholecystectomy. In 
view of the favorable results reported, surgeons will not 
hesitate to avail themselves of this recourse in suitable 
cases, notwithstanding the opposition of those who have 
no experience in its performance. 
The operations of cholecystotomy and cholecystostomy 
have been practised extensively during the period which 
has intervened since the publication of my articles in the 
second volume of the Reference Handbook. The 
343 Gall-Bladder 
and Ducts. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
former designation is applied to those cases in which the 
obstructions have been removed through an incision in 
the walls of the gall-bladder and afterward the opening 
is closed by sutures, when the viscus is either dropped 
or secured to the edges of the external wound. This last 
procedure, urged by Sanger and Wolfler, is intended to 
allow of the escape of bile externally, if the stitches yield, 
instead of being discharged into the peritoneal cavity. 
The term cholecystostomy is used for those cases having 
the incision in the gall-bladder left open and attached to 
the opening in the parietes, so as to allow of the flow of 
bile externally. This procedure has been adopted upon 
the supposition that eventually the bile would find its 
way through the common duct, and that the external 
opening might close, either spontaneously, or through 
the instrumentality of a plastic operation. The results 
of this procedure have not been always satisfactory, and 
it is not so free from risk as has been claimed by some 
who urge its adoption in preference to other measures. 
It cannot afford more than temporary relief in cases of 
occlusion of the common bile-duct, and entails upon the 
sufferer the very condition of a biliary fistula, which has 
furnished the reason, in many instances, for seeking sur- 
gical assistance. In two cases of pronounced cholaemia 
from the closure of the common bile-duct, which have 
come under my observation, a resort to the operation of 
cholecystostomy failed to arrest a fatal termination. Al- 
though in each case there was a free discharge of bile 
through the opening made by attaching the edges of the 
incision in the gall-bladder to the sides of the cut in the 
abdominal wall, no benefit was derived from either op- 
eration, and both patients (females) died in less than a 
week after undergoing the operation. It is proper to 
state, in this connection, that no gall-stones were found 
in the gall-bladder or in the ducts of either of these pa- 
tients, and that the obstruction of the common bile-duct 
resulted from adhesive inflammation of its coats, by 
which the canal was reduced to a hard, dense cord. The 
previous history of clay-colored stools and profound 
jaundice, with distention of the gall-bladder, showed 
cholaemia in both. 
The intermediate process of incising the wall of the 
abdomen only, and attaching the wall of the gall-bladder 
unopened to its edges, with gauze placed in the wound 
until adhesions have occurred, when an opening is made 
into the gall-bladder, has nothing whatever to recommend 
it. The most instructive digital examination of the gall- 
bladder and ducts is precluded by this procedure, and it 
affords no facilities for the removal of obstructions which 
may exist in the cystic or common ducts. Notwithstand- 
ing the endorsement by Riedel of the performance of this 
operation at two sittings, Korte, who has performed it 
in two cases, prefers* the operation as performed at one 
sitting, when it is possible. 
When the ductus choledochus is found free, and the 
cystic duct can be rid of obstructions, the most satis- 
factory proceeding is the immediate closure of the incision 
in the gall-bladder and its return into the abdomen, with- 
out any attachment to the parietes. This course has now 
been adopted in a sufficient number of cases, with a good 
result, to satisfy the' profession of its efficacy in restoring 
the normal relations of the gall-bladder. 
Catheterization of the cystic and common bile-ducts 
has been undertaken in a limited number of cases with 
satisfactory results. It is held by Terrier and Daily that 
it is easier under pathological conditions, but the cathe- 
terization should be undertaken with a clear idea of the 
normal relations for a guide to the operation. 
The process of disintegration of biliary concretions by 
the introduction of a needle into the mass and breaking 
up its structure, has been found advantageous in dis- 
lodging obstructions of the ducts. In connection with 
this, the use of padded forceps or pressure with the 
thumb and index-finger for crushing the gall-stones, has 
been attended with good results in some cases. 
In cases where it is impracticable to unite the gall- 
bladder with the intestinal canal, an attempt has been 
made in a few instances to bring about a communication, 
by incision and suture, between the ductus communis 
and the duodenum or a coil of the small intestine. A 
successful case is reported by Sprengel. But the diffi- 
culties attending this operation offer little encouragement 
to its repetition. The most striking developments in this 
department of surgery look to the restoration of the bile 
to the intestinal canal. 
None of these procedures is adapted to relieve im- 
paction of the ducts by gall-stones, or the agglutination 
of their walls from plastic inflammation of the tissues. 
Other measures have been resorted to within the past 
few years, which constitute the most notable advances in 
the surgery of the gall-bladder and ducts. The excision 
of biliary calculi, which are so hard as to resist crushing 
in the ducts, has been practised successfully. After in- 
cising tlie coats of the cystic or common bile-ducts and 
removing the concretions by forceps or other means, the 
opening has been closed by suture, and a satisfactory re- 
sult has been obtained in a large proportion of the cases 
reported. Not only has the incision healed kindly, but 
the duct has conveyed the bile to its proper destination. 
Incision and suture of the walls of the common bile- 
duct, with the removal of gall-stones, have been resorted 
to in thirteen cases, with two fatal results. Three of 
these operations have been done by Courvoisier, and one 
by each of the following : Kummell, Heusner, Kuster, 
Rehn, Braun, Frank, Hocheneg, Thornton, Marcy, and 
Vander Veer. A stone has also been successfully excised 
from the cystic duct by Ross. 
There is a class of cases in which nothing can avail to 
remove the occlusion of the ductus communis chole- 
dochus, and the recourse for the surgeon is to secure a 
communication from the common duct above the ob- 
struction, or froin the gall-bladder, with the duodenum 
or some adjacent 'portion of the intestinal canal. The 
best efforts of operators have been directed to this end of 
late, and what was foreshadowed in my contribution on 
duodeno-cholecystostomy seven years ago, has now been 
realized in a sufficient number of cases to guarantee the 
future success of this operation. In nothing undertaken 
during the last decade has the triumph of intelligent ef- 
fort been so marked as in overcoming the difficulties con- 
nected with complete obstruction of the common bile- 
duct. Temporary obstacles may yield to various devices 
which have been adopted, but the impermeable agglu- 
tination of the coats of the common bile-duct can only be 
remedied by opening up a new route for the passage of 
the bile into the intestinal canal. It is begging the ques- 
tion to allege that any process can restore the canal when 
it is permanently occluded by agglutination of its walls. 
In my opening address, as chairman of the Surgical 
Section at the meeting of the American Medical Asso- 
ciation in Detroit, some data upon the surgery of the 
gall-bladder and ducts were presented which may be 
appropriately incorporated in this paper. It was demon- 
strated that all cases of the obstruction of the cystic and 
common ducts by gall-stones call for their dislodgement 
by one or another procedure, to afford an outlet for the 
bile ; and that the attachment of the incision in the gall- 
bladder to the opening in the wall of the abdomen for a 
discharge of the bile externally, should be regarded as a 
mere temporary recourse. In the event of failure to 
effect an outlet for the bile through the common duct, 
then cholecystenterostomy is clearly indicated. As to 
the portion of the intestine which should be selected for 
the attachment of the gall-bladder or the ductus chole- 
dochus, we have a definite guide in the entrance of the 
bile naturally into the duodenum ; and the nearer to this 
an anastomosis can be effected, the better result may be 
expected. The relations of the duodenum and jejunum 
to the gall-bladder, ordinarily, are such as to facilitate 
their union, and I have given the preference to the duo- 
denum from physiological considerations as well as from 
surgical convenience, while objecting to the colon. 
It is, of course, presumed that there is such an occlu- 
sion of the common bile-duct as to prove irremediable 
by other means, before proceeding with an operation to 
effect an outlet for the bile by uniting the gall-bladder 
with the intestinal canal. A misunderstanding of this 
condition has led to misapprehension of the end to be 
344 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Gall-Bladder 
and Ducts. 
attained by duodeno-cholecystostomy or cholecystenter- 
ostomy ; and let me say, once for all, it is only warranted 
by occlusion of the common duct. 
In this connection the following pointed remarks of 
Greig Smith upon entero-cholecystotomy, in the last edi- 
tion of his work on abdominal surgery, place my in- 
vestigations upon this subject in a proper light before 
the profession : 
" By this operation is meant the establishment of a 
fistula between the gall-bladder and the intestine. The 
operation is indicated only in cases of incurable biliary 
fistula ; that is, in cases where there is insuperable occlu- 
sion in the ductus communis choledochus. The original 
operation of Winiwarter successfully established a com- 
munication between the gall-bladder and the colon. In 
this situation the physiological effects of the biliary se- 
cretion were lost. Dr. Gaston, of Atlanta, Ga., in a 
series of instructive experiments on dogs, showed how 
communication might be established between the duo- 
denum and the gall-bladder, thus preserving in the sys- 
tem whatever value the bile may have. Gaston speaks 
of his operation as duodeno-cholecystostomy. Some 
misconceptions and misdirected criticisms of Gaston's 
operation have appeared in various journals ; to those he 
has given satisfactory answers." 
In the comprehensive and elaborate record by Cour- 
voisier of what has been accomplished for the relief of 
biliary obstruction, he states that my experiments on ani- 
mals were undertaken in the hope thereby of clearing up 
the way for a practicable future operation on man. His 
remarks on this point are quoted : " Gaston sought to 
utilize the elastic ligature. In five dogs he carried it 
through the approximated walls of the gall-bladder and 
duodenum, in such a way that One-half of the tightly 
drawn loop lay in the former, the other half in the latter. 
The loop was to cut through both walls at the same time 
and thus form a fistula between both cavities. At the 
close of his operations Gaston placed a catgut suture 
around the place where the walls of the organs lay in 
apposition. In one animal the adhesions were completed 
by the eleventh day, and in this case there was a beautiful 
fistula, while the ligature had passed off through the in- 
testine. In 1884 Gaston also made an experiment on a 
young dog with a silk ligature, and obtained a good re- 
sult. Later on, he repeated these experiments with liga- 
tion of the common duct, without satisfactory results." 
Courvoisier further states that Golzi reports five ex- 
periments on dogs. The common bile-duct was ligated. 
Then, with a catgut suture, the surfaces of the gall- 
bladder and the nearest loop of the small intestine were 
stitched around a loop of suture, passed through each 
wall so as to cut through. It is stated that the animals 
bore the operations without material derangement of the 
digestion.. 
It is also noted by Courvoisier that Page operated in 
the same manner as Golzi did on three dogs, omitting, 
however, the ligation of the common duct. One dog 
survived, one sank with peritonitis, and the third died 
after six weeks, showing a considerable shrinkage of the 
gall-bladder, but without any fistula. The result is not 
known in the dog which survived. 
The various procedures adopted by Golzi, Page, and 
myself were undertaken with a view to guide others in 
the performance of operations upon human beings. All 
must allow that the fruit of our experiences has thrown 
much light upon the intestinal labyrinth in which we 
groped without a guide to direct us at that period. 
The difficulties encountered by me in ligating the com- 
mon bile-duct subsequently, were the greatest obstacles 
to the final success of this operation, and would not be 
encountered in case of pre-existing occlusion, which is 
the occasion of performing an operation on the human 
subject. 
These and other experiments, undertaken upon twenty- 
one dogs, are fully illustrated by the cuts accompanying 
my contribution upon "Duodeno-cholecystostomy" in 
the second volume of the Reference Handbook. 
Ii may be stated that my conception of the procedures 
indicated was not limited to the means employed in these 
experiments, and it was distinctly set forth that some 
other process might be found preferable, and it rests with 
surgeons to adopt that which proves best. 
To Nussbaum is attributed the first suggestion of re- 
lieving the occlusion of the common bile-duct, by dis- 
charging the bile into the intestinal canal through arti- 
ficial openings in the adherent walls of the gall-bladder 
and the intestine. But the credit of having first accom- 
plished this result upon the human being is undoubtedly 
due to Von Winiwarter, and it affords me the greatest 
satisfaction to award him the honor of priority in the 
execution of cholecystenterostomy in 1881. 
After a lapse of six years Monastyrski united the gall- 
bladder with the jejunum on the fourth of June, 1887. 
He incised the abdominal wall, punctured the gall- 
bladder, incised its walls and the jejunum, and sew'ed 
the edges with catgut. A fistulous communication was 
secured two metres below the duodenum, but death en- 
sued from carcinoma of pancreas, as verified by autopsy. 
The operation of Kappeler came next in the order of 
time, being done on the sixth of July, 1887, by uniting 
the gall-bladder with the ileum by Wblfler's suture. The 
patient progressed favorably for a time and returned to 
work, but eventually died on September 9, 1888, fifteen 
months after the operation. The autopsy showed that a 
biliary fistula was established about eight feet from the 
ileo-csecal valve, and that its intestinal orifice was pro- 
vided with a valve which allowed the contents of the 
gall-bladder to pass into the intestine, but prevented the 
passage of the intestinal contents into the gall-bladder. 
Doubtless, a similar provision exists in all such cases. 
In the year following the operation of Kappeler, 
Fritzche accomplished a fistulous opening from the gall- 
bladder into the jejunum, three metres below the pylorus. 
At the post-mortem examination a carcinoma of the size 
of a walnut was found at the mouth of the common bile- 
duct. 
Socin and Bardenheuer each attached the gall-bladder 
to a loop of the small intestine. The case, of the latter 
died in the fourth week and no fistula was found. It is 
said to have been done with elastic ligature. 
Robson operated, on March 2, 1889, upon a patiept who 
had undergone a previous cholecystotomy, when the 
ducts were freed and the gall-bladder was sutured to the 
abdominal wall with firm adhesions. The common duct 
being subsequently occluded, an incision was made 
through the scar from the former operation, in the semi- 
lunar line, and it was found that the attachment of the 
gall-bladder could only be effected with the colon. Both 
were incised and united with chromicized catgut in two 
rows. The former external fistula was sewed up and a 
drainage-tube inserted in the wound. After one day bile 
came out of the drainage-tube, and also fecal matter came 
from the intestinal wound, mixed with bile, on March 5th. 
Afterward, up to the 18th, faeces and bil^continued to be 
discharged, and then bile alone, the wound granulating 
and ultimately completely closing on May 6th, when the 
motions were noticed to have regained their normal color. 
The patient reported herself in July as in perfect health. 
Robson states that, "although Dr. Gaston proved the 
possibility of affixing the gall-bladder to the duodenum 
in dogs, and although this has been shown practicable in 
the human subject by Terrier's operation," he found 
that the difficulties are much greater than if a loop of 
the small intestine be selected. 
On July 13, 1889, Terrier performed an operation for 
the relief of occlusion of the common duct. An incision 
was made in the median line, above the navel. The gall- 
bladder was punctured and the bile discharged. Upon 
incising its walls and exploring its cavity no stones 
were found, and the cystic duct was open. There was 
a gall-stone impacted in an oblong enlargement of the 
common duct which could not be removed. After at- 
taching the gall-bladder to the duodenum by an oblong 
row of catgut sutures, and before tying the last stitches, 
the walls of both were incised and a rubber drainage- 
tube was introduced, so as to pass from the cavity of 
the gall-bladder into the duodenum. The fundus of 
the gall-bladder was sutured to the lower angle of the 
345 Call-Bladder 
and Ducts. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT. 
external incision, which was then closed by a catgut 
suture. There was fever until August 1st, but the itch- 
ing and jaundice gradually disappeared. The drainage- 
tube passed off with the evacuations nine days after the 
operation, and the stools gave evidence of the presence of 
bile. The external wound healed up by first intention. 
The patient was dismissed on August 10th, in ordinary 
health. The patient died in the spring of 1890, from in- 
fluenza, and no gall-stone was found in the common duct. 
Courvoisier, in like manner with Robson, performed 
the operation of natural cholecystotomy upon a patient 
without getting a satisfactory result. After the lapse of 
a year complications arose, which demanded cholecys- 
tenterostomy, and this was done March 28, 1890. An 
incision was made through the abdominal wall, below'the 
ribs, along the border of the liver. The gall-bladder w'as 
detached from the abdominal wall, and after incising 
the sac a gall-stone was removed from the common duct 
and others were scraped from the hepatic ducts. An in- 
cision into the lower surface of the gall-bladder was 
united to the colon by an oval row of catgut sutures, 
and before putting in the last stitches the wall of the 
colon was incised. The fistulous parts of the gall-blad- 
der wTere cut away and the edges stitched up. Two 
drainage-tubes were inserted and the external wound 
closed around them. There was no fever after April 2d. 
Bile was found on the dressings, but its source was not 
determined. There was bile in the stools on April 6th, 
and on the 8th the drainage-tubes W'ere removed and the 
external wound was stitched up. On April 15th the 
patient was free from jaundice and got up feeling very 
w'ell. The case was dismissed about the middle of May, 
and in July her condition was good. 
A successful case of cholecystenterostomy has been 
reported, on February 25, 1892, as done by Helferich. 
The patient, a man, aged twenty-nine, had suffered 
periodically from pains in the stomach since 1885, and 
developed jaundice in April, 1891. During the follow- 
ing month he had attacks of biliary colic, recurring every 
fortnight, the jaundice being marked after each attack. 
It was thought that the common duct was obstructed by 
calculi, and an operation for their removal was under- 
taken in November. An incision was made midway be- 
tween the lower border of the ribs and the border of the 
enlarged liver, extending vertically in the linea alba to the 
ensiform cartilage. After the liver had been retracted, 
the gall-bladder came into view ; it contained no calculi, 
but an examination disclosed a number of calculi in the 
common bile-duct, which it was found impracticable to 
remove. An opening was therefore rriade in the gall- 
bladder and another in the first part of the jejunum, and 
a communication was established between these two struct- 
ures by suturing the corresponding margins of the aper- 
tures. The fistula thus formed was of the calibre of a 
lead-pencil. Tfie patient made a rapid recovery, with 
disappearance of the jaundice. 
Korte reports a favorable result of the union of the 
gall-bladder with the wall of the duodenum, after the 
process of Terrier, thus affording two successful cases of 
duodeno-cholecystostomy. 
He states that the patient, after having shown total 
acholia in the faeces for four weeks, was operated upon. 
He was, however, unable to lay bare the choledochus, 
and it remained uncertain as to whether the obstruction 
was caused by stones or cicatricial stenosis ; the indica- 
tions were, however, in favor of the latter diagnosis. 
Finding himself completely thwarted in his efforts to lay 
bare the gall-passages, he determined to establish an 
anastomosis between the'gall-bladder and the duodenum. 
He sewed the gall-bladder to the bowel, opened both 
organs, and then stitched the edges of the cuts together. 
The act of applying a suture so deep in the abdominal 
cavity constituted not only a difficult, but most tedious, 
undertaking. For the sake of precaution he wound a 
strip of iodoform gauze around the suture and kept part 
of the abdominal wound open. The suture uniting the 
gall-bladder and intestine healed well and the bile began 
to flow into the intestine. No bile was ever discharged 
through the wound to mar the cure. 
Richelet performed this operation in one case. The 
gall-bladder was secured to the duodenum. The results 
were not very satisfactory, biliary retention persisted, 
and a second laparotomy was performed, the gall-bladder 
was opened, and an effort was made to extract the calculus. 
This resulted in a hemorrhage so severe that death re- 
sulted in an hour. At the autopsy it was found that the 
forceps had seized a calculus, which was so firmly ad- 
herent that its displacement had caused tearing of the 
gall-bladder and had resulted in hemorrhage. 
A case of temporary cure is reported by Czerny for oc- 
clusion of the choledochus by the operation of chole- 
cystoduodenostomy. This makes four recorded opera- 
tions by the process which I have designated as duodeno- 
cholecystostomy, with favorable results in three of the 
cases ; and the miscarriage in the fourth case was due to 
an accidental lesion in the extraction of a gall-stone by 
forceps in the performance of a second laparotomy. It 
is evident in this case that. Richelet had overlooked an 
essential condition for success in his first operation, by 
attaching the gall-bladder to the duodenum without 
taking the precaution to remove the calculus from the 
cystic duct. 
Cholecystocolostomy was performed in one case by 
Czerny, in occlusion of the ductus choledochus by a cal- 
culus. The immediate result of the operation appeared 
satisfactory, but death occurred two weeks afterward 
from hemorrhage. 
Another operation reported by Czerny presents feat- 
ures of interest, which warrant a record of some details 
of this case of cholecystenterostomy after temporary 
cholecystotomy. 
A vertical incision was made through the right rectus 
muscle. The enlarged blackish-yellow liver presented 
itself in the opening, and on its side was the very tense 
gall-bladder of the size of a fist. Puncture of the latter 
yielded 300 c.c. of a clear, watery fluid. The sound 
could be entered a distance of 14 ctm. through this 
puncture without meeting with calculi, but its further 
progress was arrested by some obstruction. Neither 
concretions nor any tumors could be detected by palpa- 
tion. An obstruction of the ductus choledochus was 
suspected, but no cause could be found for it, and a 
temporary biliary fistula, opening externally, was estab- 
lished in place of the cholecystenterostomy, in order 
to remove if necessary, later on, the obstruction in the 
duct, through the gall-bladder. The peritoneal cover- 
ing of the gall-bladder was stitched to the parietal peri- 
toneum. A part of the abdominal incision wras closed, 
and the opening in the gall-bladder occluded by applying 
a Pean clamp forceps. Two days after the operation, 
when the dressing was changed for the first time, 500 
c.c. of pure bile rushed forth as soon as the Pean for- 
ceps was removed. The unknown obstruction in the 
ductus cysticus was thus removed. Pure bile was now 
discharged regularly, but in spite of this, the existing 
icterus diminished but slowly, and never disappeared en- 
tirely ; the urine contained, continually, more or less bile, 
and the faeces were entirely acholic. Therefore, the occlu- 
sion seemed not to have been perfectly removed, and chole- 
cystoenterostomy was performed two months after the 
establishment of the fistula. The fistula was now tempo- 
rarily closed by sutures, and the existing opening into 
the abdominal cavity was elongated above and below. 
The separation of the gall-bladder from the parietes could 
not be accomplished without injuring its walls, which 
had several rents. The injured part of the wall of this 
organ was extirpated, and the resulting circular opening 
was diminished by two rows of catgut sutures to the 
size of a bean. A loop of small intestine was then drawn 
out and united to the posterior wrall of the gall-bladder 
by means of five sutures in the serosa. An incision 
ctm. long was then made in the small intestine, thirteen 
anterior and posterior sutures through the mucosa were 
inserted, and finally nine sutures through the serosa were 
applied. Drainage was effected by means of iodoform 
wick, and the abdominal wound was closed around it. 
Temporary improvement followed. Soon afterward, 
however, the patient sank rapidly and death took place 
346 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT. 
Gall-Bladder 
and Ducts. 
from exhaustion, induced by cancer of the pancreas, gan- 
grene of the lungs, and other complications. The fatal 
result occurred three months after the operation, and 
hence was not a direct consequence of the union of the 
gall-bladder and the intestine. 
An interesting case, in which an anastomosis between 
the gall-bladder and colon was effected by a process 
differing materially from the previous operations has 
been reported by Chavasse. 
A man, forty-eight years old, had undergone cholecys- 
totomy for relief of jaundice dependent upon biliary ob- 
struction by calculi, which was followed by the persist- 
ence of a biliary fistula. Other means failing, with the 
aid of Senn's bone-plates, a communication was estab- 
lished between the gall-bladder and the colon at its he- 
patic flexure. At first, bile and fecal matter were dis- 
charged through the abdominal wound, but ultimately 
this closed, the stools were passed naturally, and the 
general condition of the patient was much improved. 
Further experience with this process may prove as 
satisfactory as its use in intestinal anastomosis. The in- 
creasing interest exhibited by surgeons in the serious 
consequences resulting from any obstruction to the dis- 
charge of bile is strikingly manifested by these aggres- 
sive measures, and a new era has dawned upon gall- 
bladder surgery. 
A revolution has been brought about not only in the 
theoretic views of surgeons, but in the appliances resorted 
to in the surgery of the gall-bladder and ducts, which 
encourages the expectation of obtaining a satisfactory 
solution of the problem of relief for occlusion of the 
common bile-duct. 
"A comparison," says Robson, "of the statistics of 
the different operations on the gall-bladder, as collected 
by Dr. Delaganiere, would seem to show that although 
ciiolecystenterostomy is apparently the most compli- 
cated, it is the least dangerous operation." 
The practicability of effecting an outlet from the gall- 
bladder into the duodenum or the intestinal canal, can no 
longer remain in doubt, and in the view of Courvoisier 
this operation stands more and more securely as the 
details from trustworthy sources become more widely 
disseminated. 
Excluding from the reported cases those of a cancerous 
nature, all should be content with the results of the vari- 
ous procedures for uniting the gall-bladder and the com- 
mon duct with the duodenum and intestinal canal. 
The inferences to be drawn from a study of the results 
obtained in surgery of the gall-bladder and ducts are 
the following : 
1. In all cases presenting a history of biliary obstruc- 
tion with manifestation of enlarged gall-bladder, explo- 
ratory incision of the abdominal wall, and, conditionally, 
of the gall-bladder, is warranted. 
2. When obstructions of the cystic and common ducts 
from gall-stones are found, they should be removed by 
needling, crushing, or incision of the duct and suturing 
the wound. 
3. In case of the presence of a gall-stone in the cystic 
duct without impediment of the common duct, after re- 
moving the obstruction from the former, it would favor 
the restoration of normal conditions to close the incision 
in the walls of the gall-bladder without attachment to 
the parietes. 
4. Should there be a degenerated or disorganized state 
of the coats of the gall-bladder, precluding the perform- 
ance of its functions, the extirpation of the sac "with 
ligation of the cystic duct will be proper. 
5. Under circumstances of doubt as to the permea- 
bility of the cystic and common ducts, catheterization 
should be attempted with flexible bougies, guided by the 
fingers outside of the ducts. 
6. In the event of an impermeable stricture or perma- 
nent obstruction of the common bile-duct, with a patu- 
lous cystic duct and good condition of the walls of the 
gall-bladder, the latter may be attached to the duodenum 
or adjacent portion of the small intestine, so as to effect 
a communication and thus admit of the passage of the 
bile. 
7. Should the walls of the gall-bladder be likely to 
undergo disintegration and the walls of the common 
duct above the obstruction be in a favorable state, an 
incision in the duct may be united by suture with an 
incision in the duodenum or other part of the intestinal 
canal, to give exit to the bile. 
8. While the results of a communication of the gall- 
bladder or common bile-duct with the duodenum or the 
upper part of the small intestine have proved more salu- 
tary than with the large intestine, there are cases in 
which the connection with the last named is alone prac- 
ticable, and should be resorted to in preference to estab- 
lishing an external fistulous opening. 
9. Experiment has demonstrated the practicability of 
securing a union of the walls of the gall-bladder and 
duodenum with an opening by a single stitch of silk or 
elastic ligature, but the operations upon the human sub- 
ject, attended with the best results, have been by inci- 
sion and suture, with gauze tamponage. 
10. The great importance of restoring the bile to the 
alimentary canal, in all cases of permanent occlusion of 
the common bile-duct, renders it desirable that an opera- 
tion shall be undertaken at the earliest practicable period 
after obstruction to the flow of the bile into the duode- 
num is recognized as tending to cholaemia. 
11. Cholecystotomy and cholecystostomy are not ade- 
quate to the relief of occlusion of the common bile-duct, 
and duodeno-cholecystostomy or cholecystenterostomy is 
indicated wherever it is evident that there is no outlet "for 
the bile into the alimentary canal by the natural channel. 
12. In the advanced stage of cholaemic intoxication 
from occlusion of the common bile-duct, there is such 
vital depression as to preclude any benefit from an opera- 
tion, and it is only calculated to bring discredit upon the 
surgery of the gall-bladder and ducts to operate under 
such untowrard conditions. 
In 1889, Dastre communicated his experiments to the 
Physiological Congress at Basel, in which he united the 
gall-bladder with the intestinal canal with a view to study 
the effects on digestion. It was demonstrated that an ani- 
mal can live without suffering from the loss of a portion 
of the bile from the upper part of the small intestines, 
and that a smaller quantity of bile than the natural secre- 
tion or excretion is sufficient for digestion. But the 
practical inference of most importance in connection 
with his experiments, is the feasibility of effecting a 
communication from the gall-bladder into the intestinal 
tract by incising and suturing their walls together in 
cases of total occlusion of the common bile-duct. 
As in most cases requiring cholecystenterostomy it is 
requisite to make an incision of the wall of the gall- 
bladder for the removal of calculi from its cavity, or for 
proper exploration of the ducts, it is very desirable that 
some speedy process for suturing the edges of this inci- 
sion to those of a like incision in the coat of the in- 
testine shall be adopted. If mechanical devices can be 
dispensed with entirely in the junction of the gall-bladder 
and intestinal canal, and thus allow a free outlet for the 
bile, it is a consummation devoutly to be wished for in 
the performance of this important operation. 
Lambotte reports a case, in the Belgian Medical Press 
of July 3, 1892, of external biliary fistula, resulting 
from cholecystostomy, for which he performed a unique 
operation. An incision was made in the abdominal 
wall in close proximity to the fistula, and a portion of 
the colon was drawn out through it. He then availed 
himself of the enterotrite of Dupuytren to effect a com- 
munication from the fistulous tract into the bowels, 
thereby conveying the bile off through the colon, instead 
of letting it flow out through the abdominal wall. The 
external fistulous opening was subsequently obliterated 
by a plastic operation. 
The instrument presented by Grant at the late meet- 
ing of the Southern Surgical and Gynecological Associa- 
tion, at Louisville, Ky., for effecting intestinal anasto- 
mosis, meets the indications more satisfactorily than that 
of Dupuytren, for uniting the gall-bladder with the in- 
testine. Although the author had not even suggested 
this application of his instrument, the writer submits 
347 Gall-Bladder 
and Ducts. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
that a modification of the blades of this clamp, of such a 
nature that they can be carried through a small incision 
into the cavity of the gall-bladder and into the duode- 
num, or other portion of the intestine, would admit of the 
use of this instrument in effecting anastomosis of these 
viscera, and also in lateral intestinal anastomosis without 
resection. 
A paper read before the Mississippi Valley Medical 
Association, October 15th, by Dr. J. B. Murphy, of Chi- 
cago, Ill., and published in the New York Medical Rec- 
ord of December 10, 1892, presents the details of a 
process styled " button anastomosis." It is the applica- 
tion of this procedure in cholecysto-intestinal operations 
which is of special interest for our investigation. 
While this principle of anastomosis is not entirely 
new, having been adopted by another for uniting the 
viscera with an opening from one to the other, and by 
the writer in a case of gastrostomy reported at the Nash- 
ville meeting of the American Medical Association in 
1890, yet the improvements in the mode of construc- 
tion entitle Dr. Murphy to the claim of originality in 
the practical adaptation of the anastomosis button to 
this class of operations. I have the permission of the 
author to use his cuts for illustration. 
He.gives the following description of this device : 
The buttons are made in three sizes. A button con- 
sists of two small circular bowls (Fig. 163) ; size No. 2 
measures as follows: diameter, 23 mm. ; depth, 8 mm. 
There is " sweated" into a circular opening, 12 mm. in 
diameter, at the bottom of one bowl, a cylinder 15 mm. 
in length, with female screw thread on its entire inner 
surface. The cylinder extends perpendicularly from 
bottom of bowl. There is an opening in the male bowl 
in which is " sweated " a similar and smaller cylinder of 
a size to easily slip into the female cylinder. There are 
two brass springs soldered on either side of the inner 
surface of the lower end of the male cylinder, which 
extend almost to the top, where small points of them 
protrude through openings in the cylinder. These 
points are designed to catch the screw-thread when 
the male cylinder is pressed into the female cylin- 
der, and thus hold the bowls together at any point 
desired. To separate them again, they are simply un- 
screwed. 
ach is operated on. There are four openings, 5 mm. in 
diameter, in the side of each bowl, for the purpose of 
drainage. By this, it will be seen, we have two hemi- 
spherical bodies held together by invaginating cylinders 
(Fig. 163). These hemispheres of the button are inserted 
in slits or ends of the viscera to be operated on. A run- 
ning thread is placed around the slit in the viscus, so 
Fig. 164.-Showing Running Thread before (a) and after (6) Incision in 
Bowel. (After Murphy.) 
that when it is tied it will draw the cut edges within the 
clasp of the bowl. A similar running thread is applied 
to the slit in the viscus into which the other half of the 
button is inserted, and the bowls are then pressed to- 
gether. The pressure-atrophy at the edge of the bowl 
is produced by the brass ring supported by the wire 
spring. The opening left after the button has liberated 
itself is the size of the button. 
Dr. Murphy claims that this differs from all other de- 
vices in the following particulars or combinations there- 
of : 1, It retains its position automatically ; 2, it is 
entirely independent of sutures ; 3, it produces a press- 
ure-atrophy and adhesion of the surfaces at the line of 
atrophy ; 4, it insures a perfect apposition of surfaces, 
without the danger of displacement; 5, it is ap- 
plicable to the lateral, as well as to the end-to-end, 
approximation : 6, it produces a linear cicatrix, 
and thus insures a minimum of contraction ; 
and 7, it has the merit of extreme simplicity of 
technique, which makes it a specially safe in- 
strument in the hands of the every-day practi- 
tioner, as well as the more dexterous specialist. 
Dr. Murphy then describes the mode of applica- 
tion. The button is inserted in the following 
manner : An incision is made from the edge of the rib, 
two inches to the right of, and parallel to, the median 
line, extending downward three inches. The gall-bladder 
is drawn into the wound, and also the duodenum. 
The duodenum is cleared of its contents by gentle 
pressure with the finger. His short intestinal compres- 
sion forceps is placed upon the duodenum to prevent the 
escape of gas and fluids after the incision is made. A 
needle with fifteen inches of silk thread is inserted in the 
duodenum, directly opposite its mesentery and at a point 
near the head of the pancreas. A stitch is taken through 
the entire wall of bowel, one-third the length of the in- 
cision to be made. The needle is again inserted one- 
third the length of the incision from its outlet, in a line 
with the first, and brought out again, embracing the 
same amount of tissue as the first (Fig. 164). A loop 
three inches long is held here, and the needle is inserted 
in a similar manner, making two stitches parallel to the 
first in the reverse direction, and one-eighth of an inch 
from it, coming out at a point near the original insertion 
of the needle (Fig. 164). This forms a running thread 
which, when tightened, draws the incised edge of the 
Tig. 163. Appearance of Button, with and without Spring-cup Attach- 
ment. (After Murphy.) 
A small brass ring, with a thin though not cutting 
edge, to which is attached a wire spring, is placed in the 
male bowl and retained in position, projecting one- 
eighth of an inch above the edge of the bowl. This is 
held up by the wire spring, and is there for the purpose 
of keeping up continuous pressure until the entire tissue 
between the edges of the bowls is cut off. This spring 
attachment is absolutely necessary only when the stom- 
348 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Gall-madder 
and Ducts. 
bowel within the cup of the button. In the gall-bladder 
a similar running thread is inserted. An incision is now 
made in the intestine, two-thirds the length of the diam- 
eter of the button used. The button is slipped in, in the 
manner hereafter to be shown, the running string tied, 
and the button held with the forceps. 
The contents of the gall-bladder are withdrawn with 
an aspirator. An incision is then made in the gall-blad- 
der of the same length, and between the rows of sutures, 
the button is inserted in a similar manner, and the run- 
ning string tied. The serous surfaces to be approximated 
are scraped with the edge of a scalpel. The forceps is 
then removed and the two halves of the button are held be- 
tween the fingers and pressed together (Fig. 165). A suf- 
ficient degree of pressure must be used to bring the serous 
surfaces of the gall-bladder and intestine firmly in contact 
and maintain pressure upon them. The elastic pressure of 
the spring-cup of the button produces a pressure-atrophy 
of the tissue embraced within the cup, and leaves an 
opening as large as the button, the latter dropping into 
the bowel and being passed through the intestines. 
The time occupied in the case of the first woman on 
(SUPPLEMENT). 
of allowing the bile to re-enter the intestine should be 
welcomed by the surgeon and the patient. 
Dr. Murphy gives the result of five experiments upon 
dogs by uniting the gall-bladder and the duodenum with 
his anastomosis button, in three of which the animals 
were killed after the lapse of a month or more. It was 
found that the button had escaped, leaving an opening 
from the gall-bladder into the duodenum, with perfect 
union between their walls, and a valve was formed on the 
intestinal side of the opening by two folds of the mucous 
membrane closing over it, permitting the bile to flow out, 
but preventing the entrance of anything from the intes- 
tine. The writer would recall to the reader that this 
valvular provision was observed in the case operated 
upon by Kappeler, and reported in his description of the 
autopsy, the patient having died fourteen months after 
the cholecystenterostomy. 
In one of the dogs, which was subjected to the 
same operation w'ith the others, the additional experi- 
ment of tying the common duct was made and the result 
examined on the fourth day. A perfect adhesion of 
gall-bladder to bowel was found and the button was 
wnom ne operated was eleven minutes, from the 
entering of the peritoneal cavity until the closing 
of the same. On dogs he was from eleven to 
eighteen minuteain performing the operation. He 
states that the operation is more difficult to per- 
form on the dog than on man, as it is more dif- 
ficult to bring the gall-bladder into the wound. 
Dr. Murphy draws attention to the number of 
cases of chronic jaundice from obstruction to 
the common gall-duct, requiring some operation 
for relief, and to the defects of the operations 
now in vogue, namely, the unpleasant and some- 
times dangerous sequence of cholecystostomy 
--an external biliary fistula, which may of 
itself be a menace to life. He also adverts to 
the difficulties and dangers of cholecystectomy as a radi- 
cal operation. 
He says that the effect of a permanent fistula of the gall- 
bladder and the constant escape of bile secreted, as fre- 
quently follows cholecystostomy, is different, depending, 
first, on the quantity of bile that escapes from the open- 
ing, and second, upon what proportion is admitted into 
the intestinal tract. This accounts for the great differ- 
ences of opinion as to the gravity of biliary fistula ; and 
if we let the entire quantity of bile escape through a fis- 
tula, the patient soon succumbs. Therefore, a safe way 
still in position. Hair and food were 
in the gall-bladder. 
In another dog in which button 
anastomosis was employed, nothing 
unusual occurred. This animal was 
killed on the fourteenth day, and there 
was perfect union of gall-bladder to 
bowel. There was partial atrophy of 
the tissue in the clasp of the button, 
which was in position ; hair and food 
were in the gall-bladder, and the lat- 
ter was of about the normal size. 
An experiment was made upon one 
dog, with this modification : the stom- 
ach was used in place of the intestine 
for the anastomosis with the gall-bladder. A little 
difficulty was experienced in approximating the ends 
of the button, on account of the thickness of the wall of 
the stomach. The dog was sick on the following day ; 
would not eat or play. But on the third day all symp- 
toms had disappeared. The dog was killed fifty-five days 
after the operation, and the gall-bladder was found to be 
firmly united to the stomach ; the little finger could be 
passed into the stomach from the gall-bladder, and there 
was neither hair nor food in the latter, which was 
somewhat contracted. The dog did not seem to suffer 
Fig. 165.-Button as Held when its 
Two Halves are Pressed together 
in the Performance of Cholecyst- 
enterostomy. 
349 Gall-Bladder. 
Gas Analysis. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
any inconvenience from the bile passing into the stom- 
ach. 
Three operations with the anastomosis button for ef- 
fecting communication from the gall-bladder into the 
duodenum in the living human subject, have proved suc- 
cessful in the hands of Dr. Murphy. They were per- 
formed on June 11, October 19, and November 23, 1892, 
upon females aged thirty-five, thirty-eight, and thirty- 
six years. As the description of the second case embod- 
ies most of the points of interest in the operation, it will 
be given in the words of the author. 
" October 19th, I made an incision, three inches long, 
from the edge of the tenth rib directly downward toward 
the border of the ilium. The tumor was exposed and 
found to be a very much enlarged gall-bladder, with large 
calculi within. The viscus was very oedematous, red, 
and thickened. It was decided to make a cholecysten- 
terostomy with my anastomosis button (No. 2). The gall- 
bladder was aspirated and the running thread inserted. 
The running thread was then inserted into the duodenum 
and the intestine incised, and the male half of the but- 
ton inserted ; the female half was then inserted in the 
gall-bladder through a slit made between the running 
thread, and the button closed. There was no difficulty 
in inserting the button. The gall-stones were allowed to 
remain, as I do not consider it necessary to remove them 
unless they are larger than the button. They will pass 
out after the button escapes. 
" October 20th.-Temperature, 101° F. ; pulse, 96. 
Vomited considerably during the night and complained of 
headache, which seemed to be effects of the anaesthetic. 
There was no pain or abdominal tenderness. 
" October 21st.-At 5 p.m. yesterday the vomiting 
ceased, and the patient is feeling very well this morning. 
" October 27th.-The patient has had no unpleasant 
symptoms since October 20th. This morning, in the 
stool, were found two large gall-stones. The larger one 
weighed 117 grains (7.8 gm.) ; its longest diameter 1 
inch, its shortest | inch. The second stone, 102 grains 
(6.8 gm.); shortest diameter J inch and its longest | 
inch. It will be noticed that the shortest diameter of the 
larger stone measures exactly the same as the diameter of 
button used. 
"The patient is feeling very well and sitting up in 
bed. Complete primary union. Button passed eighteen 
days after operation." 
Nothing is said by Dr. Murphy in regard to the further 
progress of this case, though his report of a patient sub- 
sequently operated on is brought down to November 28, 
1892. 
There seems to be some discrepancy in the dates of this 
paper, which was presented to the Association October 
15th, containing reports of operations done on October 
19 and November 23, 1892 ; but this may, perhaps, be 
explained upon the supposition that they wrere inserted 
afterward when the paper was published in the Record. 
If the results of the experiments on dogs and the 
operations upon human subjects, reported by Dr. Murphy, 
are to be accepted by the profession as facts without 
criticism, we certainly have the most convincing proof 
of the superiority of the anastomosis button in this class 
of operations. There is an old adage that exceptions 
prove the rule, but there seems to be no discount to the 
uniform success of this new process of anastomosis for 
all the different tissues to which its author has applied 
it. He states that he performed the operation of gastro- 
enterostomy three times with the button on the human 
subject, and that Dr. Wiener did it once. " In all of the 
cases," he says, "we got a primary adhesion," and he 
adds that he will give a detailed report of these cases in 
a subsequent clinical paper on the subject. 
Nothing is communicated as to the final outcome of 
the patients operated on excepting the first, but we are 
left to infer that all went well with them, as in a great 
variety of other successful operations with the anasto- 
mosis button referred to in this paper. 
The writer has received specimens of three different 
sizes of these buttons from the manufacturer, and is con- 
vinced that a smaller button than either would be better 
(SUPPLEMENT. 
suited to effect an opening from the gall-bladder into the 
duodenum. It is not desirable to have so large an outlet 
from the gall-bladder for the biliary discharges. 
The two larger sizes of the button are of such bulk and 
weight that their passage through the small intestine may 
cause trouble, and more especially at the ileo-csecal con- 
nection. It is a known fact that gall-stones, not exceed- 
ing greatly the diameter of the largest button, have been 
arrested in the small intestine, necessitating an operation 
for removal on account of the obstruction in the canal; 
and after examination of these buttons there seems to be 
cause for objecting to the employment of the larger sizes 
in attaching the gall-bladder to the duodenum. It will 
be observed that size No. 2 was used in the case recorded 
in this paper, and that the "button passed eighteen days 
after the operation." But nothing is reported as to the 
passage of the button in the other twyo cases. He states, 
however, that the patient operated upon on June 11, 1892, 
was examined by Dr. II. R. Wittmer on October 28th, 
and that she was in excellent health. 
The weight of the buttons might be lessened materially 
by using aluminium in their construction, thus setting 
aside an objectionable feature, as the largest size at pres- 
ent weighs 340 grains. 
Further experience in the use of the anastomosis button 
is desirable, before it is finally adopted in the surgery of 
the gall-bladder. J. McFadden Gaston. 
GANGRENE. The subject of gangrene in its various 
forms was fully considered by the writer, in a previous 
article in the Handbook, to which the reader is re- 
ferred for a more extended discussion of the subject. It 
remains, however, to consider it from the stand-point of 
recent surgical pathology, more especially surgical bac- 
teriology. 
That form of gangrene which is due to lack of nutri- 
tion of the part, such as that caused by arteritis obliterans 
and by thrombosis, remains unaffected by recent experi- 
mental discoveries. We may therefore divide gangrene 
into two general classes-the first class being from lack 
of nutrition, and the second class being a gangrene of 
microbic origin. The first class, as has been known for 
a long period, includes alterations of the arteries and 
veins, and of the nerves of the arteries ; these alterations 
consisting of atheroma, thrombosis, emboli, changes in 
the blood, and alterations in the structure of the nerves. 
Reclus has given the term " direct gangrene " to the 
first class, including those produced by violent trauma- 
tism, by extreme cold, burns, and caustics; "indirect 
gangrene " to that series in which the lack of nutrition is 
due to arterial, venous, capillary, or cardiac derange- 
ments, and to the different alterations of the blood. The 
latter term is also applicable as well to the trophic or 
nervous gangrenes. Clinically, Reclus divides the gan- 
grenes into four types: gangrene by cadaverization, 
white gangrene, dry gangrene, and moist gangrene. 
Gangrene by cadaverization is an exceptional form, in 
which the skin is cold, dull, rigid, and discolored as after 
death, the epidermis is easily detached, and on punct- 
uring the integument with a needle or by light strokes 
of the bistoury, small drops of blood appear. Some- 
times the entire member is cold, but without being fa- 
tally lost, as in the case stated by Lemont, where after 
discoloration, coldness, and cornification, in about ten 
days there appeared, little by little, heat and sensation, and 
soon all traces of gangrene had disappeared. Ordinarily, 
however, says Reclus, the gangrene of cadaverization is 
succeeded by dry gangrene. 
White gangrene, as described by Ousnay, appears in 
the same form and has been confounded with the gan- 
grene of cadaverization. It appears as a hemorrhagic spot 
on the skin, a sort of limited ecchymosis, which may have 
its seat anywhere on the body ; it is always superficial. 
Dry gangrene, or mummification, is invariably pro- 
duced by blocking of the blood-vessels or by trophic 
changes. 
Moist gangrene applies to the septic variety, and is ex- 
tremely rapid in its progress. Moist gangrene is distinc- 
tively septic, as has been proved by its reproduction by 
350 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Gall-Bladder. 
Gas Analysis. 
inoculation, to such a degreethat some pathologists have 
detached gangrenous septicaemia from the traumatic gan- 
grenes. 
As a means of determining the exact location of the 
thrombosis or obstruction, in the case of arteritis obliter- 
ans. Dr. W. S. Lyon, of Edinburgh, gives the follow- 
ing method of procedure : Gently raise the limb, keep it 
raised for two or three minutes to empty it in some de- 
gree of its blood, then apply the tourniquet or piece of 
elastic webbing on the proximal side of the injury or 
supposed site of the obstruction, and keep it applied for 
about a minute ; then lower the limb and remove the 
tourniquet. If sufficient circulation remains in the part 
below the injury it will blush a rosy red and show in an 
unmistakable manner the condition of the blood-vessels. 
It must be evident that, as in the case of surface constric- 
tion when applied to a given surface, if the arteries are 
sound underneath, it will speedily cause tension below 
the ligature by reason of the accumulation of blood, and 
so, by readjusting the ligature from time to time, it is pos- 
sible to approximately arrive at the site of obstruction. 
Moist gangrene, or emphysematous gangrene, pro- 
duced by the development of gases in the decomposed 
part, or putrefactive changes, is now supposed to be due 
to a bacillus morphologically like that of the malignant 
oedema, as described by Koch and Gaffney. It is known 
by the experiments of Rosenbach and others that in 
these cases of emphysematous gangrene there are present 
one or more varieties of the proteus micrococcus, with 
other forms of bacteria, and that the ptomaines of these 
bacteria themselves in some cases may cause tissue death ; 
and that certain bacteria have the power of generating 
gases, this being true, in particular, of a variety which 
is called by the French " vibrion septique," which is 
anaerobic, and which resembles the bacillus anthracis. 
In this connection it is to be remembered that the treat- 
ment of moist gangrene has undergone a radical change ; 
deep and thorough incisions, the injection of anti-bacil- 
lary agents, copious and repeated irrigation, are meas- 
ures which are now practised, and amputation is reserved 
for cases in which the bones are so enfeebled as to be no 
longer capable of supporting the member. 
It is evident from the mutiplicity of experiments and 
observations that no one microbe can be the sole cause 
of gangrene. Godlin1 reported a case of gangrene re- 
sulting in emphysema, which started from an inflamed 
corn, rapidly extended, and in a week required thigh 
amputation. The man continued to show sapra>mic 
symptoms after the amputation, and culture experiments 
with the pus showed the presence of streptococcus pyo- 
genes and staphylococcus pyogenes albus. Lemont and 
Koch have described another bacillus which they found 
in a case of emphysematous gangrene, and which resem- 
bled the bacillus of glanders. Staphylococcus pyogenes 
aureus and staphylococcus cereus albus were found in 
metastatic gangrene of-the skin, by Ciarrochi. He also 
isolated a short bacillus which, when injected under the 
skin of animals, produced gangrenous pus. 
In conclusion it must be staled that the traumatic gan- 
grene, where the parts are pulpified or bruised, and blood 
is extravasated into the tissues, affords favorable condi- 
tions for the growth and propagation of putrefactive bac- 
teria. Senn has well summarized the etiology of septic 
gangrene as follows: 
First Condition, the microbes are so numerous in the 
capillary vessels that their presence interferes mechani- 
cally with the blood-supply, and death of the part ensues 
in consequence of greatly diminished or suspended nu- 
trition. Second, the microbes in the tissues produce 
ptomaines which destroy the tissue by their direct de- 
structive chemical action on the protoplasm of the cells. 
Third, the specific inflammation caused by the microbic 
infection is so intense that the inflammatory product in 
the perivascular tissues accumulates so rapidly and in such 
abundance that nutrition is suspended by impairment or 
Suspension of the arterial blood-supply, or mechanical 
interference of return of blood from the part, or both of 
these conditions combined. 
Coagulative necrosis, a condition confounded by some 
(SUPPLEMENT 
with gangrene, was given its name by Cohnheim, and is 
a condition which takes place in the coagulation of the 
blood, whereby the colorless corpuscles die and undergo 
a fermentative change. This is the same as the "fibrine 
ferment '' of the last decade. John B. Hamilton. 
1 British Medical Journal, July 27, 1887. 
GAS ANALYSIS. I. General Properties of 
Gases.-(a) A gas is characterized by the property of 
filling uniformly any given space. If the pressure upon 
a gas be increased, its volume will diminish, and, provid- 
ing the temperature remain constant, the volume of a 
gas will be inversely proportional to the pressure. De- 
noting the volumes by Vand v, and the corresponding 
pressures by P and p, then, 
V : v = p : P; or, 
(1) VP = vp. 
In other words, at a constant temperature the product of 
the volume and the pressure is always the same. This 
law of Boyle holds true only for relatively slight varia- 
tions of pressure and volume. If it were correct for 
gases subjected to very great pressure, then the gas 
which would be first liquefied by the pressure would 
finally attain a density greater than solid substances, a 
phenomenon manifestly impossible, because liquid bodies 
are but slightly compressible. The variations from the 
law within the limits met with in ordinary analytical 
operations are, however, so slight, that for the present 
purposes it may be regarded as correct. 
All gases expand in the same proportion when sub- 
jected to the same rise in temperature. If one volume 
of a gas be heated from 0° C. to 100° C., its volume then 
will be 1.367. The increase in volume for each degree 
would accordingly be .00367. If v is the volume at any 
temperature t, and Vthe volume at'O°, the above may be 
expressed. 
(2) v = V (1 + .00367 t). 
If a gas which has been thoroughly dried be collected 
over mercury in a tube closed at the top, and if then a 
small amount of water, sufficient to saturate the gas with 
water vapor, be introduced into the tube, it will be seen 
that the volume is thereby increased. In analytical oper- 
ations it is quite difficult to dry each portion of gas be- 
fore measuring, and in calculating the absolute volume 
of the gas, allowance is made for the increase in volume 
caused by the water vapor present. The pressure ex- 
erted by the water vapor has been determined experi- 
mentally for all temperatures, and the volume which a 
gas saturated with aqueous vapor would occupy if dry 
can be determined by ascertaining the volume which 
would correspond to the prevailing pressure, P, less the 
pressure exerted by the water vapor at the temperature 
observed. To illustrate, a gas volume saturated with 
water vapor, and measuring 63.2 cubic centimetres un- 
der a barometric pressure of 744.6 millimetres, and tem- 
perature of 18.4° C., would, in the dry state, and at the 
, . , i co o 744.6-15.72 
same pressure and temperature, equal 63.2 
744.6 
= 61.8 c.c., 15.72 being the tension of water vapor at 
18.4° C. 
It is evident that for scientific purposes, observed gas 
volumes should be reduced to the volumes which would 
be occupied under certain standard conditions. By com- 
mon consent the pressure of a column of mercury 760 
mm. high is termed the normal or standard pressure, 
and 0° C. the normal temperature. All observed gas 
volumes, then, are reduced to the volumes which the gases 
would occupy in a dry state at 760 mm. pressure and 0° 
C. The necessary data for the calculation have been 
given above. 
In equation (1), if P be taken as the normal pressure of 
vP 
760 mm., the equation becomes F= -. Equation 
760 
(2) would give for V, V = ।_L__Combining 
351 Gas Analysis. 
Gas Analysis. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
these two, and subtracting from the observed barometric 
pressure, P, the tension of the water vapor, m, at the 
observed temperature, t, we have 
TZ P - m 
V = v . 
760 (1 + .00367 I) 
To illustrate, 82.3 c.c. of a gas, measured in a moist 
condition under a barometric pressure of 748.2 mm., and 
a temperature of 18.6° C., would, under normal condi- 
tions, equal 
82.3 748,2 ~ 15,9- = 74.1 c.c. 
760 (1 + .00367 x 18.6) 
(b) Partial Pressure.-Gases mix in all proportions. 
The pressure of the mixture is the sum of the pressures 
of the various gases in the mixture. The pressure ex- 
erted by each of the gases is the same as the gas would 
exert if present alone in unchanged amount in the same 
space. This pressure exerted by each gas of a mixture 
is known as its partial pressure. One hundred volumes 
of the atmosphere contain 20.9 volumes of oxygen and 
79.1 volumes of nitrogen. If air were confined in a 
vessel under a pressure of 760 mm. and the oxygen were 
then removed, the remaining nitrogen would then fill 
the whole space and would exert a pressure of 760 x 0.791 
= 601.16 mm. Had the nitrogen been removed, the 
oxygen would have exerted a pressure of 760 x 0.209 = 
158.84 mm. These, then, are the partial pressures of the 
two chief constituents of the atmosphere. 
The well-known researches of Paul Bert have shown 
that this partial pressure of atmospheric oxygen plays an 
important role in the process of breathing. We have 
seen above that the oxygen of the atmosphere exerts a 
pressure of about one-fifth of the total pressure of the 
air. Bert has shown that animals and men can live in 
pure oxygen if the pressure of the gas be reduced to one- 
fifth of an atmosphere, or, in other words, to the pressure 
which it exerts in the atmosphere. If, on the other hand, 
animals be confined in air whose pressure has been re- 
duced to one-fifth of an atmosphere, death soon results, 
because here the partial pressure of the oxygen is only 
one-twenty-fifth of an atmosphere. 
(c) Diffusion of Gases.-Molecules of gases move con- 
stantly in all directions, and if a layer of a light gas be 
carefully introduced over a layer of a heavier one, it will 
be found that, after some time, the lighter gas above has 
passed downward and mixed with the heavy gas below, 
and vice versa. This property, known as diffusion, is pos- 
sessed by all gases. Whenever different gases are in con- 
tact, the molecules of adjacent layers tend to intermingle 
and form homogeneous mixtures. 
(d) Solution of Gases in Liquids.-All gases are more 
or less soluble in liquids, the amount dissolved depending 
upon the nature of the gas and solvent, and also upon 
the temperature and pressure. Gases which can be easily 
liquefied are more soluble than those which are liquefied 
only with difficulty, and, on the other hand, warming 
diminishes the solubility of the gas, perhaps because the 
rise of temperature removes the gas further from the 
liquefiable state. Henry, in 1830, found that at constant 
temperature the amount of gas dissolved is proportional 
to the pressure. That is, if a liquid absorbs a certain 
amount of gas at a pressure of one atmosphere, it will ab- 
sorb twice as much of the gas under a pressure of two at- 
mospheres, and at half an atmosphere half as much. 
This law of Henry is not absolutely correct, but it ap- 
proaches the truth very closely for those gases which are 
but slightly soluble. 
The amount of a gas taken up by an absorbent, as 
water, is determined by experiment with an "absorp- 
tiometer," such as that used by Bunsen,2 or by L. W. 
Winkler,9 and from the data thus obtained a table of the 
solubility of the gas at different temperatures can be 
made out. Bunsen denotes the solubility by the term 
" absorption-coefficient," by which he means the volume 
of gas reduced to 0° and 760 mm. pressure, which is ab- 
sorbed by 1 c.c. of liquid at the same pressure. 
(SUPPLEMENT.) 
It is important to remember in this connection that the 
solubility of a gas in a mixture of gases is not influenced 
by the presence of the other gases, and is not proportional 
to the total pressure of the mixture, but only to the press- 
ure exerted by the gas in question, i.e., its partial press- 
ure. Thus water exposed to the air does not dissolve 
equal amounts of oxygen and nitrogen, nor amounts pro- 
portional to the solubility of the two gases, but rather the 
volumes of the two gases which the water will absorb 
depend upon both the solubility and the partial pressure 
of the two gases. To illustrate, the pressure exerted by 
nitrogen when the total atmospheric pressure is 760 mm. 
is about seventy-nine per cent, of 760, or 600.4 mm. At 
760 mm. pressure and 20° C., 1 c.c. of water absorbs 0.014 
c.c. of nitrogen ; hence at 600.4 mm. pressure it would 
absorb 0.014 x ^P?'4 = 0.0109 c.c. Under the same condi- 
ibO 
tions 1 c.c. of water dissolves 0.028 = 0.0058 c.c. of 
,60 
oxygen. Hence, when air is dissolved by water under 
the above conditions 65.2 per cent, of the dissolved gas 
would be nitrogen and 34.8 per cent, would be oxygen, or, 
in other words, the oxygen would amount to more than 
one-third of the total volume of dissolved gas, although 
in the air it amounts to one-fifth. 
The law of partial pressure thus explains why the 
various components of a mixture of gases are taken up 
by a solvent in amounts depending upon the pressure of 
each gas and independent of the other gases present. 
When the molecules of a gas come in Contact with the 
surface of a solvent such as water, they are held fast or 
are absorbed, and this absorption continues until the 
water has taken up a certain number of the molecules. 
Some of the gas-molecules will meanwhile escape from 
the water and pass back into the gas, and when the num- 
ber of molecules which enter the water in a given time is 
equalled by the number which escape, the water is said 
to be saturated with the gas. If the pressure of the gas 
be increased the number of molecules absorbed by the 
water will also be increased, and with diminished press- 
ure the opposite will be true. 
In the absorption of the gases in a mixture the amount 
of each gas absorbed will, as we have seen, depend upon 
the partial pressure of that gas, and the escape of the 
same gas from the water will be influenced by its own 
partial pressure in the mixture, but not by the pressure 
exerted by any other constituent. In other words, the 
atmosphere of another gas prevents the escape of a dis- 
solved gas no more than would a vacuum. There are no 
molecules of the dissolved gas present to enter the water, 
and the gas, by reason of its elasticity, passes out. That 
many gases can be driven out of water by boiling, even 
although the gases are somewhat soluble in boiling water, 
may be explained by the fact that the surface of the water 
becomes covered with a layer of aqueous vapor, the partial 
pressure of the gas upon the surface of the water is thus 
made very slight, and, as a consequence, the dissolved 
gas escapes. 
II. The Analysis of Gases.-(«) The Collecting and 
Keeping of Gas Samples.-In gas analysis, as in all other 
analytical work, the proper taking of the sample is one 
of the most important operations. Notwithstanding the 
rapid movement of gas molecules, currents of gases are 
often of varying composition, especially when chemical 
processes are simultaneously going on. On this account 
the place at which the samples of gas are taken is of the 
greatest significance. In pipes or other channels the 
point of smallest cross-section is the most suitable. In 
the examination of furnace gases it is best to take the 
sample at the point where the visible flame ends, because 
farther away, on account of the porosity of the wall, 
considerable quantities of air are always mixed with the 
gases from the fire. To take the sample an iron tube is 
introduced into the furnace at a suitable point. A small 
lead pipe, such as is used for pneumatic bells, is attached 
to the outer end of the iron tube by means of a piece of 
rubber tubing. At temperatures under 300° the lead 
pipe itself may be inserted into the furnace. The great 
352 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Gas Analysis. 
Gas Analysis. 
advantage possessed by such lead pipe is that it is very 
small internally and can be manipulated as easily as rub- 
ber tubing. For very high temperatures either porcelain 
tubes or cooled iron tubes may be used. With acid gases 
glass tubes should be employed if possible. 
Long rubber tubes must be avoided, but short pieces 
may safely be used for connections. Rubber receivers 
also are to be rejected. Vulcanized rubber acts toward 
gases as does a liquid, absorbing the gases, and later, ac- 
cording to the prevailing pressure, giving them up again. 
For example, a piece of rubber tubing, 3 ctm. long and 
from 4 to 5 mm. external diameter, absorbed 0.2 c.c. of 
carbon dioxide and 0.9 c.c. of nitrous oxide, and on ly- 
ing in the air it gradually gave up these gases. 
If the place where the gases are to be collected is 
directly accessible, as, for example, in the examination of 
mine-gases, the small " medicine bottles" * proposed by 
Bunsen may be used, the neck of the bottle being drawn 
out in the flame of the blast-lamp as in Fig. 166. Bun- 
sen states that the bottle should 
first be carefully heated between 
the shoulder and the neck, and 
the neck then drawn out. by 
(SUPPLEMENT.) 
breaking the tube at b, it is tilled instantly and with the 
greatest certainty by the gas in question. The tubes are 
then closed for a 
few moments with 
a rubber cap, and 
are melted to- 
gether at a over a 
candle. The ex- 
hausting with the air-pump has the advantage of ren- 
dering one less dependent upon the care of the person 
who tills the tubes. If, 
however, it is desired to 
avoid this exhausting, 
the tubes are given the 
following form (Fig. 
170). To fill such a tube, the gas to be examined is 
drawn through it and the tube is then fused together at 
a and b in a candle flame (Fig. 171). 
Such tubes can be most safely shipped by packing them 
Fig. 169. 
Fig. 170. 
Fig. 171. 
in sawdust in boxes which have a separate compartment 
for each tube. The boxes themselves are placed in a 
larger box filled with hay. 
The tube last described is filled by the displacement of 
the air already contained therein. Naturally it is here 
presupposed that large amounts of gas are at one's dispo- 
sal. If only a small quantity of gas is obtainable, the 
receiver must be filled with water or mercury, which is 
then displaced by the gas. Water can be used only 
when it is first saturated with the gases in question, as, 
for example, is always the case with the water of bub- 
bling springs. 
To collect gas from such springs as are directly acces- 
sible, the small apparatus pro- 
posed by Bunsen is used (Fig. 
172). 
This consists of a test-tube, c, 
of from 40 to 60 c.c. capacity, 
drawn out at a before the blast- 
lamp to the size of a fine straw, 
and connected air-tight with 
the funnel b by means of a 
well-fitting cork or a piece of 
vulcanized rubber tubing. In- 
stead of the test-tube a small 
long-necked medicine bottle 
may be used, this being drawn 
out in the middle of the neck 
to a similar straw-like contrac- 
tion. The apparatus is then 
filled with the water of the 
spring. This cannot be done 
without access of air, which 
would change the composition 
of the gases diffused through 
the spring water in the tube. 
Hence the inverted apparatus, 
with the mouth of the funnel 
upward, is lowered below the level of the spring, and, 
with a narrow tube reaching to the bottom of the test-tube, 
the water which in the first filling had come in contact 
with the air is sucked out until one is satisfied that it has 
been entirely replaced by other water from the spring. 
If now the gas of the spring is allowed to rise through 
the funnel into the test tube thus filled, the purity of the 
sample is assured. If the rising bubbles stop in the neck 
Fig. 166. 
Fig. 167. 
Fig. 168. 
means of suitable tongs (Fig. 167). To fill the bottle 
with gas, the air in the bottle is sucked out through 
a small glass tube reaching to the bottom, this opera- 
tion being repeated until the air originally in the bot- 
tle is completely replaced by gas from outside. Five 
or six full breaths are sufficient. It is self-evident that 
at each exhalation of the air sucked from the bottle one 
must step aside from the spot where the gas sample is 
being taken. The tightly stoppered bottle is then slightly 
warmed over a spirit-lamp, and equilibrium between the 
expanded air inside the bottle and the outside atmosphere 
is re-established by lifting the cork for a moment. After 
cooling, the diminished pressure inside the bottle prevents 
the blowing-out of the glass when the narrow neck is 
fused together. The fusion may conveniently be per- 
formed with the blow-pipe shown in Fig. 168. The small 
lamp (a) holds 3 grammes of oil and is connected with 
the blow-pipe by means of a flexible wire that carries a col- 
lar (b) through which the tip of the blow-pipe is inserted. 
The cork c serves as a mouth-piece, by means of which 
the whole apparatus can be held and guided by the teeth 
alone. Thus both hands are left free, and the flame can 
still be moved in all directions, since the relative positions 
of the blow-pipe tip and the lamp remain the same, how- 
ever the instrument be held. 
The arrangement used by Hempel in his parallel re- 
searches "upon the composition of the atmosphere at 
different parts of the earth " is also a very convenient one. 
The air was collected in glass tubes of the form shown in 
Fig. 169. d is about 4 mm. thick ; a, b, and c, only 1 
mm. These tubes were heated in an air-bath in the labo- 
ratory to 200°, and were then exhausted with the mer- 
cury air-pump and fused together at c. By simply 
Fig. 172. 
* These so-called medicine bottles are common glass bottles about 12 
ctm. high. They were recommended by Bunsen because they can be 
found almost everywhere, even small village drug stores having a supply 
of them. 
353 Gaw Analysis. 
Gas Analysis. 
REFERENCE HANDBOOK OF TIIE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
of the funnel or at the contraction a, they can easily be 
made to ascend by tapping the edge of the funnel upon 
some hard substance. The apparatus is then placed in a 
small dish and removed from the spring, and the tube is 
melted together at a. This can easily be done with the 
blow-pipe, the moisture at the point a having first been 
driven away by warming. 
For the determination of the volume and composition 
of the absorbed gases in liquids, the Tiemann and Preusse 
not enter from without because the liquid in B is kept 
continually boiling. The apparatus is now ready for a 
determination, which is made as follows : 
The cooled flask A, whose capacity has been previ- 
ously determined, is filled with the water to be exam- 
ined, and the stopper is pressed in so far that the air in 
the tube a is completely driven out. a is then connected 
with b, care being taken that in so doing no air-bubbles 
are enclosed. The pinchcock between a and b is opened, 
and the water in A is heated to gentle boiling. The dis- 
solved gases are hereby driven over into the gas-collector 
G. Steam is formed at the same time. The heating of 
the flask A must now be so regulated that the gas and 
steam evolved never drive out more than half the liquid 
in G; otherwise there is danger of gas-bubbles entering 
the tubes d and e and thus escaping. 
After heating for about twenty minutes the flame un- 
der A is removed. In a few minutes the steam in A and 
G condenses, and water passes from B toward C and A. 
If a gas-bubble is observed in A, the flask A must again 
be heated and cooled in the manner just described. The 
operation is ended when the hot liquid flows back and 
completely fills A. The rubber tube g is then connected 
with a small tube which is filled with water or mercury, 
and the gas standing over the hot liquid in C is driven 
over into a eudiometer, gas burette, or gasometer by 
blowing into the tube x and opening the pinchcock a. 
As it is difficult, and sometimes impossible, to com- 
pletely remove the dissolved gases from water by boiling 
alone, it has been found advantageous to combine with 
the boiling of the water the use of the mercury air- 
pump. One of the best forms of apparatus thus far de- 
vised for the purpose has been recently described by 
Hoppe-Seyler4 (Fig. 174). 
A is first filled with mercury by raising C, the clamp 
b is closed, and the air in B is removed by opening c and 
lowering E, thus drawing most of the air in 7? over into 
the upper part of D. c is then closed and by raising E 
the air is driven out through e. Upon opening c some 
mercury will enter B, and the above procedure is re- 
peated until all air has been removed from B and D and 
the tubes are filled with mercury. The water whose dis- 
solved gases are to be examined, can then be drawn into 
B and A without coming into contact with the air. The 
water in A is then healed to boiling, the evolved gas 
collects in B, and, b having been closed, the gas can be 
Fig. 173. 
modification of Reichardt's apparatus3 can be recom- 
mended (Fig. 173). 
This consists of two flasks, A and B, each of about one 
litre capacity, and connected by tubes with the gas-col- 
lector G. The flask A is fitted with a perforated rubber 
stopper, in which is inserted the glass tube a, bent at a 
right angle and ending flush with the lower surface of 
the stopper, a is joined by a piece of rubber tubing to 
the tube Sc, which in turn connects with the gas-collector 
G. G is held by a clamp, has a diameter of 35 mm., is 
about 300 mm. long, and at the upper end is drawn out 
to a short, narrow, and slightly bent tube which can be 
closed with the rubber tube and pinchcock g. In the 
lower end of G is a rubber stopper with two holes, 
through one of which the tube Sc, projecting about 80 
mm. into G, is inserted. Through the other opening 
passes the tube d, which extends only slightly beyond the 
stopper and connects G with the flask B. B has a 
double-bore rubber stopper carrying the tubes e and/, c 
ends about 10 mm. above the bottom of the flask, and 
above the stopper it is bent at a right angle and is con- 
nected with d. The tube/, which need not project be- 
low the stopper, carries a thin rubber tube (#), about one 
metre in length and provided with a mouth-piece. A 
pinchcock for closing the rubber tube between a and S is 
also needed. 
The apparatus thus arranged is made ready for a de- 
termination by filling the flask B somewhat more than 
half full of boiled water, and removing the flask A by 
slipping the tube a out of the rubber connection ; then, 
by blowing into the rubber tube x, -water is driven over 
from the flask B into the gas-collector G and the adjoin- 
ing tubes until the air is wholly displaced. The rubber 
tubes at b and g are now closed with pinchcocks. The 
flask A is then filled to the brim with distilled water, the 
stopper is inserted, water being thereby driven into the 
tube a, and the flask is again connected with b, the pinch- 
cock being opened. 
The water in B is now heated to gentle boiling, and 
that in A is allowed to boil somewhat more rapidly. 
The absorbed air is thus driven out, and the gases dis- 
solved in the water which is in A and G collect in the 
upper part of G, from which they are removed by occa- 
sionally opening the pinchcock at g and blowing into the 
rubber tube x. 
When, upon cooling the apparatus, the gases which 
have collected disappear, the heating of the flask A is 
discontinued, the pinchcock between a and b is closed, 
and A is disconnected and emptied. The water in Cand 
B is now entirely free from absorbed gases, and air can- 
Fig. 174. 
drawn over into D and transferred to tiie measuring tube 
G or any other desired apparatus. 
The researches of Jacobsen and Pettersson have shown 
that it is impossible to remove the dissolved carbon 
dioxide from the water by boiling, and Iloppe-Seyler, 
in his description of the apparatus figured above, says 
that after forty boilings of a water containing carbon 
dioxide some of the gas still remained in the liquid. For 
these reasons it is best not to attempt to remove the gas 
354 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Gas Analysis. 
Gas Analysis. 
from the water, but to determine it while still in solution. 
One of the best methods for accomplishing this is one 
devised by Pettenkofer, which consists of precipitating 
the carbon dioxide dissolved in the water by adding a 
solution of calcium hydroxide of known strength, allow- 
ing the precipitate to settle, and then determining the ex- 
cess of the calcium hydroxide in an aliquot portion of the 
clear supernatant liquid by titration with dilute oxalic 
acid. Litmus solution is used as the indicator. Sutton 
describes the method as follows : 
" The following is the best method to be pursued for 
ordinary drinking-water not containing large quantities 
of carbon dioxide: 100 c.c. of the water is put into a 
flask with 3 c.c. of a strong solution of calcium chloride, 
and 2 c.c. of a saturated solution of ammonium chloride ; 
45 c.c. of lime-water, the strength of which has been pre- 
viously ascertained by means of decinormal acid, is then 
added, the flask well corked and put aside to settle. 
When the solution has fully subsided, take out 50 c.c. 
of the clear liquid with a pipette, and titrate this with 
(SUPPLEMENT.) 
Fig. 175 shows an arrangement which may be used 
when one wishes to take samples at the same time in a 
Hempel gas burette (see later). The water passes from 
the bottle A through the siphon (A into C, and thereby 
draws the gas from the tube F. When A is empty, C, 
which is now full, is put in its place, the aspirating of the 
gas continuing as long as the samples are being taken. 
While the gas is being thus drawn from F into A, a 
sample for analysis may be at any time drawn off into 
the gas burette by lowering the level-tube, as shown in 
the figure, and opening the pinchcocks d and/. 
When running water is at hand, the aspirating may be 
done by means of the ordinary glass or brass suction- 
pump attached to the faucet. 
A gas can be best kept in the fused glass tubes already 
Fig. 176. 
described, but glass bulbs supplied with two glass stop- 
cocks are also quite satisfactory (Fig. 176). 
Metallic receivers should be used for analytical pur- 
poses only when the gas is to remain in them but a short 
time. They are, however, not easily broken, and are 
especially well adapted to the transport of large quanti- 
ties of gas. 
Rubber sacks should never be employed, since gas 
mixtures confined in them rapidly 
change in composition. 
If large amounts of gas are to be 
collected and kept for analysis foi 
a considerable length of time, the 
portions of gas taken for analysis 
must be displaced with mercury. Il 
is utterly impracticable to use wa 
ter for this purpose, for continual 
changes would take place, since the 
absorption varies with the pressure 
and temperature. A gasometei 
Fig 177. 
Fig. 175. 
well adapted to keeping comparatively small volumes of 
gas is shown in Fig. 177. 
The large glass bulb A serves to hold the gas. At the 
top it carries the bent capillary tube a, and at the bottom 
it is joined to the level-bulb B by a rubber tube. The 
capillary is closed by a rubber tube and pinchcock. The 
apparatus is first filled with mercury. By lowering or 
raising the level-bulb, gas can be drawn in or driven out 
as desired. If gases are to be kept for some time, the 
capillary tube a is filled with mercury by 
means of a little pipette inserted at c. 
This closes the bulb perfectly. In such 
an apparatus gases may be kept unchanged 
for an unlimited time. 
Small glass bulbs (Fig. 178) are also 
very convenient. They are filled with 
gas in a mercury trough, and are then 
placed mouth downward in small porce- 
lain crucibles containing mercury. The 
gas is taken out with the gas pipette to 
be described later. 
(6) The Apparatus.-The amount of a gas may be de- 
termined by : 1, The direct measuring of its volume ; 2, 
decinormal acid. The quantity required must be multi- 
plied by three for the total lime solution, there being 
only 50 c.c. of the solution taken ; the number of cubic 
centimetres so found must be deducted from the original 
quantity required for the calcium hydroxide solution 
added ; the remainder multiplied by 0.0022 (the acid 
being decinormal) will give the weight of the carbonic 
acid existing free and as bicarbonate in the 100 c.c. of 
water. 
" The addition of the calcium chloride and the am- 
monium chloride is made to prevent any irregularity 
which might arise from the presence of alkaline carbo- 
nates or sulphates, or of magnesia. If it be desired to 
ascertain the volume of the carbon dioxide from the 
weight, 1,000 c.c. of the gas at 0° C., and 760 mm. press- 
ure, weigh, 1.96503 gramme." 
If the gases to be collected have a pressure less than 
the prevailing atmospheric pressure, an aspirator must be 
used. The simplest form consists of two interchange- 
able bottles of equal size and the same width of neck. 
Fig. 178. 
355 Gas Analysis. 
Gas Analysis. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
absorbing the gas with a solution of known strength, and 
then ascertaining by titration the amount of the solution 
■which has been acted upon ; 3, absorbing the gas with a 
weighed amount of an absorbent, and then ascertaining 
the increase of weight ; 4, burning the gas, and deter- 
mining the products by either volumetric or gravimetric 
methods. 
Although isolated analyses of gases had been made be- 
fore his time, Robert Bunsen2 was the first to develop 
gas analysis as a distinct branch of analytical chemistry, 
and to devise methods by which gas mixtures could be 
examined with accuracy. The forms of apparatus and 
the methods which he introduced, and which have since 
been improved by Geppert,7 have made possible, in the 
analysis of gases, an exactness that has perhaps never 
scribed apparatus and methods remarkable for their ex- 
actness and ease of manipulation. The many improve- 
ments which Hempel has made in his methods since that 
time he has embodied in a second work. " Gasanalytische 
Methoden " (1890), from the English translation1 of 
which many of the following descriptions are taken. 
Hempel's Apparatus for Technical Gas Analysis. 
- Gas Burettes.-These are carefully graduated tubes in 
which the gases are measured. 
A. The Simple Gas Burette (Fig. 179). This consists of 
two glass tubes, A and A, which are set in iron feet and 
are connected by a thin rubber tube about 120 ctm. long. 
To facilitate the cleaning of the burette the rubber tube 
is divided in the middle and the two ends joined by a 
piece of glass tubing. 
Inside the feet the tubes are bent at right angles and 
conically drawn out. The end projecting from the iron 
is of about 4 mm. external diameter and is somewhat cor- 
Fig. 1^0 
Fig. 179. 
rugated, so that a rubber tube may be tightly fastened to 
it by wire ligatures. 
The measuring tube b ends at the top in a thick-walled 
tube, c, of from i to 1 mm. internal diameter and about 3 
ctm. long. Over this a short piece of new black rubber 
tubing is wired on. The rubber tube is closed by a Mohr 
pinchcock, which is put on close to the end of the capillary. 
Notwithstanding the fact that readings cannot be made 
under the rubber tube, and that the pinchcock cannot 
always be put on above the tube in exactly the same po- 
sition, no error results therefrom, since the glass tube c 
is very small. 
The graduated measuring tube b contains 100 c.c., 
the lowest mark being slightly above the iron foot. The 
cubic centimetres are divided into fifths, and the numbers 
run both up and down. The other tube, which we will 
call the level-tube, is somewhat widened at the upper 
end, h, to facilitate the pouring in of liquids. 
B. The Hempel-Pettersson Gas Burette, Independent of 
Changes in Temperature and Atmospheric Pressure (Fig. 
been exceeded by other procedures. But the apparatus 
used by both Bunsen and Geppert is cumbersome, and 
the analysis of a gas mixture of any complexity is a long 
and tedious operation, so that while Bunsen's methods 
have met with early and lasting approval, they have not 
found wide use among chemists. 
With the growth of the great industrial processes in 
Europe, and especially in Germany, there arose a demand 
for analytic methods which, if not so exact as those of 
Bunsen, should be fairly accurate, simple, and rapid. 
This demand was met, with remarkable success, by 
Clemens Winkler, whose classical work upon qualitative 
and quantitative gas analysis6 made the field of techni- 
cal gas analysis as easily accessible as the other branches 
of analytical work developed by Rose, Mohr, Fresenius, 
and Plattner. In 1880 Walter Hempel published his 
" Neue Methode zur Analyse der Gase," and there de- 
356 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Gas Analysis. 
Gas Analysis. 
[SUPPLEMENT.) 
capillary tube being allowed to project from 2 to 3 ctm. 
above the frame. 
A short piece of. rubber tubing is wired on to the free 
end of the capillary. The distance h must be greater 
180). The graduated measuring tulfe A contains 100 c.c. 
and is fastened into the heavy cast-iron foot E. The bu- 
rette is closed at the top by an obliquely bored stopcock, 
which opens into the two capillary tubes a and b. The 
burette is connected by two short pieces of rubber tubing 
with the manometer J'7 and the Pettersson correction tube 
B. This correction tube is a plain glass tube closed at the 
bottom and joined at d to the manometer F by a piece of 
rubber tubing. Both the burette and correction tube 
stand in a wide glass tube, C, filled with water. C is open 
at the top, and is closed at the bottom by a single-bore 
rubber stopper. The U-shaped part of the manometer 
tube Fis about 6 mm. wide ; from e to c it is capillary 
when mercury is used as the confining liquid, but when 
water is used this part is 3 mm. wide. The burette is 
connected by rubber tubing with the stopcock G and the 
level-bulb H. 
Mercury, or water saturated with the gas to be ana- 
lyzed, is used as confining liquid. If the gases are to be 
measured in a moist condition, as is generally advisa- 
ble, a drop of water is introduced into the correction 
tube B. 
Before using the apparatus for an analysis, the size of 
the space between f and c in the manometer tube must be 
determined once for all. This is done by drawing some air 
into the burette, and then bringing the three-way cock into 
the position Dx, so that the burette communicates with 
the manometer. By raising or lowering the level-bulb the 
enclosed gas can easily be brought to the pressure of the 
gas in the correction tube B. This is accomplished when 
the liquid stands at the same height in both sides of the 
U-tube of the manometer. The cock G is now closed, 
and the size of the gas volume is read off on the scale. 
Upon again opening G and lowering the level-bulb, the 
liquid in the manometer tube may easily be drawn over 
as far as c; 7) is then closed again and another reading 
of the volume is taken, the gas being first brought to the 
pressure of the atmosphere by raising the level-bulb. 
The difference of the two readings gives the capacity of 
the tube between f and c. It is here presupposed that 
the air enclosed in B has the same pressure as the outside 
atmosphere. This can easily be brought about, for equi- 
librium is established by simply drawing the manometer 
tube at d out of the rubber connection. 
Other slight changes of pressure need not be con- 
sidered in making this measurement, since the volume of 
gas is itself very small. 
This constant having been determined, the measure- 
ment of gases is made as follows : 
Fill the burette completely with the confining liquid by 
raising the level-bulb, connect b by a capillary tube with 
the vessel containing the gas to be examined, and draw 
the gas into the burette. The stopcock must of course 
be in the position of D2- To measure the gas, turn the 
cock into the position Dx, and by then raising or lowering 
the level-bulb bring the liquid in both sides of the manom- 
eter to the same level. The stopcock G is now closed 
and the reading is taken. The true volume is equal to 
that read off plus the correction-constant. After meas- 
uring, draw the gas out of the manometer-tube back into 
the burette. 
The absorptions are made in gas pipettes described 
below, which are connected by means of capillary tubes 
with the tube b. 
Absorption Pipettes.-A. The Simple Absorption Pipette 
for Liquid Reayents (Fig. 181). It consists of two large 
bulbs, a and b, joined by the tube d. and of a thick-walled 
glass tube, c, of | to 1 mm. internal diameter, and bent as 
shown in the figure. 
This tube is called the capillary tube. The bulb a holds 
about 100 c.c., and b about 150 c.c., so that when 
100 c.c. of gas is brought into b sufficient space for the 
absorbing liquid will remain. To protect the pipette 
from being broken and to facilitate its manipulation, it 
is screwed to a wooden or preferably an iron standard. 
On account of the different behavior of wood and glass 
or iron toward changes of temperature and atmospheric 
moisture, it is advisable to fasten the glass at only three 
places by means of metal bands and sealing-wax, the 
Fig. 181. 
than g, so that it may be possible to enclose a gas between 
two columns of liquid in the pipette. If a wmoden stand 
is used, a white porcelain plate is set in at m to render 
the liquid in the capillary tube more distinctly visible, 
but if the stand be of iron, as shown in Fig. 182, no plate 
is necessary. 
B. The Simple Absorption Pipette for Solid and Liquid 
lieagents. The only difference between this and the 
simple pipette is that in place 
of the bulb b there is inserted 
a cylindrical bulb provided 
with a neck through which 
solid reagents can be intro- 
duced (Fig. 182). The neck 
can be closed by a cork or 
rubber stopper, held in place 
by a wire. Or a glass tube 
closed at the top, and over 
which a rubber ring, cut from 
a rubber tube is drawm, may 
be used (see cut). 
Double Absorption Pipettes. 
Reagents which are acted 
upon by oxygen, i.e., potas- 
sium pyrogallate, cuprous 
chloride, ferrous salts, etc., 
cannot, of course, be kept in 
the above form of pipette, 
since the reagent in a would 
become inactive in a short time through contact with the 
air. To avoid this difficulty, Hempel devised 
C. The Double Absorption Pipette (Fig. 183). The rea- 
gent is contained in the bulbs a and b. The bulbs c and d 
contain water and prevent all access of air to the reagent. 
a is of about 150 c.c. capacity, and b, c, and d contain 
each about 100 c.c. The bulbs are connected by the bent 
tubes e, f, and g, and end in the bent capillary tube k. 
To permit of the use of solid reagents in this double 
pipette, it may be modified as was the simple pipette. 
D. The Double Absorption Pipette for Solid and Liquid 
Reagents (Fig. 183). The solid reagent is introduced into 
the cylindrical bulb a through the neck, a hole being 
bored through the wooden base opposite the neck to per- 
mit of this. 
The double pipettes are prepared for use as follows : If 
a solid substance is to be used, the last-named pipette (Fig. 
183) is employed and the solid is introduced into a through 
the neck. Thb cork is then inserted and wired in. The 
Fig. 182. 
357 Gas Analysis. 
Gas Analysis. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
method of filling is now the same for either of the double 
pipettes. Pour some water through m into the bulb d 
until g is full. Insert into the rubber tube I a funnel, and 
fill the funnel with the liquid reagent to be employed. 
Attach to m a piece of rubber gas-tubing about a foot 
and a half long, and suck with the mouth. The rubber 
tube may, of course, be connected with the aspirator, 
but in that case care must be taken that the suction 
(SUPPLEMENT.) 
To analyze a gas with the apparatus described, the 
burette is filled with distilled water which has been pre- 
viously saturated, by shaking, w'ith the gas in question. 
The saturating of liquids is best done in a flask half filled 
with the same, a rapid stream of gas being led through 
the liquid, and the flask vigorously shaken. If simple 
pipettes are used, these are so filled with the absorbent 
that the bulb a remains empty. The absorbent also must 
be saturated, by shaking, with the gases which are but 
slightly soluble in it. 
In technical work, where the same analyses are repeat- 
edly made, the absorbent is kept saturated through con- 
tinual use. 
Before beginning the analysis pour into the level-tube 
of the gas burette (Fig. 185) enough water to fill the 
measuring tube b and the connecting rubber tube, taking 
care to drive all air out of the latter by suitably raising 
and lowering the tubes. Then join the burette to the 
vessel containing the gas by means of a glass or rubber 
Fig. 183. 
does not become strong enough- to crush the bulbs. 
After there has been drawn into a and b sufficient reagent 
to fill a, the bulb d is nearly filled with water, and the 
gas remaining in a is driven out through the capillary by 
blowing into m. The pipette is now closed at I, and 
shaken for some time to remove from the bulb b the 
gases absorbable by the reagent. After any gas-bubbles 
which may now be in a have been driven out, suction is 
applied at m, and so much gas is sucked out of the bulb 
b that the liquid in d will enter and completely fill c. If 
the water first poured in is not sufficient, more must be 
added from time to time. 
In pipettes thus prepared the tubes k and e and the 
bulb a are filled with the absorbent, the space from b to 
f with a gas free from oxygen, c and g with water, and d 
with air (Fig. 184). While the reagent in the simple 
Fig. 185. 
tube filled with water. (This connecting tube can be 
easily filled with water by raising the level-tube). 
To fill the burette with the gas to be examined, place 
the level-tube on the floor and open the pinchcock/. The 
water will now flow into the level-tube and the gas will 
be drawn into the burette. When b is filled with the gas, 
close the pinchcock/, disconnect b from the gas-holder, 
and after the liquid has run down from the walls of the 
burette, take up the tubes by the iron feet and by raising 
or lowering bring the water in the tube to the same level. 
The gas is now under atmospheric pressure and its vol- 
ume is read off. To measure off exactly 100 c.c., bring 
somewhat more than 100 c.c. of the gas into the burette, 
close the latter with the pinchcock, and let the water run 
down. Now compress the gas to less than 100 c.c. by 
raising the level-tube, close the rubber tube at g with the 
thumb and first finger of the left hand, set the level-tube 
on the table, and raising the burette in the right hand to 
the level of the eyes, carefully open the rubber tube and 
let the water run back until the meniscus stands at the 
100 c.c. mark. Keeping the rubber tube still com- 
pressed, open the pinchcock for a moment; the excess of 
Fig. 184. 
pipette may be considered to be saturated with gas only 
when it is kept in continual use, that in the double pipette, 
on the contrary, remains saturated for an exceptionally 
long time, since the diffusion must take place through 
the confining 100 c.c. of w'ater and through the narrow 
tube ff. The error caused by this theoretical possibility 
may be wholly disregarded in using the pipette. When 
a new filling of the pipette is necessary, the reagent may 
easily be driven out by inverting the pipette and blowing 
into I. 
Manipulation of the Hempel Burette and Pipettes.- 
358 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Gas Analysis. 
Gas Analysis. 
gas will escape, and there remains in the burette exactly 
100 c.c. of gas under atmospheric pressure. 
If the pipettes have the temperature of the room, as can 
easily be ascertained by introducing a thermometer at k 
(Fig. 185), the apparatus is now arranged as there shown. 
The pipette is placed on the wooden stand G and is 
connected with the burette by the capillary tube F, which 
is a piece of thermometer tubing of about 0.5 mm. in- 
ternal diameter. 
To avoid the enclosing of air-bubbles F is first inserted 
in d, the level-tube a is raised, and the pinchcock opened 
for a moment. Fis, in this way, filled completely with 
water. Then the rubber tube i of the pipette is squeezed 
between the thumb and the first finger of the right hand, 
and while thus compressed and free from air the capillary 
connecting tube is inserted. 
Upon raising the level-tube a and opening the pinch- 
cock the gas passes through the connecting tube into the 
absorption pipette. Any small air-bubbles which may 
have been enclosed when F was inserted into i are, at the 
beginning, separated from the gas by the water in F. If 
these bubbles do not take up more than 5 to 10 mm. 
space in the capillary of the pipette, they may be disre- 
garded, since the error arising therefrom is about 0.03 
c.c. If the bubbles are larger, although with a little 
cleverness this may always be avoided, the gas is brought 
back into the burette by lowering the level-tube, and the 
operation is repeated. 
When the gas has passed over into the pipette, about 
| c.c. of water is allowed to follow, this water serving 
to rinse the capillary and to free it sufficiently from the 
absorbing liquid which it previously contained. The gas 
is now enclosed between two columns of liquid, the ab- 
sorbent on the one side, and the water in the capillary on 
the other. 
The pinchcocks at d and i (the latter is not shown in 
the figure), are closed, the pipette is disconnected by 
drawing F out of i, and by shaking the pipette horizon- 
tally the absorption of the gas is effected. 
The burette and pipette are then reconnected, the level- 
tube is placed on the floor, and the gas is brought back 
into the burette, care being taken that the absorbing 
liquid does not pass farther than the bend in F above d. 
The pinchcock d is closed, the pipette removed, and the 
reading of the remaining volume is made as before de- 
scribed. 
The manipulation of the pipettes filled with solid ab- 
sorbents is still simpler, for in this case no shaking is 
necessary, because of the large surface between the solid 
and the gas. On this account, also, the apparatus need 
not be disconnected. 
A separate pipette is used for each absorbent, and aside 
from the economy of reagents the frequent cleaning of 
the apparatus is thus avoided. An especial advantage 
is, further, the complete assurance that no loss can take 
place through ill-fitting glass or rubber stopcocks while 
the gas is in the pipette or when the pipette is vigorous- 
ly shaken, and that without fear of error due to the tak- 
ing up of gases not chemically absorbable, large amounts 
of reagent may be used, and the work be thereby 
greatly shortened. After using, the pipettes are closed 
at i with a piece of glass rod, and at k with a small cork. 
It is advisable to record the number of cubic centimetres 
of gas which the reagent has absorbed. When the 
wooden support for the pipette is used, this record is 
kept upon a piece of paper fastened to the back. If the 
iron support shown in Fig. 182 is in use, a ground glass 
plate fastened between the sides of the base may be con- 
veniently employed for the purpose. If the absorbing 
power of the reagent be known, waste may be avoided, 
and with one filling of the pipette several hundred anal- 
yses (the number depending upon the nature of the gases 
examined) may be made, with certainty throughout as to 
the efficiency of the absorbent. 
If the work has not been carelessly done, the gas bu- 
rette stands ready for the next analysis. If, on the other 
hand, reagents have been allowed to enter the burette, it 
must be cleansed, its simple construction rendering this 
quite easy. 
(SUPPLEMENT.) 
With the Hempel apparatus just described, analysis of 
gas mixtures may be made with great rapidity and con- 
siderable accuracy, the exactness being increased by the 
use of the Hempel-Pettersson burette. But as the un- 
avoidable error in measuring the gas volume in the bu- 
rette amounts to about 0.1 c.c., i.e., to 0.1 per cent., it is 
clear that if greater accuracy is desired certain modifi- 
cations in the method become necessary. Hempel has 
devised an apparatus with which results agreeing as 
closely as those of Bunsen and Geppert may easily be 
obtained, and as his method is more rapid and the appa- 
ratus simple in form and easy to handle, a brief descrip- 
tion of it is here given. 
Hempel's Apparatus for Very Exact Gas Analy- 
sis.-Usually in analytical work the gases are measured 
under constant (atmospheric) pressure, the observed 
changes in the volume, as each constituent is absorbed, 
giving the percentage composition of the gas. In the 
method about to be described the measurements are, 
however, made under constant volume and varying 
pressure. That is, after the absorption of each consti- 
tuent the gas is expanded to exactly the volume which 
it occupied in the beginning, and the change in the press- 
ure which it exerts is read off on a graduated barometer 
tube. 
Following Boyle's law, the values so found bear the 
same proportion to one another as do gas volumes under 
the same pressure, and hence give the percentage re- 
sults directly. If the gases are saturated with moisture 
when measured, corrections for the tension of aqueous 
vapor and for barometic pressure are unnecessary. 
The gases are expanded to a certain volume in small 
glass bulbs, which can easily be brought into communi- 
cation with a barometer. The expanding is done by 
lowering a movable vessel filled with mercury. The 
pressure exerted by the gas is then read off on the barom- 
Fig. 186. 
359 Gas Analysis. 
Gas Analysis. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
eter scale. The temperature is kept constant through- 
out by surrounding all parts of the apparatus with run- 
ning water. The absorptions are made in the gas pipettes 
to be described later. 
Description of the Apparatus.-Fig. 186 gives a sec- 
tional view of the apparatus. The iron mercury-trough 
A is fastened to the wooden stand G, and is con- 
nected with the graduated barometer tube D by the 
iron tube b. The barometer tube is connected at m, by 
means of a rubber tube, J, with the level-bulb II. The 
upper part of the mercury-trough consists of the reser- 
voir E, whose overflow-tube (this is not given in the 
drawing) can be connected with a barrel by means of 
glass or rubber tubes. 
The sides of the water reservoir E are glass panes, one 
of which, e, extends only so deep into the mercury as to 
leave it easily possible to bring under it the end" of the 
capillary tube of the pipette B. The measuring bulb C 
serves to hold the gas. The tubes b and D are surrounded 
with larger glass tubes, and the rubber tube J is double, 
so that b, D, and J may be cooled with water. By means 
of a glass tube with three arms (this tube does not appear 
in the figure) water is admitted simultaneously through 
the tubes o, p, and q when the apparatus is in use. o, p, 
and q are joined to the three-arm tube by rubber tubes 
supplied with glass stopcocks. A part of the water enters 
at o, surrounds b, and enters the water reservoir E through 
a small canal, r. The water entering at p surrounds the 
barometer tube D and its bulb s. and runs through a side 
opening and the tube t into E. To prevent the spat- 
tering caused by the air-bubbles drawn along with 
the water, a wider tube, u, is hung upon t by means of 
the thread ®. A third stream of water entering at q 
passes through the outer rubber tube of J, and through 
the double-walled level-bulb and the rubber tube w into 
E. 
The outer wall of the level-bulb is simply made by 
joining together the ends of two broken bottles by the 
rubber band z. The rubber tube w is joined to the bulb 
by means of a cork and a bent-glass tube. 
By this arrangement it is possible to keep all parts of 
the apparatus at the same temperature. 
The Gas Pipettes for the Exact Apparatus.-They con- 
slowly ; hence it is easily possible to bring the gas resi- 
due in the pipette to less than toVo of a cubic centimetre 
without danger of the absorbent entering the measuring 
bulb. 
The pipettes must be so made that the distance a (Fig. 
187) is only as large as or smaller than 3 : the capillary 
must be bent close to the bulb b. The pipettes are fast- 
ened to the wooden standard in such a manner that the 
capillary d comes to within a few7 millimetres of the bot- 
Fig. 188. 
Fig. 1s9. 
tom of the mercury-trough when the pipette is placed in 
the position shown in Fig. 186. 
The hulbs of the pipettes must be considerably larger 
than the volume of the gas to be brought into them. The 
inconvenience of carefully cleaning the pipette after the 
absorption is avoided by using a special pipette for each 
reagent. Pipettes of very different sizes are employed, 
the sizes depending naturally upon the dimension of the 
measuring bulbs. 
Manipulation.-One of the pipettes is filled with mer- 
cury, and the gas to be analyzed is passed into the pipette 
through the capillary. A little mercury is allowed to 
follow the gas and fill the capillary from g to z (Fig. 
187). The gas is thus confined between two surfaces of 
mercury, g and w. 
If the samples of gas have been collected in the glass 
tubes shown in Figs. 169 or 170, the tubes are opened in 
a small mercury-trough by breaking off the immersed 
end of the tube with pliers. A small crucible is then 
slipped under the tube, and the tube is lifted out and 
placed in a cylinder containing mercury. The capillary 
of a gas pipette filled with mercury is then lowered be- 
neath the surface of the mercury and introduced into the 
tube containing the gas, and the gas is drawn over into 
the pipette by sucking with the mouth upon a rubber 
tube attached to the open end tube of the bulb a. One 
of the measuring bulbs {C, Fig. 186) with its iron holder 
is then cleaned and dried, and is brought into the mer- 
cury-trough of the apparatus by placing it in two porce- 
lain crucibles, one within the other (see Fig. 188), and 
filling these with mercury. If these are then lowered 
through the cooling water of the trough into the mer- 
cury, and the longer crucible removed by lowering it 
still further, the measuring bulb may now be lifted out 
of the small crucible under the surface of the mercury 
without a trace of water entering it. If only one cruci- 
ble is used, water may easily get into the bulb, the prob- 
able cause being surface adhesion. The instrument 
shown in Fig. 189 is then lowered into the mercury- 
trough A (Fig. 186), the end of its tube is introduced 
into the measuring bulb, and the air in the latter is 
sucked out completely. 
The pipette containing the gas is now placed as shown 
in Fig. 186, the measuring bulb, which now is full of 
mercury, is lowered over the end of the capillary of the 
pipette, and, by blowing into the open end of the pipette, 
some of the gas is driven over into the measuring bulb. 
The pipette is removed and the measuring bulb is placed 
over the end of the tube b (see Fig. 186), and, by means 
of the screw at/ is pressed down tightly upon the rub- 
ber stopper surrounding the end of b. The level-bulb is 
lowered until the meniscus of the mercury column at I 
exactly coincides with the cross-hair of a magnifying- 
Fig. 187. 
sist of two bulbs, a and b (Fig. 187) of the same size, 
joined together by the tube c and ending in the bent ca- 
pillary tube d. A very small-bore thermometer tube is 
used as the capillary, thus making it easy to avoid the 
introduction of absorbent into the measuring bulb or the 
remaining of any considerable quantity of gas in the 
pipette. 
Gases move rapidly in capillary tubes, but liquids, 
especially concentrated solutions of salts, move very 
360 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Gas Analysis. 
Gas Analysis. 
glass fastened to the mercury trough. (This magnifier 
does not appear in the figure.) The reading of the ba- 
rometer tube, which is best done by means of a telescope, 
gives then directly the pressure of the gas ; this pressure 
is obviously independent of barometric changes, since 
the barometer vacuum is closed with mercury. If the 
gas being measured is saturated with moisture, the cor- 
rection for the tension of aqueous vapor is unnecessary, 
(SUPPLEMENT.) 
lary, this corresponds to approximately 0.001 c.c. of gas, 
since the total 35 ctm. length of the capillary has a vol- 
ume, determined by weighing the mercury which it 
holds, of 0.038 c.c. Hence from this source no appreci- 
able error arises. 
The measuring bulb is again brought into the position 
shown in Fig. 186, the mercury in the bulb adjusted ex- 
actly at e by raising or lowering the level-bulb, and the 
variation in pressure is read off on the graduated barom- 
eter tube D. As the original pressure is to the change 
in pressure as the original volume is to the volume ab- 
sorbed, the per cent, of the absorbed constituent is easily 
calculated. 
The other necessary measurements, absorptions, and 
explosions now follow, their order being determined by 
the nature of the gas. 
The Quantitative Analysis of a Gas Mixture.- 
Before proceeding with the quantitative determination of 
the various gases in any gas mixture, it is, of course, 
necessary to know what gases are present. If this is not 
known, a qualitative analysis of the sample must first 
be made. As a description of the methods of qualita- 
tive gas analysis would take too much space, and as the 
constituents of mixtures with which we purpose here to 
deal are usually known, the reader is referred for in- 
formation upon qualitative gas analysis to the exhaust- 
ive treatise of Clemens Winkler? 
Assuming that it is known what gases are present, 
the remainder of the article will be devoted to descrip- 
tions of the various methods by which the amounts of 
these gases may be ascertained. 
In the analysis of a mixture of gases the usual pro- 
cedure is to measure off a definite volume of the gas, and 
then, with the apparatus already described, to absorb 
Fig. 190. 
because there is in the bulb of the barometer aqueous 
vapor which at the same temperature exercises the same 
pressure in an opposite direction. 
The exact adjustment is made with the micrometer 
screw of the level-bulb, and the reading on the scale 
is then immediately made with the telescope. It is 
advisable to repeat both the adjustment and the read- 
ing. 
Into one of the pipettes filled with mercury there is 
now introduced, through the capillary, a suitable amount 
(about two cubic centimetres) of the desired reagent. The 
measuring bulb is removed from the end of the barom- 
eter tube, and the bulb and pipette are brought into the 
position shown in Fig. 190. 
The gas is drawn into the pipette by sucking with 
the mouth on a rubber tube attached to m. The suc- 
tion is discontinued at the moment when the mercury 
begins to flow from the capillary into the bulb of the 
pipette. 
The pipette then contains (see Fig. 187) mercury from 
® to w, absorbent from io to x, gas from x to g, and mer- 
cury from g to z, so that the pipette, after it is taken out 
of the mercury trough, may be vigorously shaken and a 
rapid absorption effected. 
To drive the gas from the pipette back again into the 
measuring bulb, the apparatus is brought into the posi- 
tion shown in Fig. 191. 
One must at first blow into the pipette at m to set the 
gas in motion; when it has once started, the mercury 
in the measuring bulb acts with an aspirating effect, so 
that the gas passes over of itself. At the moment when 
the absorbent has risen to about one centimetre from the 
end of the capillary in the measuring bulb, the capillary 
is lowered under the mercury and mercury is drawn into 
the capillary by sucking on the rubber tube attached to 
m. In this manner the entering of the reagent into the 
measuring bulb may be avoided with certainty. 
If a gas thread about 1 ctm. long remains in the capil- 
Fig. 191. 
one after another of the gases present, the diminution in 
the volume of the gas after each absorption showing the 
amount of the absorbed constituent which was present 
in the original mixture. Those gases which cannot be 
absorbed, such as certain hydrocarbons and nitrogen, 
will still remain after the absorption of the others. The 
hydrocarbons are usually determined by burning them 
with oxygen or air, and the gas now remaining is ni- 
trogen. 
361 Gas Analysis. 
Gas Analysis. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
The absorbable gases whose determination is most 
frequently called for are : , 
water with the same pipette. If care be taken that the sul- 
phuric acid is stopped, after the absorption, at the same 
point in the capillary at which it stood when the burette 
and pipette were first put together, then the small volume 
of air contained in the empty capillary tubes in the be- 
ginning causes, of course, no error in the determination 
of the heavy hydrocarbons or other gases, with the ex- 
ception of nitrogen. In the nitrogen determination al- 
lowance may be made for this air volume, but as each 
centimetre of the empty capillary corresponds to only 
0,008 c.c., this value falls below the limit of the usual 
unavoidable experimental errors. 
After the absorption the rubber tube is taken off from 
the pipette, and the capillary and the larger tube are 
closed air-tight by little glass caps, which are pushed 
over narrow rubber rings placed upon the tubes. 
Cuprous Chloride.-This solution may be conveniently 
prepared as follows : Twenty-five parts of crystallized 
copper sulphate, and 12 parts of sodium chloride are put 
into 50 parts of water, which is then heated until all dis- 
solves. Some sodium sulphate may separate as a white 
powder. Filter it off and add 100 parts of concentrated 
hydrochloric acid and 13 parts of copper turnings (also a 
few pieces of platinum foil to hasten the solution of the 
copper) and boil until decolorized. Pour the solution 
into a glass-stoppered bottle and keep tightly stoppered 
until needed. 
Palladium Sponge.-Finely divided metallic palladium 
is heated, in portions of about one gramme at a time, 
nearly to redness upon the cover of a platinum crucible. 
The platinum cover is slowly lifted out of the flame, the 
palladium, as it cools, becoming covered with a coating 
of palladious oxide. About four grammes of the sponge 
thus prepared is placed in the U-tube shown in Fig. 193. 
To illustrate the procedure in an analysis of a gas mixt- 
ure with the Hempel apparatus the analysis of a sample 
of illuminating gas is given. 
First of all, the water with which the burette is to be 
filled must be saturated with the gas, as described above. 
The carbon dioxide is first absorbed with caustic potash, 
then the heavy hydrocarbons with fuming sulphuric acid, 
then oxygen with alkaline pyrogallol, and lastly carbon 
monoxide with the cuprous chloride solution. The resi- 
due, which consists of methane, hydrogen, and nitrogen, 
is measured, and is then led back into the cuprous chlo- 
ride pipette, and a portion is taken for the explosion 
analysis. 
With ordinary illuminating gas about 12 c.c. of the 
residue suffice for the explosion. 
These 12 c.c. are measured off exactly in the gas 
burette, and enough air is drawn in to bring the mixture 
to about 100 c.c. In all these measurements the running 
down of the liquid must be most carefully waited for, be- 
cause the amount of gas taken is so small that any errors 
that may be made are greatly multiplied. Three minutes 
is a sufficient time to wait for the water to run down the 
sides of the burette, but whatever brief interval is taken 
it should be the same for each measurement. To insure 
uniformity in this respect, a three-minute sand-glass may 
be used with advantage. 
The gas mixture is now burned in the explosion pipette 
(Fig. 192). 
This consists of the thick-walled explosion-bulb a, and 
the level-bulb b, which are joined together by a wrapped 
piece of rubber tubing. At c two fine platinum wires 
are fused into the explosion pipette, the ends of the wires 
being about 2 mm. apart. At d is a glass stopcock, and 
the pipette terminates in the capillary e, whose end is 
closed by a short piece of rubber tubing and a pinch- 
cock. In general the pipettes and burettes for technical 
gas analysis are filled with aqueous solutions, but the 
explosion pipette is filled with mercury. By using mer- 
cury as confining liquid during the explosion it is pos- 
sible to afterward determine the carbon dioxide formed 
by the combustion. If the explosion is made over water, 
a subsequent measuring of the carbon dioxide formed is 
inadmissible, because the pressure in the pipette is so 
high during the explosion that considerable quantities of 
carbon dioxide are absorbed by the water. By explod- 
Gases. 
Absorbable by 
Carbon dioxide (CO2). 
Potassium hydroxide .or barium 
hydroxide. 
Alkaline pyrogallol or phosphorus. 
Oxygen (0). 
The " heavy hydrocarbons," 
as Fuming sulphuric acid. 
ethylene, propylene, etc. 
Carbon monoxide (CO). 
Cuprous chloride. 
Hydrogen (H). 
Palladium sponge. 
The solutions just mentioned may be prepared as fol- 
lows : 
Potassium Hydroxide Solution.-One part of commercial 
caustic potash is dissolved in two parts of water. 
This solution is put into the simple pipette for solid 
and liquid reagents (Fig. 182), the cylindrical part b, be- 
ing first closely filled with very short rolls of iron-wire 
gauze. The gauze has a mesh of 1 to 2 mm., and the 
rolls are from 1 to 2 ctm. long and about 5 mm. thick. 
When the per cent, of carbon dioxide is not too high 
it can be completely absorbed by simply passing the gas 
once into the pipette. The complete manipulation does 
not take one minute. 
Small quantities of carbon dioxide are best determined 
by absorption in a solution of barium hydroxide and 
titration with oxalic acid (see Analysis of Air). 
Alkaline Pyrogallol {Potassium Pyrogallate).- Dis- 
solve 150 grammes of potassium hydroxide in 100 c.c. of 
water and allow it to stand until the insoluble residue 
has settled. Five grammes of pyrogallol (pyrogallic 
acid) dissolved in 15 c.c. of water is then mixed with 
four-fifths of the caustic potash solution, only the clear 
portion of the latter being used for this purpose. In the 
Hempel apparatus for technical analysis this solution is 
used in the pipette shown in Fig. 183. The 15 c.c. of 
the alkaline pyrogallol should first be run into the bulb a 
through the capillary, and then the caustic potash solu- 
tion be run in after it. If there is not enough solution 
to fill the bulb a, more of the two solutions, in their 
proper proportions, should be added. The solution must 
not be diluted with water. 
The absorptions should not be carried on at a tempera- 
ture under 15° C., for it has been observed that the po- 
tassium pyrogallate used for absorption is very much 
less active at a temperature under 7° C. At a tempera- 
ture of 15° C. or higher tire last trace of oxygen can be 
removed with certainty in the space of three minutes by 
shaking with the solution of potassium pyrogallate, while 
at lower temperatures the absorption is not complete after 
six minutes ; moreover, the liquid begins to foam, and 
this, in exact determinations, is very troublesome. 
A solution prepared as above gives off no carbon mon- 
oxide during the absorption, or at the most only such 
slight traces that the error- thus caused comes within the 
limit of error of the readings. 
Fuming Sulphuric Acid.-The sulphuric acid used 
should be so concentrated that when the temperature is 
slightly lowered, crystals of pyro-sulphuric acid will 
separate. The acid is used in a Hempel pipette which 
has above the large bulb b, Fig. 181, a small bulb filled 
with glass beads which serve to give to the sulphuric 
acid the largest possible surface. With this arrangement 
the complete absorption of the heavy hydrocarbons, and 
of ethylene in particular, is effected by passing the gas 
into the pipette but once. 
In this reaction some sulphur dioxide is usually formed, 
and, moreover, the vapor of fuming sulphuric acid has a 
very high tension, so that the gas residue, before being 
measured, must be freed from the acid vapors in the 
caustic potash pipette, a single passage of the gas into the 
pipette being also here sufficient. 
To avoid having the rubber connections between the 
pipette and burette attacked by the fuming sulphuric 
acid, the apparatus is so put together that the sulphuric 
acid does not quite fill the capillary of the pipette, and 
the connecting capillary is allowed to remain empty ; the 
short rubber tube of the burette is also freed from liquid 
by means of a narrow-tipped suction pipette, any reagent 
remaining in the rubber tube being first washed out by 
362 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Gas Analysis. 
Gas Analysis. 
ing over mercury very satisfactory results are obtained, 
even if the carbon dioxide is afterward measured in a 
burette which is filled with water. 
After the gas is burned in the explosion pipette it is 
transferred to the burette and the total contraction is meas- 
ured. Then the carbon dioxide is absorbed with potas- 
sium hydroxide, and finally the oxygen in excess is ab- 
sorbed with phosphorus. The last determination is made 
merely to be sure that a sufficient excess of oxygen was 
present in the combustion. 
The manipulation and the results obtained in an anal- 
ysis of a sample of illuminating gas with the Hempel 
apparatus were as follows : 
Exactly 100 c.c. of the gas was measured off in the 
burette. 
Passed into caustic potash pipette and drawn directly 
back into the burette ; measured after three minutes. 
Measurement gave 4.1 c.c.; hence there was present 4.1 
c.c. or per cent, carbon dioxide. 
Burette now connected by means of a dry piece of rub- 
ber tube and a dry capillary with the pipette containing 
fuming sulphuric acid. Gas driven over and drawn back 
at once into the burette. Gas now passed again into 
caustic potash pipette, and after being drawn back into 
the burette and allowed to stand three minutes, again 
measured. The measurement gave 8.4 c.c.; hence there 
(SUPPLEMENT.) 
This mixture is now brought into the explosion pipette 
filled with mercury, care being taken that the capillary 
remains full of water. The rubber connecting-piece is 
closed by a strong pinchcock, and a piece of glass rod 
is slipped into the end of the rubber tube. The pipette 
is then vigorously shaken, the glass stopcock is closed, 
the pipette is connected with the poles of an induction 
coil, and by turning on the current from a fairly strong 
battery the mixture is exploded. 
The glass stopcock is at once opened and the remain- 
ing gas is transferred without delay to the burette, and, 
after three minutes, measured. The result here was 78 
c.c. 
The total contraction was therefore 99.6 - 78 = 21.6 
c.c. 
The gas remaining from the combustion is now passed 
into the caustic potash pipette, drawn directly back 
into the burette, and, after three minutes, measured. 
The reading was 73.2 c.c. Hence by the combustion 
78- 72.2 = 4.8 c.c. of carbon dioxide was formed. 
Although this gave all the data necessary for the cal- 
culation of the analysis, the remaining gas was neverthe- 
less passed into the alkaline pyrogallol pipette in order 
to be sure that an excess of oxygen was present in the 
combustion, or, in other words, that the gas was com- 
pletely burned. The measurement gave 70.2 c.c. 
Hence there was 73.2 - 70.2 = 3 c.c. of oxygen in ex- 
cess. 
In the combustion of the marsh-gas its own volume of 
carbon dioxide is formed, as may be seen from the equa- 
tion representing the reaction : 
1 vol. 2 vol. 1 vol. 
CH< 4-20, = CO2 + 2H2O. 
Hence in the 13.2 c.c. of the gas residue taken for the 
explosion there wrere 4.8 c.c. of marsh-gas. 
The marsh-gas in the total gas residue of 82 c.c. is 
found by the proportion : 
13.2u 82 = 4.8:®, 
x = 29.8 per cent, marsh-gas. 
Since marsh-gas in burning unites with twice its volume 
of oxygen, the contraction which has resulted from the 
combustion of the hydrogen is found by subtracting 
twice the volume of the carbon dioxide found from the 
total contraction. 21.6 - (2 x 4.8) = 12 c.c. contraction 
due to the burning of hydrogen. 
One volume of hydrogen unites, in burning, with one- 
half its volume of oxygen ; hence the volume of the 
hydrogen is found by multiplying 12 by |. Thus the 13.2 
c.c. of the gas residue taken for the explosion contained 
8 c.c. of hydrogen. The total amount of hydrogen is 
given by the proportion : 
13.2:82 = 8 :®, 
x = 49.6 per cent, hydrogen. 
The nitrogen is found by subtracting the sum of all 
the other constituents from 100. This gives 2.6 per 
cent. 
Hence the illuminating gas contained : . 
4.1 per cent, carbon dioxide. 
4.3 " heavy hydrocarbons. 
0.0 " oxygen. 
9.6 " carbon monoxide. 
29.8 " methane. 
49.6 " hydrogen. 
2.6 " nitrogen. , 
100.0 
Instead of determining the hydrogen indirectly, as just 
described, it may be absorbed by means of palladium 
Fig. 1U2. 
were 8.4 - 4.1 = 4.3 c.c. or 4.3 percent, of heavy hydro- 
carbons present. 
The gas now passed into the double pipette contain- 
ing alkaline pyrogallol, the burette and pipette closed 
with pinchcocks, the pipette disconnected and shaken 
for three minutes. Then connected with the burette 
again, drawn over and measured at the end of three 
minutes. Reading gave 8.4 c.c.; hence no oxygen was 
present. 
The gas was then passed into the pipette contain- 
ing cuprous chloride, and was shaken for three min- 
utes. Drawn back into the burette and measured after 
three minutes; the reading was 18 c.c.; hence there 
was 18 c.c. - 8.4 = 9.6 c.c. or per cent, carbon mon- 
oxide present. 
The remaining 82 c.c. of gas was then passed back into 
the cuprous chloride pipette, and the pipette was closed 
with an ordinary pinchcock. 
The water in the burette is poured out, the burette 
washed with hydrochloric acid and then with distilled 
water, and then filled with water which is saturated, not 
with illuminating gas, but with air. 
Twelve to fifteen c.c. of the gas residue is now meas- 
ured off into the burette. In this case 13.2 c.c. -was 
taken. 
So much air is then drawn in that the total volume of 
the gas residue taken and the air amounts to about 100 
c.c. In this case it was 99.6 c.c. 
363 Las Analysis. 
Gas Analysis. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
sponge. The arrangement of the apparatus for carrying 
out the reaction is shown in Fig. 193. 
The gas burette A and the gas pipette B are joined 
together by means of the capillary tubes E and the tube 
II. This tube H is of about 4 mm. internal diameter 
and 20 ctm. total length, and it contains 4 grammes of pal- 
ladium sponge. 
The gas pipette upon the stand G is filled with water, 
and its only use is to render it possible to repeatedly pass 
the gas through the palladium tube. 
To determine the amount of hydrogen present in a 
mixture of hydrogen, nitrogen, and marsh-gas, from 
which, so far as possible, the absorbable constituents have 
already been removed, measure the gas in the burette, 
join it in the manner described to the pipette B, which 
is filled with water nearly to i, place the tube II in a 
large beaker containing warm water of from 90° to 100° C., 
and, after opening the pinchcock d, drive the gas three 
times back and forth through 
I the palladium by raising and 
lowering the tube a. Then re- 
place the hot water with water 
of the temperature of the room, 
and lead the gas residue twice 
back and forth through the tube 
in order to completely cool the 
gas. It is in this manner pos- 
(SUPPLEMENT. 
moving any -drops of moisture winch may collect, so 
that the palladium may easily be shaken out of the tube 
in the form of a dry powder ; and then superficially 
oxidizing the metal by heating it on the lid of a platinum 
crucible. 
The residue of nitrogen and marsh-gas which remains 
after the absorption of the hydrogen is burnt by explo- 
sion in the manner described. 
The Analysis of Air.-The atmosphere of the earth 
consists chiefly of nitrogen, oxygen, a small amount of 
carbon dioxide, and varying quantities of water vapor. 
In addition to these constant constituents we may expect 
to find, at times, the various gaseous products of the 
many chemical processes on the earth, such as ammonia, 
hydrocarbons, sulphur dioxide and sulphur trioxide. The 
presence of solid substances, floating in the air in finely 
divided form, has also been detected. A small amount 
of the oxygen exists in the form of ozone, the quantity 
of this gas varying with the weather, time of year, and 
locality. In an analysis of air, aqueous vapor, carbon 
dioxide, and oxygen are usually determined. No direct 
method for determining nitrogen being known, its per- 
centage amount is ascertained by subtracting the sum of 
the other constituents from 100. In addition to the 
quantitative determination of the foregoing, qualitative 
tests to show the presence or absence of carbon monoxide 
and ozone are often desired. For sanitary purposes the 
determination of carbon dioxide and water are those 
most frequently called for. 
The Determination of Aqueous Vapor in the Atmos- 
phere.-The water can be determined with great exact- 
ness by leading a measured or weighed volume of air 
through tubes filled with calcium chloride or phosphorus 
pentoxide, and ascertaining their increase in -weight. It 
hardly need be mentioned that the calcium chloride must 
first be treated with carbon dioxide, so that it may con- 
tain no basic salt which, by taking up carbon dioxide, 
could change in weight. The common phosphorus pent- 
oxide is never pure, but always contains traces of phos- 
phorus and phosphorous acid. For this reason a current 
of dry air should be led for some time through the ab- 
sorption apparatus before it is used. 
For most purposes the hair hygrometer and the psy- 
chrometer give sufficiently accurate results. 
A very fine form of the hair hygrometer, devised by 
Saussure, is made by Hermann Pfister, in Berne. 
The construction of the instrument is based upon the 
property possessed by hair from which the oil has been 
removed, of lengthening or shortening according to the 
amount of moisture in the air. By alternately moisten- 
ing and drying the hair thoroughly for a number of times, 
it is given, according to Pfister, the property of quite 
regular expansion. 
Figure 194 shows the arrangement. A hair, prepared 
as above mentioned, is fastened to a suitable frame. 
The hair passes around a little wheel below, and the 
changes in length cause the pointer to move and give the 
relative moisture directly on the scale. 
August's psychrometer is based on the fact that water 
exposed to the air evaporates the more rapidly, and 
thereby extracts more heat from its surroundings, the 
farther the air is removed from the condition of satura- 
tion. From the lowering of the temperature (t - t') of 
a thermometer which has been moistened in a suitable 
manner, the tension e of the water vapor in the air is 
calculated from the formula- 
e = e1 - k (t - f) b, 
in which c1 is the tension corresponding to the tempera- 
ture tx, b the barometric pressure in millimetres, and k 
an empirical factor which has, according to the re- 
searches of Regnault, the following values : 
In small closed rooms 0.00128 
" large closed rooms 0.00100 
" balls with open windows 0.00077 
"courts 0.00074 
" open air (no wind) 0.00090 
Fig. 193. 
sible to absorb with certainty every particle of hydro- 
gen. Upon drawing the gas so far back into the meas- 
uring tube that the water in the pipette again stands near 
i, the difference between the two measurements made 
before and»after the absorption corresponds to the hydro- 
gen plus the amount of oxygen in the air enclosed in the 
U-tube when the apparatus was put together. This air 
volume, and therewith its oxygen contents, may be de- 
termined with sufficient exactness once for all by closing, 
with a piece of rubber tubing and a glass rod, one side of 
the tube filled with palladium, cooling the tube to about 
9° C. by placing it in cool water, and then, after con- 
necting it by a capillary with a gas burette completely 
filled with watef, warming it to 100° C. by placing it in 
boiling water. The expansion of the enclosed air vol- 
ume corresponds to a difference of temperature of 91° C., 
i.e., to a third of the enclosed volume of gas. 
The palladium is regenerated after the reaction by first 
leading air over it, whereby it becomes quite hot; re- 
364 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Gas Analysis. 
Gas Analysis. 
The Determination of Carbon Dioxide in the Atmosphere. 
-The most varied experience has shown that through 
the process of breathing the air acquires properties 
which cause it to act deleteriously upon health when the 
products of breathing exceed a certain limit. Brown- 
Sequard and d'Arsonval8 have shown that air expired 
by animals has a poisonous action upon other animals, 
and that this poisonous property is not due to the carbon 
dioxide present. In fact, they themselves breathed air 
containing twenty per cent, of carbon dioxide, but oth- 
erwise pure, without experiencing any serious inconven- 
ience or lasting effect. Rabbits breathing air which had 
already been breathed by other rabbits died in from two 
to six days. The expired air from the first rabbits was 
(SUPPLEMENT.) 
rectly ascertained by determining the amount of carbon 
dioxide in the room, and for this reason we make use of 
Pettenkofer's suggestion and judge of the purity of the 
air by the per cent, of carbon dioxide present. 
In the open air the per cent, of carbon dioxide is quite 
constant, the average amount being 0.04 per cent, by vol- 
ume, or four parts in ten thousand. In rooms where the 
air impresses the new-comer as being " good," the car- 
bon dioxide usually varies from 0.055 per cent, to 0.087 
per cent. Pettenkofer states that as soon as the carbon 
dioxide reaches 0.1 per cent., an odor becomes noticea- 
ble, and he places this amount as the limit of admissible 
carbon dioxide resulting from breathing. Yet the air in 
crowded school-rooms and in well-tilled halls and thea- 
tres will be found in most cases to contain carbon dioxide 
far in excess of 0.1 per cent., the amount often rising to 
from 0.25 to 0.4 per cent. To ascertain the rate of in- 
crease of carbon dioxide in smaller rooms, the writer re- 
cently analyzed the air of a room about 40 x 20 ft. and 
11 ft. high, occupied by thirty-eight adults. At the be- 
ginning of the session the air contained 0.058 per cent, of 
carbon dioxide, and 
at the end of 28 minutes, 0.070 per cent. CO2, 
" " 39 " 0.101 
" " 58 " 0.128 " 
" " 83 " 0.148 
" " 103 " 0.240 " 
One of the best methods for quantitatively determining 
the carbon dioxide in the atmosphere is that first used 
by Saussure,18 and modified by Pettenkofer.19 It con- 
sists in absorbing the carbon dioxide of a measured vol- 
ume of air with a barium hydroxide solution of known 
strength, and then determining, by titration with oxalic 
acid, the amount of barium hydroxide still unacted upon. 
This method has been used by many investigators, and 
has been modified in minor details. A very practical 
form is that devised by W. Hesse, which is as follows :6 
The necessary apparatus may be divided into a station- 
ary and a portable portion. 
A. The reserve apparatus in the laboratory comprises 
the following: 
1. A glass balloon, or large bottle, holding several litres, 
and filled with a concentrated solution of barium hydrox- 
ide. One kg. of barium hydroxide and 50 grammes of 
barium chloride are put into from 4 to 5 kg. of distilled 
water. As the solution is used it is replaced by water 
as long as there is material in excess to saturate the 
water. 
2. A bottle containing dilute baryta water. The bot- 
tle is provided with a small absorption flask containing 
pumice-stone saturated with caustic potash, for freeing 
the entering air from carbon dioxide (Fig. 195). This 
dilute baryta water is made by adding about 30 c.c. of 
concentrated barium hydroxide solution to 1 litre of 
wTater, or directly by dissolving 1.7 gramme of a mixture 
of barium hydroxide and barium chloride (20 : 1) in 1 
litre of distilled water. 
3. A solution of oxalic acid containing 5.6325 grammes 
of crystallized oxalic acid in 1 litre of water. 1 c.c. = 1 
c.c. CO2. 
4. A solution of phenol-phthalein, 1 part in 250 parts 
of alcohol. 
B. The portable apparatus comprises- 
1. Five thick-walled conical Erlenmayer flasks of 
and litre capacity, and supplied with well-fitting 
double-bore rubber stoppers. The point to which the 
rubber stopper reaches is marked on the first four flasks, 
and their capacity up to this mark is written on the out- 
side of each flask with a diamond. The openings of the 
stoppers of these four flasks are closed with pieces of 
glass rod from 3 to 5 ctm. long. These rods are well 
rounded at the lower ends, the upper ends being widened 
like a button. 
2. A thick-walled 10 c.c. pipette. 
3. A glass stopcock burette holding from 10 to 15 c.c., 
graduated in tenths, and having a tip 7 to 10 ctm. long. 
4. A 300 c.c. flask provided with a small guard bottle, 
as in A, 2, and tilled with dilute baryta water. This is 
Fig. 194. 
then passed through concentrated sulphuric acid, before 
being breathed by the other rabbits. This sulphuric acid 
destroyed the poisonous matter coming from the lungs, 
but allowed the carbon dioxide to pass. The air thus 
deprived of the pulmonary poison, but charged with the 
carbon dioxide as before, had no poisonous action upon 
the animals breathing it. 
In examining the air of rooms, halls, or theatres, it is 
of the utmost importance that we be able to ascertain to 
what extent the air has been vitiated by the exhalations 
of the people present. Unfortunately we are not able 
by ordinary means to determine the amount present of 
the organic impurities given off by the lungs, but inas- 
much as these injurious substances are exhaled simulta- 
neously with carbon dioxide their amount can be indi- 
365 Gas Analysis. 
Gas Analysis. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
filled in the laboratory by connecting it with the large 
reserve bottle containing dilute baryta water, and driving 
the solution over through the siphon. Before beginning 
the experiment a few drops of a solution of rosolic acid 
are added to the barium hydroxide solution. The fainter 
the color the sharper is the reaction, but the color must 
not be so faint as to be indistinct. The proper coloration 
will last for about three days ; it is then so indistinct that 
a few drops of rosolic acid must again be added. 
5. A 250 c.c. bottle filled with dilute oxalic acid. This 
is prepared by bringing 25 c.c. of the standardized oxalic 
acid into the 250 c.c. flask, and then filling the flask to 
the mark with water. 
6. A thermometer. 
7. A barometer (a small aneroid). 
The amounts of solutions here given for the portable 
apparatus are sufficient for thirty separate determina- 
tions ; in other words, at least ten analyses, including a 
control determination each time and the standardizing of 
the solution, can be made with the above quantities. 
Each determination of carbon dioxide by Hesse's 
method is a double one, the two determinations being 
made with volumes of air of different size. Accordingly, 
flasks of i and J, or i and i, or | and litre capacity 
are used for taking the samples of air, the sizes of the 
flasks chosen depending upon whether a smaller or a 
larger amount of carbon dioxide in the air is to be ex- 
pected. The samples are 
taken by completely filling 
the flasks at the place 
where the air is to be ex- 
amined with water which 
has the temperature of the 
place, and then emptying 
the flasks and rinsing them 
(SUPPLEMENT.) 
total oxalic acid necessary is thus determined. By pro- 
ceeding in this manner a very exact standardizing of the 
solution is possible, even in an atmosphere containing 
much carbon dioxide, because the solution is never 
strongly alkaline enough to absorb appreciable amounts 
of carbon dioxide from the air. 
The baryta water which has been shaken with the air 
is titrated without previously removing the barium car- 
bonate. The titration is made as follows : 
Remove the glass rod from one of the openings in the 
stopper, and immediately insert the tip of the burette 
which has already been tilled with oxalic acid solution. 
The tip of the burette should reach as far as possible into 
the flask (Fig. 196). Open the stopcock of the burette 
and allow the oxalic acid to enter rapidly at first, but at 
the last only drop by drop. If the increased pressure 
resulting inside the flask checks the flow of liquid from 
the burette, this pressure is removed by lifting the glass 
stopper for a moment. When the solution is neutral. 
i.e., when it is completely 
decolored, the height of the 
solution in the burette is 
noted, and the contents of 
the second flask is titrated in 
the same manner. 
It is clear that when the 
amount of carbon dioxide 
present is small, the accuracy 
of the determination is in- 
creased by using larger vol- 
umes of air. For this reason 
Hesse uses a flask of } or 1 
litre capacity whenever the 
carbon dioxide is probably 
below the limit for dwelling- 
rooms, as, for example, in 
the open air. He also uses 
these sizes when erreat ac- 
Fig. 195. 
with distilled water. In this operation care must be 
taken that the flask is not warmed by the hand, and that 
no air exhaled by the operator enters the flask. 
To absorb the carbon dioxide, the 10 c.c. pipette is put 
through one of the openings of a stopper fitting the flask, 
its end is inserted in the rubber tube of the supply flask, 
and the pipette is rinsed with a little barium hydroxide so- 
lution drawn up into it. The pipette is now filled to the 
zero mark by suction, and the stopper through which it 
passes is inserted in the neck of the flask containing the 
sample of air. The barium hydroxide is now run into 
the flask, the second opening of the stopper being ob- 
structed with the finger or a glass rod to such an extent 
that the displaced air can just escape. The glass rod is 
then pushed into place, and the pipette is freed from the 
few drops of solution adhering to it by closing it at the 
top and warming it with the hand. The pipette is then 
drawn out of the stopper, and the second opening is 
closed with a glass rod. The same proceeding is re- 
peated with a second flask of different capacity. The 
two flasks are allowed to stand for some time with occa- 
sional shaking, and in the meantime the strength of the 
baryta water is determined. 
The strength of the baryta water is determined by 
putting into the small flask of litre capacity nearly as 
much standardized oxalic acid solution as will be required 
in the titration, and then running in 10 c.c. of the solu- 
tion of barium hydroxide. The solution is then neu- 
tralized by slowly running in more oxalic acid, and the I 
curacy is desired. Of course sufficient barium hydroxide 
solution must be taken to insure its being present in ex- 
cess up to the end of the operation. The small amount 
of carbon dioxide which the baryta water takes up from 
the air that it displaces when running into the flask may 
be disregarded. 
In using this method for determining the carbon diox- 
ide present in the soil or in walls Hesse employs the ap- 
paratus shown in Fig. 197. The air in the soil is drawn 
through the flask by means of a rubber pump ; the glass 
tubes are then removed, and the openings in the stopper 
are closed with glass rods. The titration is made as be- 
fore described, but more concentrated reagents are re- 
quired. In examining the air of graves, Hesse used a 
solution of barium hydroxide ten times as strong as that 
previously given (10 c.c. = about 10 c.c. oxalic acid so- 
lution A3 = 10 c.c. CO2). 
In calculating the analysis the volume of air taken is 
reduced to normal pressure and temperature, so that cor- 
rect comparisons may be made. This calculation takes 
considerable time, and to Hesse belongs the merit of 
having compiled a table 21 giving the figures by which the 
amounts of carbon dioxide found in the uncorrected gas 
volume are to be multiplied. The table contains for 
each degree of temperature the multiplier for any baro- 
metric pressure. 
Example- 
V - 223 c.c., t = 19°, b = 739 mm. ; 
Fig. 196. 
366 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Gas Analysis. 
Gas Analysis. 
(SUPPLEMENT.) 
the titration of the baryta water gave 10 c.c. baryta 
water = 11.5 c.c. oxalic acid, and in the experiment 6.2 
c.c. oxalic acid was used. Hence the amount of carbon 
dioxide which had already united with the barium hy- 
droxide was equivalent to 11.5 - 6.2 = 5.3 c.c. oxalic 
compensator and pipette is, from the beginning of the 
experiment, separated from the external atmosphere by 
closing the stopcocks f, g, and c, any variations in the 
external atmosphere have no effect. This is also true of 
changes in temperature ; these eliminate themselves by 
acting in the same manner and to the same extent upon 
the tension of the air in A and G, provided that the water 
in the outer vessel which surrounds the main parts of the 
apparatus is sufficiently stirred. For these reasons no 
observation of temperature or barometric pressure is nec- 
essary. The changes in volume read off on the scale 
give directly the amount of carbon dioxide 
in hundredths of per cent, by volume. 
" Each analysis consists of three opera- 
tions. 
" 1. The air is drawn in from the outside 
and is measured, the level of the mercury in 
the graduated tube being brought to the 
zero mark. The upper and narrower part 
of the scale, where each division denotes tuooo of the 
volume of the pipette, is used in analyses of atmos- 
pheric air, or the ordinary air of rooms, where the per 
cent, of carbon dioxide is at the most not higher than 
0.4 per cent. In the analysis of very impure air the 
lower part of the graduated tube is used, each division 
here corresponding to TiAnr of the whole volume. In 
measuring the volume the stopcocks f, g, b, c, and d must 
be closed. 
" 2. The stopcocks d and b are opened, a is closed, and 
the air is passed from A to B. After one or two minutes 
Fig. 197. 
acid, corresponding to 0.53 c.c. CO2, 
and we have the proportion- 
[223 - 10] 1 or 213 : 0.53 = 1000 : x, 
x = 2.49 c.c. (in unreduced litre). 
The multiplier corresponding to this 
temperature and barometric pressure is 
1.100 ; hence in the reduced litre there 
are 2.49 x 1.100 = 2.7 c.c., or in the 
^air examined 2.7 parts per thousand of 
CO2 present. 
The whole operation, including the control determina- 
tion and the calculation, may be completed in from a 
quarter to half an hour. 
Pettersson and Palmqvist have described10 an apparatus 
for determining carbon dioxide in air, with which very 
accurate results can be obtained in a few minutes. Their 
description of the apparatus is, in part, as follows : 
" Fig. 198 shows the apparatus which we used, and 
which is easily portable. The apparatus can be covered 
by a wooden box which fits over it, and to which a metal 
handle is strongly fastened (this cover is not shown in the 
figure). When the apparatus has been brought to the 
place where the air is to be examined, the glass jacket is 
filled with water, the outside air is drawn in through the 
tube c, and by a few simple manipulations, which take 
only a few minutes, the carbon dioxide is determined 
with an accuracy of about 0.01 per cent. The dimen- 
sions of the apparatus are as small as possible. For ex- 
ample, the pipette A into which the air to be analyzed is 
drawn holds only about 18 c.c. With larger volumes of 
air it would be easy to attain greater accuracy. 
" The carbon dioxide is absorbed in the Orsat potash- 
tube B, and the air is measured, before and after the 
absorption, in the pipette A and its graduated tube. The 
measuring pipette can be filled with mercury or air, or 
emptied of the same, by raising or lowering the mercury 
reservoir E, which is joined to the lower end of the 
graduated tube of A by means of a rubber tube wrapped 
with copper wire. There must always be a drop of 
water on the surface of the mercury ; the air standing 
over the mercury is thus kept saturated with moisture. 
In reading the volumes the meniscus of the mercury is 
each time so adjusted that the pressure in A is exactly 
the same as the pressure of the air in the compensation 
cylinder C. 
" A differential manometer containing a drop of a col- 
ored liquid (petroleum, in which azo-benzol is dissolved), 
and connected by capillary glass tubes on the one side 
with A and on the other with C, serves as the indicator 
in these operations. By moving the reservoir E and 
then-having closed the stopcock d-suitably turning 
the screw e, the level of the mercury in A is so adjusted 
that the drop of liquid in the manometer stands at zero. 
It is obvious that in this manner it is always possible to 
bring back the air in A to the same pressure as that pre- 
vailing in the compensator C. Since the air in both the 
Fig. 198. 
the carbon dioxide is absorbed and the air may be 
brought back into A, b is then closed, and a is opened. 
"3. The mercury level in A is so adjusted that the 
index again takes its normal position. The decrease in 
volume is then read off on the scale." 
The Determination of Oxygen in the Atmosphere.-The 
367 Gas Analysis. 
Gas Analysis. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
great significance which the oxygen in the atmosphere 
has for all living beings has made this gas the subject of 
frequent investigations. The amount in a sample of air 
can be determined with considerable accuracy with the 
Hempel technical apparatus already described, the oxy- 
gen being absorbed in the Hempel pipette filled with al- 
kaline pyrogallol. If, however, ■ great accuracy is de- 
sired, methods which admit of more delicate measure- 
ment of the gas volumes before and after absorption 
must be used. The best agreeing results upon the 
amount of oxygen in the atmosphere seem to have been 
obtained by Hempel with his apparatus for exact gas 
analysis (Fig. 186). He collected the samples of air in 
glass tubes which had previously been exhausted of air, 
as already described. The oxygen was absorbed with 
alkaline pyrogallol. Four analyses of the same sample, 
by one of Hempel's assistants, gave 20.936, 20.938, 20.938, 
and 20.938 per cent, oxygen. 
•The Detection of Carbon Monoxide in the Air of Rooms. 
-The extremely poisonous character of this gas and the 
ever-present possibility of its production by defective 
heating apparatus make its sure and easy detection a 
matter of great importance. If the poisonous effects of 
carbon monoxide showed themselves only when compar- 
atively large amounts of the gas were present, its detec- 
tion and the determination of its amount could easily be 
effected in the customary absorption analysis. Inas- 
much, however, as decided symptoms of poisoning are 
observed when less than of one per cent, of carbon 
monoxide is present, and as death would probably result 
from breathing air containing only one per cent, of the 
gas (a mouse breathing air containing 2.9 per cent, 
carbon monoxide died with convulsions in from one to 
two minutes) it is clear that quite delicate tests for the 
presence of the gas are necessary. The change pro- 
duced in the absorption spectrum of blood, upon its taking 
up carbon monoxide, was first utilized by H. W. Vo- 
gel,11 for the detection of small amounts of the gas in 
the air of a room. 
Blood which has been highly diluted with water shows 
in a layer two centimetres thick (a large test-tube) 
the absorption spectrum plotted in 1, Fig. 199, and 
sketched in 2. If this blood be then shaken with car- 
bon monoxide, the bands of the oxyhaemoglobin are re- 
placed by those of carbon monoxide haemoglobin, 3, 
the latter lying slightly nearer the violet end of the spec- 
trum. This displacement of the bands, though but 
slight, is yet sufficient to admit of its being sharply meas- 
ured, and, in the hands of a practised spectroscopist, is 
sufficient evidence of the presence of carbon monoxide 
in the blood. The test is, however, rendered much more 
delicate by taking advantage of the fact that certain re- 
ducing agents, when added to the blood, change the 
spectrum of oxyhaemoglobin to a broad and weakly de- 
fined band, 4, but produce no variation in the spectrum 
of the carbon monoxide haemoglobin. In applying these 
(SUPPLEMENT.) 
Upon pouring the blood into a test-tube and observing 
its spectrum through the spectroscope two absorption 
bands are of course visible, either those of the oxyhae- 
moglobin or of the carbon monoxide haemoglobin, or all 
together. Upon now adding a few drops of strong and 
freshly prepared ammonium sulphide to the blood, the 
spectrum, if no CO was present in the air of the room, 
will change in a few moments to that shown in 4. But 
Fig. 200. 
if the two absorption bands shown in 3 are still seen, the 
presence of carbon monoxide in the air under investiga- 
tion is definitely proved. 
Vogel states that amounts down to 0.25 per cent., or 
2.5 parts in 1,000, can be clearly detected, but that the 
delicacy is not increased by using great volumes of air. 
Later, Hempel12 increased the delicacy of the test by 
using live mice instead of the dilute blood solution. A 
mouse was made to breathe for some time the air in 
question, and was then killed and its blood examined 
spectroscopically, as above. By this means Hempel was 
able to detect as small an amount as 0.03 per cent, of 
carbon monoxide. 
In 1880 C. H. Wolff described 13 a very effective ab- 
sorption apparatus adapted to the use of small amounts 
of blood. As his method is quite as delicate as Hempel's, 
and does not call for the presence of the difficultly ob- 
tained and elusive mouse, a description of it is here 
given. 
The apparatus used by Wolff for absorbing the carbon 
monoxide is shown in Fig. 200. 
The tubes are closed at a, b, and c with carefully 
ground stoppers. In filling the apparatus a little wad 
of glass-wool is inserted into d from above, and gently 
pressed into place, and the remainder of the tube as far 
as/is then filled with moderately fine powdered glass. 
This powdered glass is about as fine as ordinary gun- 
powder. It is freed from any fine powder and dust by 
sifting, and is then digested with hydrochloric acid, and 
carefully washed and dried. 
The glass powder is moistened with wrater from above ; 
strong suction is then applied at e by attaching an aspi- 
rator thereto, and the excess of water which is thus drawn 
off from the powdered glass is removed at c. Two cubic 
centimetres of dilute blood (1 to 40) is then allowed to drop 
from above, from a pipette, upon the moistened glass, a 
is closed, and by gently blowing into h with the mouth a 
uniform distribution of the blood solution throughout 
the column of powdered glass down to the glass-wool is 
effected. The apparatus is ready for the absorption, and 
it is now connected either ate with the aspirator or at h 
with the bottle, depending upon whether the 10 litres of 
air are to be drawn through or driven through. An or- 
Fig. 199. 
characteristics of the blood spectrum to the detection of 
carbon monoxide in the air of rooms, Vogel filled a 100 
c.c. bottle with water, emptied the bottle in the room 
containing the gas, and then poured into the bottle two or 
three centimetres of blood highly diluted with water and 
showing only a faint red color, yet still giving the oxyhae- 
moglobin. bands in a column as thick as a test-tube. The 
blood is then shaken in the bottle for some minutes. 
368 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Gas Analysis. 
Gas Analysis. 
dinary bottle containing somewhat more than 10 litres is 
very well suited to the taking of the sample of the air to 
be examined. This bottle is supplied with a double- 
bore rubber stopper, through the openings of which 
pass two glass tubes bent at right angles above the 
stopper. 
One of these tubes ends just below the stopper, and 
the other reaches to the bottom of the bottle. Pieces of 
rubber tubing of sufficient length, and closed by Bunsen 
screw-pinchcocks, are slipped over the free ends of both 
tubes. Since the bottle holds more than 10 litres, it is 
provided near the bottom with a mark, from which point 
up to the stopper the capacity is exactly 10 litres. To fill 
the bottle with the air to be examined, it is filled com- 
pletely with water, and this is then run out through the 
rubber tube which is connected to the longer glass tube, 
and which acts as a siphon. When the water has fallen 
to the 10-litre mark both pinchcocks are closed. To pass 
the air through the absorption apparatus, the same rub- 
ber tube which has acted as a siphon is attached to a bof- 
tle filled with water, and standing higher than the first 
bottle, and the other rubber tube is connected with the 
absorption apparatus. The current of air, which may 
be very exactly regulated by means of the screw-pinch- 
cock, must pass through the absorption apparatus very 
slowly-on an average 1,000 c.c. in twenty to twenty- 
five minutes. To be able to observe and regulate the 
passage of the air through the apparatus, 2 to 3 c.c. of 
water are run in at b, after the powdered glass has been 
moistened with the blood solution. When the experi- 
ment is ended this 'water is let out at c. Any burette- 
holder is suited to holding the absorption apparatus ; 
a Vogel "universal stand" is also well adapted to the 
purpose. If it be desired to draw the air of the room 
in question directly through the apparatus-a proceed- 
ing which is, however, not to be recommended, be- 
cause of the possible change in the composition of the 
air during the long duration of the experiment-the end 
h is joined by a cork to a so-called calcium chloride cyl- 
inder containing pieces of pumice-stone moistened with 
water. The air enters the cylinder from below, becomes 
saturated with moisture, and then passes into the absorp- 
tion apparatus. When 10 litres of air have been led 
through, in one manner or the other, the stopper at c is 
removed to let out the water. A small test-tube, upon 
which is a mark for 3 cubic centimetres, is then placed 
under c, the stopper at a is removed, and pure water 
is slowly dropped from a pipette upon the powdered glass. 
The blood solution is thus gradually displaced, and the 
washing is continued in this manner until the liquid in 
the test-tube amounts to 3 c.c. The tube is then taken 
away, several cubic centimetres of water are allowed to 
flow through the powdered glass, all the stoppers are in- 
serted, e is connected with the aspirator, and when the 
excess of water has thus been removed the apparatus is 
ready for another experiment. 
The same powdered glass may be used for from fifty 
to sixty determinations without renewal. 
The absorption apparatus contained originally 2 c.c. of 
dilute blood, 1 to 40; hence the 3 c.c. now in the test- 
tube have a concentration of 1 to 60. 
Small rectangular bottles with flat sides, which are 
0.5 ctm. and 1 ctm. wide, are very well suited to holding 
the blood solution for the observations with the spectro- 
scope : these little bottles hold about 1.5 c.c. of solution, 
and are closed with carefully ground stoppers. One of 
these bottles is filled with the blood solution used in the 
experiment, and a second bottle is filled with the origi- 
nal blood solution, also diluted to 1 to 60. One drop of 
ammonium sulphide is added to the contents of each 
bottle ; the bottles are shaken, and after half an hour the 
spectra of the two solutions are examined, preferably by 
lamp-light, with a delicate pocket spectroscope. 
Wolff states that when there is 0.03 per cent, carbon 
monoxide in atmospheric air,'both absorption bands are 
distinctly recognizable. When the air contains less car- 
bon monoxide, about 0.02 per cent., the presence of the 
gas is show'n merely by a somewhat stronger absorption 
in the absorption spectrum, which now appears at D as 
a broad band, tbe maximum absorption of the reduced 
blood solution lying toward E. 
It is very desirable to possess for these experiments a 
solution of blood which is clear and which will keep for 
a long time.. Wolff recommends Jaderholm's method of 
mixing together equal volumes of blood freed from 
fl brine, and of cold saturated borax solution, and he says 
that the solution remains clear for months and does not 
need to be filtered before being used for the spectroscopic 
examination. 
To determine quantitatively the amount of carbon 
monoxide in the blood, Fodor suggests placing the blood 
in a small flask provided with a perforated stopper car- 
rying two glass tubes. One of the tubes reaches to the 
bottom of the flask, and through it is led in a current of 
air which has been previously freed from carbon mon- 
oxide by passing it through a solution of palladious 
chloride. The air, after leaving the flask through 1he 
shorter tube, is passed through a wash-bottle containing 
a solution of lead acetate, tlien through a second bottle 
containing dilute sulphuric acid, and finally through two 
U-tubes containing a palladious chloride solution as free 
as possible from acid. The flask is now warmed upon 
the water-bath to 90° C. for from one-fourth to one-half 
an hour, the current of air being passed through slowly 
and the flask being frequently shaken. The carbon mon- 
oxide is thus driven out of the blood, and passing through 
the two wash-bottles it enters the palladium solution, from 
which it precipitates metallic palladium. The precipitated 
palladium is collected, dissolved in aqua regia, and the 
amount of palladium determined by titration with a 
standard solution of potassium iodide. If a solution 
containing 1.486 gramme of potassium iodide to the litre 
is employed, then each cubic centimetre corresponds to 
0.1 c.c. CO. 
The Detection of Ozone in the Atmosphere. - A large 
number of reagents may be used for the detection of 
ozone. For the detection of such small amounts of 
ozone as are present in the atmosphere, so-called ozone 
papers are employed. 
Houzeau 14 has suggested that this be prepared by dip- 
ping strips of Swedish filter-paper into a wine-red lit- 
mus solution which contains in a cubic centimetre about 
0.013 gramme of the extracted constituents dried at 100° 
C. : the paper is dried and then impregnated to a fourth 
of its length with a one per cent, solution of neutral and 
pure potassium iodide free from iodate. The dried 
paper must be protected from the air, and is on this ac- 
count kept in tightly closed bottles. 
This paper is colored slightly blue by from 0.0002 to 
0.0003 mm. of ozone. In air containing of its 
weight of ozone the paper turns blue at once. The part 
of the paper which is colored with the litmus solution, 
and is not impregnated with tbe potassium iodide, 
serves to show the presence in the air of acid or alkaline 
substances which might influence the reaction. By the 
action of ozone the potassium iodide is decomposed and 
potassium hydroxide is formed, which turns the litmus 
paper blue. Chlorine, nitric acid, and other acid sub- 
stances do not, of course, turn the paper blue ; in this 
respect it is superior to those which follow. 
According to Schonbein,16 strips of paper are satu- 
rated with a dilute starch and potassium iodide solution 
(1 KI + 10 starch q- 200 water), and these strips are ex- 
posed to the air. A distinction of ten shades from white 
to dark blue is made. 
Wurster 16 uses tetra-methyl-para-phenylene-diamene, 
which, upon taking up one atom of oxygen, is quantita- 
tively oxidized to a blue coloring matter, and by fur- 
ther union with six oxygen atoms changes to a colorless 
substance. 
To detect ozone, the paper prepared by one of the 
foregoing methods is fastened over the end of a glass 
tube by means of a rubber band, and a measured quan- 
tity of gas is drawn through the tube by an aspirator. 
Houzeau found that the ozone in the atmosphere 
reached its maximum in May and June, and was least in 
the winter months. Bockel11 states also that there are 
daily variations, the air usually containing more ozone 
369 Gas Analysis. 
Genito-Urinary. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
in the evening of days from July to September than in 
the morning, while the reverse is true for the remaining 
months of the year. 
The Gases of the Blood.-Various forms of appa- 
ratus have been devised20 for the extraction of the gases 
from blood. Probably as satisfactory as any is the Pfliiger 
Mercurial Pump, shown on page 201, Vol. VI., of this 
Handbook. For facilitating the measurement of the 
blood before pumping out the gases, Geppert1 has pro- 
posed (page 631 a form of apparatus which with some 
slight modifications might be of considerable value. 
As the blood-gases are chiefly oxygen, nitrogen, and 
carbon dioxide, the analysis of the mixture is easily per- 
formed, the method employed depending upon the 
amount of gas at the operator's disposal, and upon the 
degree of accuracy desired. L. M. Dennis. 
1 Walther Hempel: Methods of Gas Analysis. 1892. 
2 Robert Bunsen : Gasometrische Methoden, 2d edition. 
3 Berichte der deutschen chemischen Gesellschaft, 1879. p. 1768. 
4 Hoppe-Seyler : Zeitschrift fiir analytische Chemie, 1892, 31, p. 367. 
6 Francis Sutton : Handbook of Volumetric Analysis. 
6 Clemens Winkler : Anleitung zur chemischen Untersuchung der In- 
dustrie-Gase. 
7 J. Geppert: Die Gasanalyse und ihre physiologische Anwendung, 
1885. 
8 Brown-Sequard and d'Arsonval: Comptes rendus, 1889, 108, 267. 
9 L. W. Winkler : Berichte der deutsch. chem. Gesellschaft, 24, p. 89. 
10 Otto Pettersson and A. l'almqvist : Berichte der deutsch. chem. 
Gesellschaft, 20. 2129. 
11 Hermann W. Vogel: Berichte der deutsch. chem. Gesellschaft, 
10, 792. and 11. 235. 
17 Walther Hempel : Zeitschrift fiir analytische Chemie, 18, 399. 
13 C. H. Wolff: Correspondenzblatt des Vereins analytischer Chemiker, 
1880. 3. 46. 
11 Auguste Houzeau : Annales de chimie et de physique, 3d series, 
1863. vol. Ixvii., p. 466 
15 SchBnbein : Poggendorff's Annalen, 93, p. 627 : 94, p. 335. 
16 Wurster : Berichte der deutsch. chem. Gesellschaft, 1888, p. 921. 
17 Th. Btickel: Annales de chimie et de physique, 4th series, 1865, 
vol. vi., p. 235. 
18 Th. v. Saussure: Poggendorff's Annalen, 19. p. 391. 
19 Pettenkofer: Jahresbericht der Chemie, 1857, p. 132. Also, Quar- 
terly Journal of the London Chemical Society, 10. 292. 
20 Zuntz : Handbuch der Physiologic, vol. iv., Part TI., pages 24-32. 
21 Walter Hesse : Tabellen zur Reduction eines Gasvolumes auf 0° Tem- 
peratur und 760 mm. Luftdruck. Braunschweig, 1879. 
GENITO-URINARY SURGERY. Since the publica- 
tion of the first edition of the Reference Handbook of 
the Medical Sciences the advances which have been 
made in the department of genito-urinary surgery have 
been mainly in the direction of therapeutics and pathol- 
ogy. But little has been added to our knowledge of the 
anatomy and physiology of these organs. 
Space will not admit of an exhaustive consideration of 
all the literature which has appeared, the views which 
have been advanced, or the many new or revived meth- 
ods of treatment which have been suggested. 
It will, however, be the aim of the writer to take up 
the subjects, as far as practicable, in the order in which 
they originally appeared, and to give, as briefly as possi- 
ble, the practical results of our accumulated experience. 
Bladder. 
Exstrophy.-In cases of exstrophy of the bladder, 
Trendelenburg, with a view to narrowing the anterior 
gap between the pubic bones, has suggested and suc- 
cessfully practised double posterior symphysiotomy. 
Inflammation {Cystitis).-Etiology. - Th. Rossing has 
contributed the results of some elaborate experiments 
regarding the etiology of cystitis, and concludes that the 
urine usually contains one of several varieties of patho- 
genic organisms. These organisms may be pyogenic or 
non-pyogenic. Of the organisms which he isolated, all, 
with the exception of the tubercle bacillus were found to 
be capable of causing a decomposition of the urea. This 
decomposition would give rise to vesical irritation, and if 
the organism was of the pyogenic variety a suppurative 
cystitis would result. 
In twenty-three out of thirty healthy individuals ex- 
amined by this author bacteria were found in the 
urethra which were capable of producing this decompo- 
(SUPPLEMENT.) 
sition of urea. In this manner he explains the frequently 
observed fact of the occurrence of cystitis after the most 
careful employment of surgically clean urethral instru- 
ments. 
It was also found that the injection of pure cultures of 
these organisms into the bladder frequently gave rise to 
no symptoms of irritation when the urine was allowed to 
pass at regular intervals. If, however, an artificial re- 
tention was produced in the animal by ligature of the 
penis for from six to twelve hours, a decomposition 
would be occasioned which would give rise to an in- 
flammatory reaction. 
Similar results have been obtained by Guyon, Albar- 
ran, and others, and these facts seem to explain the 
remarkable tendency to infection observed in patients 
suffering from retention due to stricture or obstructive 
disease of the prostate. 
In a paper published by P. Bazy, the statement is made 
that in nearly every case of cystitis, where there is a 
genuine purulent inflammation, the origin may be traced 
to gonorrhoea, tuberculosis, or infection by means of in- 
struments. 
Mechanical irritation alone, such as that produced by a 
foreign body, new growth, or obstructive urethral or 
prostatic disease, cannot give rise to a suppurative in- 
flammation. There are, however, certain rare cases, 
where a cystitis appears spontaneously, without the pos- 
sibility of gonorrhoea, tuberculosis, or direct septic infec- 
tion being present. These are usually loosely spoken of 
as due to " cold " or the somewhat mysterious action of 
rheumatism or gout. 
This author made several such cases the object of care- 
ful investigation. In one of these he discovered that an 
alveolar abscess preceded the symptoms of cystitis by 
several days ; in another, a purulent balano-posthitis, 
and in still another, a suppurative tonsillitis had been 
present a short time before the occurrence of the hitherto 
unexplained vesical inflammation. 
The author stated, as his belief, that the disease in each 
of these instances had been produced by direct infection 
of the bladder by pathogenic organisms passing from the 
blood through the renal filter into the urine, the origin 
of which could be traced to the antecedent septic dis- 
ease. 
Diagnosis.-The possibility of confounding the symp- 
toms of cystitis with those of a posterior urethritis was 
pointed out in the former edition of this work. Since 
that time much has been written on the subject, and it is 
now a generally accepted fact that the occurrence of 
frequent micturition, vesical tenesmus, and pyuria do not 
necessarily indicate the presence of intra-vesical inflam- 
mation. In fact, in the majority of cases, these symp- 
toms simply indicate the presence of a posterior urethritis, 
for experiments have abundantly demonstrated the fact 
that the desire to urinate is due, in a great measure, to 
an irritation of the peripheral nerves located in the pros- 
tatic urethra, caused generally by the relaxation of the 
internal sphincter, and the consequent introduction of 
the urine into this portion of the canal. The presence, 
moreover, of any slight irritation, such as the introduc- 
tion of a foreign body, or the occurrence of an inflamma- 
tion of the mucous membrane in this region, will give 
rise to the desire for frequent micturition, and, if more se- 
vere, to marked vesical tenesmus. It has also been con- 
clusively shown that pus generated in that portion of the 
urethra posterior to the compressor urethrae muscle, when 
present in any considerable amount, invariably flows 
backward into the bladder. 
If, therefore, in a condition of acute posterior urethri- 
tis, the urine be passed in two glasses, both specimens 
will be found to contain free pus, which continually 
flows backward from the seat of the inflammatory pro- 
cess into the bladder. The first specimen, in addition, 
will contain the washings of the canal, which will appear 
as minute, thread-like bodies, to which the name of 
Tripperfaden lias been given by the German surgeons, 
who first discovered them and demonstrated their im- 
portance. 
The presence of an anterior urethritis, which might 
370 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Gas Analysis. 
Genito-Urinary. 
account for these bodies, may be excluded by a previous 
irrigation of the anterior portion of the canal. 
In cystitis (excepting in those rare instances where the 
infection is purely a tubercular one) the decomposition 
of urea gives rise to the presence of a free alkali. This, 
if allowed to remain in the bladder for a moderate length 
of time, by its action on the pus, forms a thick, tenacious 
substance resembling mucin, which collects at the bot- 
tom of the bladder, is expelled with the last portion of 
urine passed, and is pathognomonic of intra-vesical in- 
flammation. 
Finger describes three conditions usually spoken of as 
cystitis: First, posterior urethritis; second, posterior 
urethritis, with a moderate amount of cystitis in the im- 
mediate vicinity of the internal urethral orifice, and third, 
cystitis without posterior urethritis. 
As an easy method of determining which of these con- 
ditions are present in a given case, if the patient urinates 
in three glasses, the following facts will be observed : 
(SUPPLEMENT.) 
procedures in cases of ruptured bladder. When the rent 
in the bladder-wall is known to be extra-peritoneal, 
measures should be at once taken to insure free drainage, 
and the wound left to heal by granulation. With this 
end in view, Cabot, of Boston, advises an immediate 
laparatomy, with a view to accurately determining the 
region of greatest infiltration which should guide the 
surgeon in the selection of his point of incision for drain- 
age. 
Since the report by Hofmokl and MacCormac of suc- 
cessful laparotomies and vesical suture in cases of intra- 
peritoneal rupture of the bladder, there no longer re- 
mains any question as to the indications for treatment in 
this condition. A number of other successful cases have 
since been reported by European and American surgeons, 
so that now it is generally conceded that, in the presence 
of symptoms indicating an intra-peritoneal rupture of the 
bladder, an exploratory laparotomy should be performed 
at once, and the wound promptly united. A subsequent 
perineal section should then be made, to insure adequate 
bladder drainage. 
A number of cases of rupture of the bladder have been 
collected and reported by Ullmann, the result of injec- 
tions made preparatory to the operation of supra-pubic 
cystotomy. 
New Growths.-Under this head maybe mentioned the 
nodular or follicular cystitis, described by Dr. Samuel Alex- 
ander, in a paper read before the American Association 
of Genito-urinary Surgeons, at Richfield, in June, 1892. 
This papef was a preliminary report based upon a num- 
ber of cases of intense cystitis, associated with haematuria, 
upon which the author had operated, in most cases by 
the supra-pubic method. 
In all of these cases similar lesions were found in the 
bladder. The mucous membrane was intensely con- 
gested, and was studded, especially in the region of the 
trigone, with nodules varying in size from one-eighth to 
one inch in diameter, usually oval, soft, and limited to the 
mucous membrane proper. These tumors consisted of 
lymph nodules and more diffuse collections of lymphatic 
cells, the former resembling the nodules found in the 
intestine in certain cases of enteric inflammation. These 
vesical nodules were surrounded by an exceedingly rich 
net-work of newly formed capillaries with exceedingly 
thin walls. The nodules were covered by the upper 
epithelial layer of the mucous membrane. 
This condition has been mentioned by Chiari, Weichel- 
baum, Hamburger, Toldt, Ziegler, and others, and the 
post-mortem appearances have been described by Pader- 
owski, who regarded them asffubercular growths. Alex- 
ander differs from this view and believes that lymph- 
nodules exist in the normal urinary tract, and that they 
may enlarge as the result of intense inflammation, and be 
often mistaken for tubercles in the bladder. He described 
the clinical history of these cases and advises supra-pubic 
cystotomy and thorough drainage. 
An extended report and description of this most inter- 
esting, and hitherto imperfectly understood, condition is 
soon to be published. 
Stone {Lithotomy, Litholapaxy, Supra-pubic Cystotomy). 
-The statistics published by Sir Henry Thompson, 
Dittel, and a large number of other operators, em- 
bracing thousands of cases of calculus disease, operated 
upon by all methods, conclusively show the great ad- 
vantage 'and low mortality of litholapaxy over all other 
procedures. Although several modifications have been 
made in the tubes and evacuating apparatus, practically 
nothing can be added to the description of the operation 
of litholapaxy which appeared in the first edition of this 
work. 
The advantages which the supra-pubic method of open- 
ing the bladder offers over the perineal incision, for ex- 
ploration and the removal of foreign bodies and new 
growths, are now generally recognized by surgeons. 
Trendelenburg advises for this operation a specially con- 
structed operating-table, which insures an elevation of 
the patient's pelvis eighteen or twenty inches above the 
head and shoulders. He also advocates the transverse 
section of the recti muscles. 
Condition. 
First specimen. 
Second speci- 
men. 
Third specimen. 
Posterior ure- 
Reaction generally 
Moderate amount 
Moderate amount of 
thritis. 
acid. Large 
amount of free 
pus and urethral 
shreds. 
of free pus. 
free pus. 
Posterior ure- 
Reaction faintly 
Moderate amount 
Larger amount of 
thritis, with 
cystitis about 
internal ure- 
thral orifice. 
acid or neutral. 
Large amount of 
free pus; ure- 
thral shreds. 
of free pus. 
pus, and moder- 
ate amount of 
mucoid material. 
Cystitis with- 
Reaction alkaline. 
Moderate amount 
Large amount of 
out posterior 
urethritis. 
Moderate amount 
of free pus. 
of free pus. 
pus and mucoid 
material, with 
crystals of triple 
phosphate. 
Treatment.-A few suggestions only can be added to 
those already mentioned in the first edition of this work. 
Internal Treatment.-Many drugs have been employed 
with a view to rendering the urine antiseptic, and thus 
preventing or inhibiting the further development of 
pathogenic organisms in the bladder. Of these, boric 
acid and salol have been found most useful. To be of 
value, however, they must be given in large doses, from 
twenty to thirty grains of the former and from forty to 
sixty grains of the latter during the twenty-four hours. 
Local Treatment. -It is desirable in cases of bladder 
inflammation, especially if acute, to avoid the use of in- 
struments beyond the compressor urethrae muscle. The 
old method of bladder irrigation by means of the cathe- 
ter had the disadvantage of producing often mechanical 
irritation and septic infection. 
Lavaux, of Paris, has shown that the bladder can be 
successfully irrigated without the use of a catheter by 
means of hydrostatic pressure furnished by the fountain 
syringe. 
To inject the bladder by this method the patient 
should be made to recline on his back with the thighs 
raised to relax the abdominal muscles. The nozzle of 
the syringe should be placed just within the meatus, the 
lips being firmly compressed upon it, and the reservoir 
raised to a height of three or four feet above the patient's 
body. If the patient will then take three or four deep 
inspirations, the fluid will usually pass rapidly beyond 
the compressor urethrae muscle into the bladder. As 
soon as the bladder becomes distended, a strong desire to 
urinate will be experienced, and the solution can be ex- 
pelled in the usual manner. This method has the addi- 
tional advantage of insuring thorough irrigation of the 
whole urethral canal, the deeper portion of which is usu- 
ally involved in cases of cystitis. In the milder cases a 
saturated solution of boric acid will be found most use- 
ful as a bladder-wash. Permanganate of potash, 1 to 
10,000 ; nitrate of silver, 1 to 5,000, and bichloride of 
mercury, 1 to 30,000 will often be found useful in the 
more chronic and obstinate conditions. 
Injuries of the Bladder.-The tendency among surgeons 
during the past few years has been toward more radical 
371 Genito-Urinary 
Surgery. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Regarding the question of primary vesical suture, 
Watson, of Boston, reaches the following conclusions 
from the analysis of one hundred cases : 1. Suture should 
be employed where the pathological changes in the 
bladder are slight. 2. Suture should be avoided when 
the bladder-walls are much thickened, when there is 
much liability to hemorrhage within the bladder, or 
when there is a foul cystitis. 3. Short needles and cat- 
gut should be used with that form of suture which is 
most easily introduced. 
Tuberculosis.-The treatment of tubercular cystitis by 
supra-pubic opening, curetting and cauterizing the ulcers, 
and the subsequent employment of iodoform, has been 
sufficiently successful in the hands of Guyon, Reverdin, 
and others to justify the hope that in early cases marked 
relief may often follow and recovery occasionally result. 
Cystoscope. 
An instrument designed for the purpose of affording 
the possibility of an ocular inspection of the interior of 
the human bladder. This idea was most successfully car- 
ried out by Josef Leiter, of Vienna. 
The following diagram and description of this instru- 
ment appeared in the Medical liecord for May 5, 1888 : 
introduced within the tube of the cystoscope, a limited 
area of the bladder-wall can be made out. If the fluid 
remains clear and the light is of sufficient strength, the 
mucous membrane may be minutely studied, its vessels, 
folds, and color easily appreciated, and 
any pathological lesion detected. By 
changing the position of the instru- 
ment, the whole interior of this viscus 
may be examined. 
This instrument has been modified 
in many ways. When the illuminat- 
ing and reception windows are placed 
on the posterior portion of the beak, a 
better view can often be had of the 
barfond in contracted bladders which 
do not admit of sufficient distention to 
permit of free rotation of the beak 
downward. Care should be taken not 
to allow, for any length of time, the 
contact of the illuminated beak with 
the bladder, as the heat generated by 
the lamp might cause a superficial 
destruction of the mucous membrane. 
There can be no question of the 
great diagnostic value and importance 
of this discovery. By the aid of this 
instrument, accurate knowledge re- 
garding the presence or absence of tu- 
mors, ulcerations, wounds, foreign 
bodies, and diverticula may be ob- 
tained without the necessity of an ex- 
ploratory operation. 
Another and most important use of 
the cystoscope is to determine from 
which kidney the blood or pus pro- 
ceeds in cases of grave pyelitis or renal 
hemorrhage. By watching the open- 
ings of the ureters, the periodic dis- 
charge of urine from the kidneys can 
be observed, and the presence of ab- 
normal substances in the secretion de- 
tected. 
Endoscope. 
An instrument for the visual in- 
spection of the urethral mucous mem- 
brane. 
As it would be a useless expendi- 
ture of time to describe the old and 
cumbersome instruments of Desonneaux and Cruise, 
mention will be made only of the modern instruments of 
Leiter, Brown, and Otis. 
The following description of the Leiter endoscope is 
quoted from a recent article by W. K. Otis : " Roughly 
described, this instrument consists of a sheet metal trough, 
two inches and three-quarters in length by an inch and a 
half wide, at the proximal end of which a concave mirror, 
about an inch and a half in diameter, is placed. 
At the distal end of the trough is the funnel- 
shaped opening of the urethroscopic tube, the 
Fig. 202. 
Fig. 201.-The Leiter Cystoscope in Position in the Bladder. 
"The Leiter cystoscope (Fig. 202) consists of a metal 
tube about seven inches in length, of a calibre of 22 F., 
having at the proximal end a funnel-shaped ocular open- 
ing, at the distal end a short beak, similar to that of the 
catheter coude. A window of rock crystal is set in the 
end of this beak, behind which a small electric lamp con- 
trolled by a switch at the ocular end is placed. A rec- 
tangular prism, the hypothenuse plane of which is sil- 
vered, is placed in the end of the straight portion of the 
tube, its superior face being seen just anterior 
to the angle formed by the beak. The dis- 
tended bladder is illuminated by the electric 
lamp, the rays reflected from its walls fall- 
ing on the prism experience total reflection, 
an inverted image being formed within the 
tube. The size of the image thus obtained 
is greatly increased by means of a telescope 
introduced into the tube. The image seen 
through the cystoscope is inverted, but right 
and left are not transposed." 
To properly examine a bladder by means 
of this instrument, the patient should be 
placed in the horizontal position on the table 
or operating - chair. The bladder should 
be emptied of urine and afterward slightly distended with 
a solution of boric acid. The cystoscope is then intro- 
duced and the current turned on. If the eye of the 
operator is placed at the eye-piece of the small telescope 
Fig. 203.-A, Brown's Wire Urethral Speculum. Open, c, The lever for spreading the 
vesical end, which is governed by the right-angled rod attached to the travelling screw 
button b ; a, the screw which spreads the base or meatus part of the speculum. 
B, Brown's Wire Urethral Speculum, Closed. Shows the small square aperture in the 
binding screw for the attachment of the illuminator. 
upper edge of which is about half an inch above the 
upper edge of the mirror. About an inch and a half 
from the mirror, coming through the bottom of the 
trough, a small electric lamp is placed, the electrical 
372 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Genito-U rlnary 
Surgery. 
connections to which run through a round handle four 
inches long by half an inch in diameter, with a some- 
what complicated arrangement for controlling the lamp, 
fitted with binding-posts at its lower end, to which 
the cords from the battery are fastened. The urethro- 
scopic tubes are attached to the funnel by means of a 
sliding joint. The rays of the lamp falling upon the 
mirror are rendered parallel, and enough light thrown 
down the tube to give very excellent illumination at its 
distal end, the eye looking directly over the upper edge 
of the mirror." 
The urethral speculum, devised by Dr. F. Tilden Brown, 
of New York, and seen in the accompanying illustration 
(SUPPLEMENT.) 
" The instrument is attached to the urethroscopic tube 
by means of a stout wire an inch and a half in length, 
with hinged joints at each end, which swing in opposite 
directionsand are furnished with set-screws, thus allow- 
ing the instrument to be put in any position, though 
when once adjusted it will rarely be necessary to move it. 
If the ordinary form of tube is used the distal end is 
provided with a simple ring sliding-joint ; but, as I have 
already said, 1 greatly favor the use of the tube of Dr. 
Klotz.' I have arranged the instrument for this form of 
tube. 
" When the instrument is in position and the lamp il- 
luminated, a strong beam of light is thrown down the 
urethroscopic tube and the urethral mucous 
membrane more easily and clearly observed than 
with any other form of urethroscope with which 
I am familiar. 
"The advantages of this instrument are : 1. The 
exclusion of all extraneous light, the presence of 
which is a most annoying fault in the urethroscope 
of Leiter. 2. A very much more ready access to the 
urethral field, both to the eye and for instrumental 
applications. 3. Increased illumination. 4. By 
abandoning the funnel and sliding-joint an inch and 
a half in distance is gained from the source of 
illumination to the distal end of the urethroscopic tube, 
increasing the illumination and allowing the eye to be 
placed just so much nearer the mucous membrane to be 
examined. 5. Its extreme compactness and lightness, 
weighing less than one ounce, even when constructed of 
brass. 6. Its great simplicity, which should insure a 
moderate cost." 
Epididymitis. 
In the Journal of Cutaneous and Genito- 
urinary Diseases, May, 1888, the writer pub- 
lished the results of some experiments in the 
treatment of acute epididymitis by means of 
the Paquelin cautery. The method em- 
ployed was that first suggested by Halsted, which con- 
sists in lightly touching the surface of the skin overlying 
the affected organ with a white-hot cautery point. This, 
if successfully performed, requires but a few seconds, and 
is but moderately painful. A dressing of iodoform or 
boric acid ointment is then applied, and a suspensory 
bandage adjusted, so as to relieve any dragging upon the 
cord. Instant relief of pain often follows this procedure, 
and absorption of the inflammatory induration takes 
place rapidly. 
As a means of hastening the absorption of the prod- 
ucts of inflammation, after the acuteness of the at- 
tack has subsided, the dry poultice will often be found to 
be most useful. This dressing was de- 
scribed by the writer in a paper read be- 
fore the American Association of Genito- 
urinary Surgeons, at Washington, in 
1891, and consists in a moderately thick 
layer of cotton-wool applied over the in- 
flamed testicle. This is covered by a 
layer of rubber protective tissue so fash- 
ioned as to completely enclose the in- 
flamed organ, with its edges extending 
onto the healthy skin of the scrotum in a manner to 
partly overlap but not enclose the healthy side. This 
is secured by a snugly applied gauze dressing, and the 
whole held in place by a suspensory bandage. 
By insuring protection, heat, moisture, moderate com- 
pression, and suspension, this dressing fulfils all the in- 
dications to be met in this condition, and will be found 
to be a great source of comfort to patients whose occu- 
pations necessitate any considerable amount of standing 
or walking. 
Hydrocele. 
Diagnosis.-As an easy method of making an accurate 
diagnosis in cases of suspected hydrocele, the electric 
illuminator devised by Dr. William K. Otis may be em- 
ployed. This instrument consists of small incandescent 
lamp contained in a cylindrical hard rubber hood (Fig. 
taken from his paper, being wholly of wire, 
allows a thorough inspection of the entire an- 
terior urethra at a glance. For a more minute 
examination, he employs a small mirror, con- 
structed on the same principle as the laryn- 
geal mirror. This, by being obliquely fastened 
to the handle, when passed within the canal, reflects the 
image of any inequality or pathological condition of the 
mucous membrane. By means of the urethral digit (Fig. 
205), the presence of any submucous deposit or band of 
stricture can be readily appreciated. The light which 
Dr. Brown employs is from a strong electric lamp, with 
lens condenser reflected by means of a head-mirror. 
Fig. 205.-Brown's Straight Six-inch Urethral Digit. C, The movable 
probe-tip controlled by U-spring and thumb-screw at handle. Inch marks 
are indicated along the upper rod. 
The Otis perfected urethroscope (Fig. 206) is perhaps 
the most perfect appliance for urethral illumination. 
From his article in the New York Medical Journal the 
following description is taken : 
" This instrument consists of a metal tube or cylinder, 
an inch and a quarter in length by half an inch in diam- 
eter, closed at one end. A quarter of an inch from the 
open end of this tube is a plano-convex lens, so arranged 
that it may be easily removed for cleaning. On the in- 
ferior surface, near the closed end of the 
tube, an elbow is let in, a quarter of an inch in 
length and half an inch in diampipr thrmiph 
Fig. 206. 
which the source of illumination (a small incandes- 
cent electric lamp) is introduced, a row of holes being 
bored at its base to allow of ventilation. The handle 
of the instrument consists of a piece of hard rubber 
an inch long by half an inch wide, the electrical con- 
nections running through it to the lamp which is 
placed on top. This handle fits into the elbow by means 
of a bayonet-joint, bringing the lamp immediately be- 
hind the plane side of the lens. A thumb-screw 
' switch ' in the handle places the lamp under control, 
so that it may be turned on or off at pleasure. 
373 Genito-lt ri nary 
Surgery. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
207). If the patient be examined in a darkened room, and 
the open extremity of this instrument firmly held against 
the posterior portion of the scrotal tumor when the cur- 
rent is turned on, the whole cavity of the tunica vagi- 
nalis will be brilliantly illuminated, and the exact loca- 
tion, shape, and size of the testicle can be determined. 
Treatment.-The injection into the tunica vaginalis of 
a small amount (minims 10 to 30) of the liquefied crys- 
tals of carbolic acid, which was mentioned in the earlier 
edition of this work, is the method most generally em- 
(SUPPLEMENT.) 
was regarded as a thoroughly justifiable procedure, and 
the great superiority of the supra-pubic over the perineal 
method was fully recognized. 
Dr. Keyes's method consists in making a supra-pubic 
opening, and then, by means of the finger-nail, sharp 
spoon, curved scissors, or rongeur forceps, completely 
removing all that portion of the hypertrophied gland 
which surrounds or obstructs the internal urethral ori- 
fice, leaving no pocket or pent-up prostatic sinus. The 
success which has attended the thorough operation ad- 
vocated by Dr. Keyes would seem to justify 
the hope that permanent relief may be ob- 
tained in, at least, a certain number of these 
exceedingly annoying and unfortunate 
cases. For many obvious reasons, the oper- 
ation in a large number of instances is im- 
practicable, and in these regular catheter- 
ization must be employed. 
Much has been written upon the great danger of infec- 
tion attending the first passage of the catheter in cases of 
chronic retention of urine with atony of the bladder from 
this cause, and the necessity for unusual care in begin- 
ning the " catheter life " of the patient. 
Professor Guyon, in the Annales des Maladies des Or- 
gaiies Genitounnaires, for May, 1889. gave the results 
of a series of experiments upon animals, illustrating the 
tolerance of the bladder to injected pathogenic organisms 
when the urine was allowed to pass at regular intervals, 
and the marked tendency to septic infection which fol- 
lowed even a temporary retention after the introduction 
of pure cultures of the staphylococcus aureus, strepto- 
coccus pyogenes, and the septic bacillus of Clado. 
The following method should be employed at the first 
catheterization of an individual suffering from chronic re- 
tention of urine : The patient should remain in bed for 
at least twenty-four hours after the introduction of the 
catheter. Previous to its introduction the meatus and 
glans should be bathed with a solution of bichloride of 
mercury, 1 to 5,000 ; the urethra, if suppurating, should 
be injected with a solution of bichloride, 1 to 5,000, or 
nitrate of silver, 1 to 500 ; if normal, a solution of boric 
acid, five per cent, will answer. The catheter, if metal- 
lic, should be boiled ; if of rubber or gum-elastic, it should 
be thoroughly washed and treated with seventy per cent, 
alcohol, followed by a solution of bichloride of mercury, 
1 to 1,000. If great distention of the bladder exists, only 
a portion of the urine should be withdrawn at the first 
operation, that the circulation may accustom itself to the 
altered condition of the bladder-walls. Complete empty- 
ing of this viscus in extreme cases of distention, should 
be delayed for eight or ten days. After the removal of 
the urine a small amount of a saturated solution of boric 
acid should be introduced and allowed to remain in the 
bladder. These precautions should be continued until 
the bladder can be completely emptied without reaction. 
Stricture of the Urethra. 
The admirable chapter on this disease which appeared 
in the first edition of this work leaves little to be said 
on the etiology, pathology, and symptomatology of this 
condition. 
During the past few years the tendency among sur- 
geons has been toward the practical abandonment of di- 
vulsion and electrolysis in the treatment of urethral strict- 
ure. Regarding the choice of procedures in cases of 
stricture in the anterior portion of the canal, the same 
rules will hold as mentioned in the first edition, although 
it is now the generally accepted belief that internal ure- 
throtomy, when properly performed, offers the only hope 
of a radical cure in cases of genuine organic stricture. 
This method has, therefore, become the operation of 
choice among those surgeons who have to do largely 
with this class of cases. 
The operation advised by Otis is so simple, and, when 
confined to the anterior portion of the canal, so abso- 
lutely devoid of danger, that a brief description of the 
method of procedure may not be out of place in this con- 
Fig. 207. 
ployed at present. The usual manner of employing this 
agent is the following : 
A hypodermic syringe containing the required amount 
of carbolic acid is inserted through the scrotum into the 
upper portion of the distended cavity of the hydrocele, 
and held by an assistant. A large trocar or aspirating 
needle should then be introduced into the lower and an- 
terior part of the tumor through which the fluid is evac- 
uated. After the complete emptying of the sac, the con- 
tents of the hypodermic syringe (the needle of which is 
still within the cavity of the tunica vaginalis) should be 
slowly injected, and, after removal of the needle, evenly 
distributed throughout the entire cavity by gentle mas- 
sage. The patient should be instructed to remain quietly 
at home, preferably in the reclining posture, until all re- 
actionary pain has subsided. 
With a view to avoiding the double puncture, the 
writer employs a small trocar and cannula provided with 
a stopcock and threaded extremity to fit an ordinary 
hypodermic syringe (Fig. 208). This should be intro- 
duced and the fluid withdrawn. The stopcock is then 
turned to prevent the entrance of air, and the hypoder- 
Fig. 208. 
mic syringe containing carbolic acid screwed into place ; 
the stopcock is again opened and the contents of the 
syringe injected. 
Prostate. 
Senile Enlargement.-Nothing Jias been added to our 
knowledge regarding the causes of this common affec- 
tion. During the past few years the tendency among 
progressive surgeons has been toward more radical 
measures, with a view to the removal of the obstructing 
portion of the hypertrophied mass. The practice of in- 
cising or removing a portion of the bar, which often 
exists just within the internal urethral orifice, by means 
of the instruments of Mercier and Gouley, without open- 
ing the bladder, has been practically abandoned by most 
surgeons, owing to tbe danger attending the operation 
and the uncertainty of result. 
For several years past occasional reports have been 
published of the successful removal of an hypertrophied 
third lobe, or obstructing bar at the neck of the bladder, 
by means of a perineal or supra-pubic opening, with 
more or less complete restoration of the function of 
voluntary urination. It was not, however, until the 
publication by A. F. McGill, of Leeds, and E. L. Keyes, 
of New York, of their series of cases, that the operation 
374 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Ge ii it o-Uri it ary 
Surgery. 
When the stricture occurs at the meatus, or within 
three-quarters of an inch from the orifice, the operation 
should consist of an incision made with a straight, blunt- 
pointed bistoury on the floor of the canal ; in cases where 
the stricture occurs at a point deeper than three-quarters 
of an inch from the external opening, dilating urethrot- 
omy, by means of the Otis dilating urethrotome, should 
be practised, the cut being made on the roof of the ure- 
thra. Cocaine is usually employed for anaesthesia. The 
method of producing cocaine anaesthesia is as follows. 
By means of an Ultzmann, or long-pointed, syringe, 
about thirty minims of a four per cent, solution of coca- 
ine is injected into the bulbous portion of the urethra. 
As the syringe is withdrawn, the lips of the external ori- 
fice are gently compressed with the thumb and fore- 
finger. The solution is in this manner retained for ten 
minutes, which is found to be sufficient to render the 
entire anterior urethra insensitive, save that portion 
compressed by the fingers. As this is always the most 
sensitive part, the hypodermic injection of tw'o or three 
minims of the solution just below the meatus wall render 
the whole absolutely insensitive to pain. Where this 
method is fully carried out, the patients rarely complain 
of pain during the operation. It is necessary to employ 
ether for anaesthesia only in cases of great nervous irrita- 
bility, where the sight of blood and the various necessary 
manoeuvres would be followed by disagreeable mental 
effects, and where the careful exploration of an abnor- 
mally sensitive deep urethra or bladder is necessary. 
The exact location of the deepest band of stricture is now 
determined by means of the bougie d boule, or urethrom- 
eter of Otis, and the dilating urethrotome introduced so 
that the location of the blade as it emerges from the 
staff is one-half inch below the stricture. The instru- 
ment is then opened until the indicator points to a cali- 
bre corresponding to the normal size of the canal, or 
until the band is stretched to its fullest capacity. The 
blade is then quickly withdrawn and returned. Each 
band should be treated in this manner until a full-sized 
bulb will pass to the bulbo-membranous junction with- 
out the slightest obstruction. The hemorrhage is usually 
slight, and soon ceases by gentle external compression. 
Regarding the after-treatment, it has been found that 
the daily passage of a full-sized sound to the bulbo-mem- 
branous junction, during the first four or five days, is by 
far the most comfortable for the average patient, as the 
pain attending its passage is always more marked and the 
hemorrhage more severe after the cut surfaces have been 
allowed to glue together for two or more days. A sound 
is usually passed also on the seventh, fourteenth, and 
twenty-first days after the operation. In cases where an 
acute urethritis follows the operation, or where the ure- 
thra is for any other reason abnormally sensitive, the 
daily passage of sounds seems often to increase the sever- 
ity of the symptoms, and in these instances the intervals 
should be increased to three or four days. 
It is rarely advisable to employ cocaine for the passage 
of sounds during the after-treatment. Where dilating 
urethrotqmy has been practised, the patient should be 
kept in bed until the danger from hemorrhage has passed, 
usually from three to five days. 
If recontraction of the stricture is to take place, it is 
usually possible to detect a tendency toward this within 
fourteen days from the date of the operation. When 
this is found, further use of the sound should be aban- 
doned, both on account of the severe pain caused by 
forcing a full-sized sound through an imperfectly di- 
vided and recontracting stricture, and also on account of 
the utter uselessness of attempting to prevent recontrac- 
tion by means of dilatation. The patient should be al- 
lowed to wait until the cut resulting from the first op- 
eration has healed, when a second and deeper incision 
should be made with a view to completely severing the 
cicatricial band upon which seems to depend the only 
possibility of a radical cure. 
If after three weeks the urethra is healed, and there is 
no evidence of recontraction of the strictures, the use of 
the sound may be discontinued, unless the presence of 
granular patches, an irritable deep urethra, or other similar 
conditions, calls for its employment. The use of sounds 
for an indefinite period after an operation, with a view to 
"keeping the stricture open," is wholly unnecessary. 
If a stricture is to be cured by urethrotomy, it must be 
by thorough division, which does away with the neces- 
sity of prolonged after-treatment by dilatation. 
Regarding the complications which are said to arise so 
frequently from this operation, the following may be 
quoted from a paper read by the writer before the New 
York Academy of Medicine, December 9, 1889, in which 
an analysis of one hundred and twenty personal cases of 
internal urethrotomy is reported, and which may serve to 
call attention to the comparative frequency and treat- 
ment of these conditions : 
"Among the unfavorable complications which are 
likely to occur as a result of this operation may be men- 
tioned, first, severe hemorrhage. This occurred in six of 
the one hundred and twenty cases. Of these, three were 
primary, occurring at or near the time of the operation, 
and three secondary, occurring after a period varying 
from one to three weeks. Of the latter, two resulted 
from a too early indulgence in sexual intercourse ; in one 
it occurred on the ninth day without any ascertainable 
cause. In but one instance was the hemorrhage alarm- 
ing, and that was in a case cut on the floor of the urethra. 
" In the treatment of hemorrhage it is rarely necessary 
to institute measures other than rest and gentle pressure 
applied against the lips of the urethral orifice, as it is only 
under very exceptional circumstances that the pressure 
is sufficient to force the blood beyond the compressor 
urethrae muscle into the bladder. By the use of the peri- 
neal crutch properly applied (a procedure first suggested 
by Dr. F. N. Otis) a more or less constant pressure may 
be exerted against the deeper portion of the urethra, 
thereby preventing the backward flow of blood into the 
bladder, if at any time the action of the muscle seems in- 
adequate. As an effective method of controlling even 
the most violent hemorrhages from the anterior urethra, 
Dr. Otis has suggested the introduction of a full-sized 
endoscopic tube, upon which any amount of pressure 
may be brought to bear by means of an external ban- 
dage. The prolonged application of heat by means of 
the retrojection of very hot water served in one instance 
to check a persistent and very annoying hemorrhage. 
"It may be stated, I think, with a reasonable degree 
of certainty, that by careful watchfulness and the em- 
ployment, when necessary, of these methods, in no case 
where urethrotomy has been performed need the patient 
be seriously inconvenienced by loss of blood. 
" Chills and fever will be mentioned as the second com- 
plication likely to follo-w urethrotomy. This followed 
the operation in three cases-in one, fever without a 
chill. In every instance the chill followed the passage 
of a sound through the deep urethra. The fever without 
the chill was accompanied by a severe lymphangitis and 
local sloughing, due to a division of a very narrow me- 
atus during the progress of an acute urethritis. 
" Epididymitis, as a complication of this operation, oc- 
curred in tw'o patients, and in each it followed the pas- 
sage of a sound through the deep urethra. 
"Infiltration of urine into the cellular tissue of the 
penis occurred in one case, where the cut was made on 
the floor of the urethra. The treatment of this condition 
consisted in regular catheterization, hot retrojection, and 
the external application of heat, the object being to pre- 
vent its recurrence, to prevent septic infection of the in- 
filtrated tissues, and to promote absorption. 
"An acute urethritis followed the operation in ten 
cases. In seven of these the operation was undertaken 
shortly after an attack of acute gonorrhoea, and w'as pre- 
sumably due to the fact that the gonococci had not en- 
tirely disappeared from the urethral mucous membrane. 
In the remaining three cases it could be accounted for 
only by the use of imperfectly cleaned instruments. 
" A slight ecchymosis appeared in the skin of the penis 
in the vicinity of a cut in four of the cases, and is of in- 
terest only on account of its relation to a more or less 
lasting curvature of the penis on erection. Of the four 
cases in which ecchymosis was noted, curvature occurred 
375 Genito-Urinary 
Surgery. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
in three, or seventy-five per cent. In the remaining one 
hundred and sixteen patients in which no ecchymosis was 
noted, curvature occurred but twice, or in about 1-^ per 
cent, of the cases. In but one of the five cases of cur- 
vature did the symptoms occasion any marked inconven- 
ience. In this instance the penis, when erect, was bent 
upon itself at an almost right angle, and was at first ex- 
tremely painful ; this condition continued to a greater or 
less extent for some seven months. In all five cases, 
however, the organ eventually became straight and the 
resulting annoyance was usually slight. 
" In three of the five cases of curvature there had been, 
during the first six or eight days following the operation, 
an almost entire absence of complete erection of the 
penis, owing, in two instances, to efforts on the part of 
the patient to avoid the pain usually attending such an 
erection. In no instance was there any well-marked in- 
duration at the angle of curvature. 
" To account for the presence of an ecchymosis of the 
skin, the escape of blood must have taken place into the 
loose connective tissue lying between the fasciae, in clos- 
ing the cavernous and spongy bodies of the penis. For 
this to have taken place the cut must have extended 
through the urethra, the corpus spongiosum, and its 
fibrous capsule-in other words, the incision was unnec- 
essarily deep. In view of the fact that the large majority 
of cases of curvature occurred in patients exhibiting an 
ecchymosis of the skin, it is not irrational to attribute the 
occurrence of curvature to the same condition, which 
might easily result in a slight inflammatory thickening of 
the tissues outside the urethra, or from the presence of an 
organized clot, either of which would be sufficient to 
cause a diminution in the elasticity of the tissues which 
would result in curvature on erection. 
" If this view be correct, it is easy to understand how 
an absence of vigorous erections during the first few days 
following an operation might favor, while their presence 
might diminish, the tendency toward formation of in- 
inflammatory adhesions. 
''In the treatment of this condition use has been 
made of inunctions of oleate of mercury, of the galvanic 
current, and of massage. Of these, the latter has proved 
to be by far the most useful. The method of its appli- 
cation was that suggested by Dr. Frank Hartley, who 
advises the introduction of a full-sized steel sound ; the 
massage being confined to the neighborhood of the angle 
of curvature, against the resistance afforded by the 
sound. 
" The prognosis regarding the time necessary to cor- 
rect this deformity should be extremely guarded ; as 
often, in well-marked cases, a period varying from six 
months to a year is necessary before the complete disap- 
pearance of the symptom. 
" Although my records do not furnish an example, 
suppression of urine may occur as a grave complication 
in cases of urethrotomy. This may arise either from 
nervous shock, from injury or violence to the deep ure- 
thra, or as a result of septic nephritis, and is best avoided 
by the practice of confining all operative procedure to 
the anterior urethra, and by the employment of strict 
antiseptic precautions." 
At the close of the paper the following conclusions 
were drawn, which may fairly be stated as representing 
the present opinion regarding this operation : " 1. That 
internal urethrotomy as a means of treating stricture 
of the anterior urethra is a comparatively safe opera- 
tion, no deaths occurring in my series of cases, and but 
one case of severe illness, and that directly traceable to 
my own bad judgment regarding the method of operating. 
2. That by the intelligent application of a few well- 
known measures alarming hemorrhage can in nearly all 
cases be avoided. 3. That the occurrence of a more or 
less lasting curvature of the penis after operation is 
probably due to the extension of the incision beyond the 
necessary limits, and that a tendency toward this is ag- 
gravated by the prevention, by any means, of complete 
erection of the organ subsequently to the operation. 4. 
That with the exception of the meatus, the practice of 
dividing anterior strictures on the floor of the urethra 
should be condemned as a dangerous procedure. 5. 
That the passage of instruments through the deep urethra 
should, if possible, be avoided immediately after the op- 
eration. 6. That in a majority of cases, by a thorough 
and complete division of all stricture bands, a radical cure 
and complete restoration of the canal to its normal cali- 
bre, may be expected. 7. That all attempts to prevent 
recontraction in imperfectly divided strictures by means 
of dilatation, are useless." 
liesection of the urethra for dense, indurated stricture 
located in the membranous portion of the canal, has been 
successfully practised by Heusner, Konig, and others. 
Heusner's method consists in first dissecting out the cica- 
tricial tissue. The urethral mucous membrane above 
and below the stricture is then separated by curved scis- 
sors from the submucous connective tissue and the edges 
united with catgut sutures. The wound is drained and a 
catheter tied in. By this method it is said that the ne- 
cessity for constant dilatation after external urethrotomy 
in these cases is avoided. 
Urethritis (Gonorriicea). 
Since the publication of the first edition of this work 
a very considerable amount of progress has been made in 
our knowledge of this disease, its causes, its varieties, its 
general behavior, and its treatment. For several years 
subsequent to the discovery by Neisser of the gonococ- 
cus, the relationship between this micro-organism and 
the severer forms of urethritis was seriously questioned 
by the majority of the more conservative members of 
the profession. This was in part due to the fact that 
certain views regarding the origin of this affection had 
long been entertained and taught by many of the most 
distinguished authorities upon the subject, which were 
at variance with the conclusions logically following the 
acceptance of this theory. But the evidence which has 
been furnished by the pathologists has been so conclusive, 
and the analogy to other forms of contagious diseases so 
well marked, that to-day few who have taken the trouble 
to investigate the subject will undertake to deny the 
causative relationship which this organism bears to the 
ordinary contagious form of this affection. 
The acceptance of these views has naturally led to a 
gradual change in nomenclature, classification, prognosis, 
and treatment. The tendency to abandon the old and 
etymologically incorrect term gonorrhoea, and to adopt the 
more scientifically correct urethritis, has induced the 
writer to consider the subject under this heading. 
Varieties.-Acute Specific Urethritis, the so-called true 
gonorrhoea. A severe, highly contagious inflammation of 
the urethra, having a distinct period of incubation and 
characterized by an abundant purulent discharge contain- 
ing gonococci. This form of disease is invariably caused 
by contact with the secretions from the diseased organs of 
a person similarly affected. The duration of this variety, 
if untreated, is never under four weeks, and usually con- 
tinues over a period of many months. 
Acute Non-specific Urethritis.-A mild contagious ure- 
thral inflammation, having a period of incubation char- 
acterized by a scanty muco-purulent or purulent dis- 
charge, containing no gonococci. This disease has been 
described by Bochart and others, who attribute the symp- 
toms to infection from micro-organisms contained in the 
vaginal secretions occurring in leucorrhoea, cancerous 
disease of the cervix, or during menstruation. The 
duration of this form of urethritis is seldom over twelve 
or fourteen days. 
Acute Exacerbation of a Chronic Specific Urethritis.- 
A purulent urethritis, usually mild in character, occurring 
generally without or with but a brief period of incuba- 
tion in persons having an uncured urethral inflammation, 
who, however, may present no outward manifestations of 
the disease. The secretions usually contain gonococci. 
Urethritis may also be occasioned by traumatism, by 
chemical or thermal agents, by rheumatism, gout, and 
the lesions of tuberculosis, chancroid or syphilis, but 
these varieties are so infrequent as to render their con- 
sideration in this connection superfluous. 
376 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Ge nito-Urinary 
Surgery. 
Until quite recently the majority of writers upon the 
subject of venereal disease admit the possibility of an 
idiopathic urethritis which may be occasioned by the 
cohabitation of a perfectly healthy man with a perfectly 
healthy woman, and claim, moreover, that the symptoms, 
duration, and ultimate results of such a condition differ 
in no respect from those accompanying the severer and 
more virulent forms of the disease. Ricord even goes 
so far as to enumerate, in his now famous " receipt," the 
conditions of temperament, complexion, the kind and 
amount of exercise, the diet and the drink which, in his 
opinion, favor this peculiar and spontaneous evolution of 
disease. 
More evidence, however, must be furnished in sup- 
port of this theory than that contained in the usual state- 
ments that "the man had no discharge " and that the 
most "careful speculum examination of his companion 
failed to reveal the slightest trace of disease." 
The writer has expended a very considerable amount 
of time and trouble during the past few years to discover 
an example of this variety of urethritis, and has investi- 
gated with no little care a large number of these sup- 
posed cases of "strain," with the result that in no in- 
stance was the urethritis to be accounted for in any 
manner other than by contagion from the gonococci- 
bearing secretions from some portion of the genito-uri- 
nary tract in the female or from the awakening of an 
uncured urethritis in the male. 
In view of our increased knowledge regarding the 
behavior of gonorrhoeal disease in both sexes, no reason 
exists at present for our accepting this unscientific theory 
of an idiopathic urethritis. 
Diagnosis.-The microscopic examination of the pus 
derived from a given case of urethritis, with a view to 
determining the presence or absence of gonococci, fur- 
nishes the most reliable data upon which to base an 
opinion regarding its nature, prognosis, and treatment. 
If gonococci can be demonstrated in the secretions, we 
have to do with a case of genuine gonorrhoeal or specific 
urethritis. 
The method of making this examination is as follows : 
A small fraction of a drop of freshly exuded pus is 
spread into an exceedingly thin layer on a glass slide. 
This, after drying by passing it rapidly through the flame 
of an alcohol lamp, is treated with a saturated solution of 
methyl-blue or gentian violet in aniline water. This is 
allowed to remain sufficiently long to stain the nuclei of 
the cells, leaving the surrounding protoplasm clear. The 
staining fluid should then be thoroughly washed off with 
distilled water and, after the application of a cover-glass, 
the specimen examined with a 12th oil immersion. If 
gonococci be present, they will be seen in clusters in the 
protoplasm of the pus-cells surrounding the nuclei, as 
deeply stained, biscuit-shaped diplococci, arranged in 
pairs or fours. If present in large numbers they may 
completely fill the cell without exhibiting any special ar- 
rangement. 
Other varieties of diplococci are said to present appear- 
ances so similar to those described above as to render this 
test alone insufficient to establish a positive diagnosis in a 
doubtful case. In such instances, use should be made of 
the test described by M. Gabriel Roux, of Lyons, which 
is based upon the fact that the gonococcus alone, of all 
the micro-organisms likely to be found in pus, is not 
acted upon by Gram's fluid, and consequently loses its 
color when treated by absolute alcohol. 
Roux's test should be made as follows : A specimen of 
pus should be stained, in the manner above described, with 
the methyl-blue or gentian-violet, treated with Gram's 
iodo-iodide solution, mounted, and examined. If diplo- 
cocci are present in the pus-cells, which wholly disappear 
after decolorization with absolute alcohol, the organisms 
are surely gonococci, as all other varieties of cocci retain 
their stain after this treatment. 
Prognosis.-The only point in prognosis which should 
be added to that contained in the first edition of this 
work is in regard to the duration of the contagious stage 
of a specific urethritis. The question is a serious one, 
especially when considered in its relation to marriage, 
(SUPPLEMENT.) 
and should, I believe, be regarded as equal in importance 
to that of syphilis. 
It is not infrequently the experience of physicians to 
be consulted by young men, a few weeks or months be- 
fore a contemplated marriage, -with a history of one or 
more attacks of gonorrhoea in former years, and who 
believe themselves to be well, yet who, upon a careful 
examination, present the unmistakable signs of a chronic 
urethritis. 
The only evidence of disease remaining in these cases 
may be, and frequently is, the presence in the urine of 
small thread-like bodies, to which the name of Tripper- 
faden has been given by the German surgeons who first 
discovered them and demonstrated their importance. 
These minute shreds are composed of mucus, pus, and 
epithelium, and represent the secretions which adhere to 
any granular patch or area of chronic inflammation re- 
maining on the urethral mucous membrane. 
Since the establishment of the relationship of the gono- 
coccus to this disease but one opinion can logically be 
held by those who accept this theory of gonorrhoeal in- 
flammations, and that is, that all secretions containing 
this micro-organism are capable of transmitting the dis- 
ease under favorable conditions. In his recently pub- 
lished work upon this subject Ernest Finger emphasizes 
this point, and states, regarding marriage, that it should be 
absolutely prohibited in all cases where the existence of a 
chronic urethritis is evidenced by the presence of the 
" morning drop" or Tripperfaden in the urine, until the 
following facts have been established : 1, That after from 
two to four weeks of daily observation the secretions 
from the urethra are found to be free from pus and made 
up wholly of epithelial cells ; 2, that no gonococci can be 
detected by the microscope, even after a purulent dis- 
charge has been established by the employment of irri- 
tating injections of corrosive -sublimate or nitrate of 
silver ; and, 3, that neither prostatitis nor stricture exists. 
Treatment.-The general acceptance of the more mod- 
ern views regarding the etiology of urethritis has led to 
the adoption of new therapeutic measures. When we 
consider that urethritis is a purely local affection, limited 
during the first few days, at least, to the anterior portion 
of the urethral mucous membrane, the conclusion is in- 
evitable that the most successful method of treatment 
will consist in thorough irrigation of the diseased portion 
of the canal with some agent capable of destroying the 
germs or, at least, inhibiting their development. Of the 
remedies employed the most successful have been bichlo- 
ride of mercury and nitrate of silver. 
Bichloride of Mercury.-The first systematic experi- 
ments with this agent were made by Dr. William S. Hal- 
sted, at the Roosevelt Hospital, in 1884. He found that 
by irrigating the anterior urethra with a large amount of 
a very diluted solution of this agent (1 to 40,000) a 
marked amelioration in the symptoms was at once ap- 
parent. His method consisted in allowing from one to 
two quarts of the solution to pass through the urethra 
twice daily by means of a fountain syringe and glass 
nozzle. About the same time bichloride solutions were 
also employed, though in somewhat more concentrated 
solutions, by Dr. II. Holbrook Curtis, by means of his 
hot retrojection apparatus (Fig. 209). 
This apparatus consists of a tin pail beneath which is 
fastened a platform for an alcohol lamp or Bunsen 
burner. The pail is connected by means of a rubber 
tube with a No. 14 F. soft-rubber catheter. The patient, 
seated in front of a slop-jar or pail, introduces the cathe- 
ter to within one inch of the bulbo-membranous junc- 
tion. The pail is then elevated, by means of a pulley and 
cord, to a height of three feet, and the solution allowed 
to pass rapidly through the urethra from behind forward. 
The temperature of the fluid is regulated by means of the 
lamp, and should be gradually raised until it is as hot as 
the patient can bear. 
Some five years ago an opportunity was granted the 
writer of undertaking a series of experiments at the out- 
door department of Roosevelt Hospital, with a view to 
testing the efficacy of the various methods of treating 
gonorrhoeal urethritis. By far the largest number of 
377 Genito-Urinary 
Surgery. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
cases were treated with bichloride of mercury, for the 
reason that the results which followed the use of this 
drug seemed far more satisfactory than those of any of 
the others. At the end of the first year, by request of 
the President of the New York Dermatological Society, 
I reported to that body the results of my work in a paper 
entitled " Some Observations upon the Modern Treat- 
ment of Urethritis." In that communication I limited 
myself to the consideration of two comparatively new 
methods of treating this disease, i.e., by continuous irri- 
gation with bichloride of mercury, and by hot retrojec- 
tion. 
From an analysis of about one hundred and fifty cases 
treated by these methods I felt justified in drawing the 
following conclusions : 1. That in uncomplicated cases 
of acute gonorrhoeal urethritis, treated by prolonged and 
(SUPPLEMENT.) 
astringents and heat. 5. That the percentage of compli- 
cations occurring in cases treated by these methods is far 
below that observed where the ordinary treatment is em- 
ployed. 
At the close of my second year of experiments, at the 
request of the editor of the Journal of Cutaneous and 
Genite-urinary Diseases, I gave a brief resume of the re- 
sults in a short contribution to that journal, entitled 
" Genito-urinary Notes." In this paper one hundred and 
two additional cases were reported which were treated 
by the above methods, and at the conclusion of the re- 
port the statement was made " that the results obtained 
were even more satisfactory than at first and fully justify 
the conclusions with which I closed my first paper." 
Regarding the inflammatory complications, I stated 
that I had encountered but live in over two hundred and 
fifty cases, or about two per cent., while in three hundred 
anil fifty-two cases treated by other methods, epididy- 
mitis alone occurred in sixteen per cent, of the patients. 
Cases were occasionally encountered which would not 
yield to these methods. In all such the urethra was 
found to be the seat of one or more strictures which 
rendered its walls rigid and inelastic, thereby preventing 
the free circulation of fluid within its cavity. 
During the past three years I have continued to em- 
ploy bichloride of mercury in the treatment of this dis- 
ease at the Vanderbilt Clinic, Presbyterian Hospital, and 
in private practice, substituting largely the ordinary 
urethral syringe for the methods by irrigation. 
The method adopted in the hospital cases wTas as fol- 
lows : As soon as the patient presented himself at the 
clinic, he was instructed in the proper use of the syringe 
and given a large amount of a solution of bichloride of 
mercury, varying in strength from 1 to 16,000 to 1 to 
50,000, according to the sensitiveness of his urethra and 
the stage of the disease. This he was instructed to use 
twice daily by taking ten injections in the morning and 
ten at night, holding each one in the urethra one minute, 
to imitate as nearly as possible the result obtained by ir- 
rigation. The patients were usually seen three times a 
week. As soon as the discharge lost its purulent char- 
acter the bichloride was suspended and a mild astringent 
substituted, preferably bismuth suspended in glycerine 
and water. 
Although bichloride cannot be said to be a reliable 
and abortive agent in the treatment of urethritis, still it 
undoubtedly exerts a more marked influence in subduing 
the painful and disagreeable symptoms of this disease 
than any other remedy at present in use. 
Nitrate of Silver.-This agent has long enjoyed the 
reputation of exerting a most favorable effect in acute 
and chronic urethral inflammations. Formerly it was 
largely employed in strong solutions (twenty to forty 
grains to the ounce) in the early stages, with the idea of 
aborting the disease. 
Quite recently an article appeared in the London Lancet 
describing a method which had been successfully em- 
ployed by a British surgeon in forty cases of acute ure- 
thritis. His method consists in completely removing the 
pus from the anterior urethra by means of a cotton swab, 
through an endoscopic tube, and then applying a ten per 
cent, solution of nitrate of silver over the entire mucous 
membrane anterior to the bulbo-membranous junction, 
an extra amount of the solution being used in the fossa 
navicularis. The patient is then instructed to remain in 
bed for two days, and employ at intervals a mild astrin- 
gent injection. The reaction which follows is often 
quite severe, but of short duration, and no further treat- 
ment is required. 
Experiments in this country with this method have 
failed to furnish results as favorable as those reported by 
this writer. 
Guiteras's method of employing this agent consists in 
administering every second day a single injection of a 
solution of nitrate of silver, beginning with a strength of 
one-half to one grain to the ounce of water, and increas- 
ing by one grain at each application until the strength of 
ten grains is reached. Before and after this application 
the anterior urethra is irrigated with a saturated solution 
Fig. 209. 
frequent irrigation with bichloride of mercury, recovery 
may be expected within two weeks. That this period 
may be considerably shortened by the early inauguration 
of treatment, by absolute rest, and by the avoidance of 
stimulants ; that it may be indefinitely prolonged by ir- 
regularity in treatment, by inordinate physical exertion, 
and by indulgence in alcoholic and venereal excesses. 2. 
That the retrojection of a hot solution of bichloride pos- 
sesses all the advantages of the former procedure, and in 
addition causes a more rapid subsidence of the inflam- 
matory symptoms, a greater feeling of comfort to the 
patient, and is attended with less annoyance and trouble. 
3. That in cases of acute non-specific urethritis the fa- 
vorable influence of each of these methods is strikingly 
apparent. 4. That in cases of chronic purulent ure- 
thritis no agent produces such rapid and permanent im- 
provement as irrigation, especially when combined with 
378 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Genito-U ri nary 
Surgery. 
(SUPPLEMENT.) 
The first effect of the treatment is to cause a slight in- 
crease in the pain and dysuria. This is later followed 
by a decided amelioration in all the distressing symp- 
toms. The relief in such cases is often strikingly satis- 
factory ; the most acute and painful seem often to yield 
most promptly. If the condition becomes subacute or 
chronic, great benefit often follows irrigation of the 
posterior urethra and bladder by means of the Ultz- 
mann deep urethral irrigating catheter (described under 
Chronic Prostatitis in the earlier edition of this work); 
the solutions found to be most serviceable in this con- 
dition being a saturated solution of boric acid, per- 
manganate of potassium (1 to 5,000), and nitrate of silver 
(from 1 to 2,000 to 1 to 10,000). 
Chronic Urethritis. 
Practically nothing can be added to the excellent de- 
scription of chronic urethritis which appeared in the 
earlier part of this work. In the treatment of this 
most obstinate condition, however, much has been 
learned which will be found to be of positive value. 
These advances have been largely in the line of local 
treatment. 
As perhaps the best method of calling attention to the 
advances in the therapeutics of chronic urethritis, and of 
noting the indications for each procedure, the following 
plan of treatment may be mentioned, which embraces 
the best of the old methods, together with any new sug- 
gestions which have been made during the past few 
years, and which have been found to be of real value. 
When a patient suffering from a chronic urethral dis- 
charge presents himself for treatment, the first step is to 
determine the location of the diseased area from which 
the secretion arises. This can be accomplished by an 
ocular inspection of the anterior portion of the canal by 
means of the endoscope, and by the careful employment 
of the two-glass urine test. 
The next step is to determine the presence or absence 
of four conditions which are known to prevent or retard 
the restoration of the mucous membrane to its normal 
condition of health. These conditions are stricture, the 
use of alcohol, sexual indulgence, and general ill-health 
from tuberculosis, syphilis, anaemia, malarial poisoning, 
etc. If stricture exists it should be removed by ure- 
throtomy or its untoward influence overcome by the use 
of sounds. The use of alcohol should be prohibited 
and all sources of sexual excitement removed. The gen- 
eral health, if impaired, should be restored by the use of 
rational hygienic and medicinal measures. After this 
has been accomplished local measures must be relied 
upon to effect a cure. 
If the inflammation is limited to the anterior urethra, 
injections of solutions of the mineral astringents may be 
employed. Of these, the best are the acetate, sulphate 
or sulpho-carbolate of zinc, permanganate of potassium, 
nitrate of silver, or bismuth suspended in glycerine and 
water. Of all agents used to cause a rapid cessation 
of a chronic, muco purulent discharge from the anterior 
urethra, none can be relied upon to act more happily 
than injections of the subnitrate of bismuth suspended 
in glycerine and water, in the proportion of one ounce 
of bismuth to four ounces of the fluid. This should be 
well shaken to insure a complete distribution of the 
bismuth throughout the fluid, and a syringeful slowly 
injected after each urination. The mixture should be 
held in the urethra at least sixty seconds, to allow a 
thorough precipitation of the powder upon the urethral 
walls. 
While the effect of this agent is not always in itself 
curative, by subduing any co-existing irritation of the 
canal it not infrequently happens that under its use the 
chronically inflamed surfaces take on a healthy, repara- 
tive action. The use of full-sized sounds to distend the 
canal once or twice a week, will often be found to be 
of great value, alone or combined with the local use of 
astringent agents. 
If no improvement follows the careful use of these 
measures, after a conscientious trial of from ten days to 
of boric acid. During the intervals between the injec- 
tions, which are administered by the surgeon, the patient 
employs an urethral wash of boric acid, or a mild solu- 
tion of zinc acetate. This method is at present being 
tested in a number of clinics, and with no small meas- 
ure of success. 
Posterior Urethritis. 
The importance of posterior urethritis as a complica- 
tion of the acute form of the disease has not until quite 
recently been fully appreciated. Under ordinary cir- 
cumstances, in an attack of acute urethritis, the inflam- 
matory process is limited to the pendulous urethra or 
that portion of the canal anterior to the compressor 
urethrae muscle. The reason of this is that the mem- 
branous urethra, being much less vascular and almost 
devoid of glands and follicles, offers an effective barrier 
to the backward progress of the inflammation. When, 
however, this barrier is passed, and the disease extends 
to that portion of the canal posterior to the compressor 
muscle, we have to do with a condition far more grave, 
not only from the fact that the discomfort to the patient 
is greatly increased by painful and distressing symp- 
toms, but also from the fact that a much larger extent 
of the mucous membrane is involved, and the liability 
of a still further extension to other important organs is 
rendered probable. 
Symptoms.-This complication may occur with practi- 
cally no subjective symptoms. Generally, however, the 
patient experiences a heavy feeling in the perineum, ac- 
companied by an increased frequency in urination and 
pain extending along the course of the urethra at the 
close of the act. In the severer cases, the calls to uri- 
nate may occur every few minutes, and be accompanied 
by marked dysuria and bladder tenesmus. There is also, 
generally, marked sexual hypersesthesia. Not infre- 
quently the last few drops of urine passed will contain 
blood. 
If the urine be examined by means of the two-glass 
urine test (described under Inflammation of the Bladder) 
the first portion will contain free pus and urethral 
shreds, the last free pus, and possibly a certain amount 
of blood, due to the violent contraction of the prostatic 
muscle. This condition is often mistaken for acute cys- 
titis. For the differential diagnosis of these conditions 
the reader is referred to the section on Diseases of the 
Bladder. 
Prognosis.-If the occurrence of this complication is 
recognized early, before the inflammation has had suffi- 
cient time to penetrate the glands and follicles of the 
prostate, and prompt measures are undertaken for its 
relief, the duration is often but a few days. If, how- 
ever, the case is neglected and allowed to become 
chronic, it presents serious difficulties, and is frequently 
most rebellious to treatment. The chief importance, 
however, lies in the fact that it renders the patient far 
more liable to an extension of the disease to the prostate, 
seminal vesicles, bladder, and testicles. It is highly 
probable that none of these complications ever occur 
without a previous posterior urethritis. The importance, 
therefore, of an early diagnosis and prompt treatment is 
patent. 
Treatment.-When the diagnosis of an acute posterior 
urethritis has been established, absolute rest in bed 
should be insisted upon, and an increased flow of urine 
brought about by the use of diuretics. The pain and 
frequency of urination should be controlled by opium or 
morphine suppositories. The local application of a solu- 
tion of nitrate of silver by means of the Keyes deep 
urethral syringe is perhaps the most useful procedure 
which can be employed in this condition. The strength 
of the solution should be at first not more than five 
grains to the ounce of distilled water. Of this, five or 
ten drops should be deposited in the deep urethra, after 
the manner described in the earlier edition of this work. 
Later, the strength should be gradually increased until 
that of fifteen or twenty grains to the ounce is reached. 
These applications should be made not oftener than once 
in three or four days. 
379 Genito-U rinary. 
Gonorrhoeal. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
two weeks, local application should be made upon the 
granular patches, superficial erosions, or areas of chronic 
inflammation by means of the endoscope and cotton ap- 
plicator. 
Of all the agents employed for topical application ni- 
trate of silver will be found to be the most useful. A 
strength of two and one-half grains to the ounce should 
be at first employed, and this gradually increased until 
a strength of twenty to thirty grains is reached. These 
applications should be made not oftener than once in 
every four or five days. It is often advisable to alter- 
nate this treatment with that by the passage of sounds. 
The duration of the treatment is exceedingly variable. 
When the disease is of comparatively recent origin, re- 
covery may be expected in two or three weeks. If, 
however, the process has been going on for months or 
years, the disease has in all probability penetrated the 
glands and follicles emptying into the urethra, each of 
which with its surrounding capillary net-wmrk acts as a 
miniature incubator for the development of micro-organ- 
isms of disease, and exudes at intervals minute drops of 
germ-laden pus which serve to reinfect the surrounding 
mucous membrane. 
When the disease has involved these glandular struct- 
ures of the urethra it can be eradicated only by the most 
persistent measures, and often treatment extending over 
a period of many months is necessary to effect a cure. If 
the disease is found to be located in the posterior urethra 
measures must be employed which insure thorough irri- 
gation of this portion of the canal and the application 
of astringent or antiseptic agents. This is best accom- 
plished by the use of the deep urethral irrigating catheter 
and syringe of Ultzmann. The catheter should be intro- 
duced as far as it will go, which insures the beak being 
just beyond the compressor urethre muscle. A syringe- 
ful of the fluid should be rapidly injected and allowed 
to remain for several minutes in the bladder. This 
should afterward be passed out by the expulsive efforts 
of the patient, which insures a double irrigation of the 
posterior urethra and the therapeutic effect of the sub- 
stances contained in the injected fluid. 
Of the agents employed in this manner may be men- 
tioned carbolic acid, 1 to 100, permanganate of potas- 
sium, 1 to 5,000 or 10,000, sulphate of zinc, 1 to 500, 
and nitrate of silver, 1 to 10,000 to 1 to 2,000. This treat- 
ment should be employed every day. 
The occasional local use of a stronger solution of ni- 
trate of silver, by means of the Ultzmann or Keyes deep 
urethral drop-syringe, is often of great value in connec- 
tion with the plan above described. Five or ten minims 
of a solution varying in strength from one to twenty grains 
to the ounce, may be employed once or twice a week. 
Dr. Keyes has also successfully employed with this 
instrument a somewhat larger amount (thirty to forty 
minims) of a solution of sulphate of copper, thallin, and 
other astringents. 
Sounds are often of the greatest service in the treat- 
ment of posterior urethritis. The same rule should gov- 
ern their employment as in the cases where the disease is 
confined to the anterior portion of the canal. It not in- 
freqently happens that the introduction of any instru- 
ment into the posterior urethra results in marked local 
inflammation and grave systemic disorders. In these 
cases the irrigation of the whole urethra and bladder 
should be accomplished from the meatus by means of 
the fountain syringe, in the manner described under the 
treatment of cystitis, the same solutions being employed 
as with the deep urethral irrigating catheter. These 
cases are often extremely persistent and annoying, and 
the treatment should be accompanied by the greatest 
amount of patience and care, special attention being paid 
to the removal of all the causes mentioned above as 
likely to retard the recovery. 
Vesiculitis. 
An inflammation of the seminal vesicles and their 
excretory ducts. This complication of urethritis, though 
an infrequent one, is often most annoying alike to the 
patient and the physician. The symptoms of the acute 
stage are throbbing pain in the perineum and rectum, in- 
creased by defecation, and a more or less persistent pria- 
pism with frequent seminal emissions, accompanied by 
excessive voluptuous sensation. The fluid ejaculated is 
brownish in color, and if examined microscopically is 
found to contain pus, blood, and dead spermatozoa. 
The symptoms of the chronic condition are chiefly those 
of a chronic posterior urethritis and sexual neurasthenia, 
with sterility. 
In the acute stage the seminal vesicles can often be felt 
through the rectum as elongated fusiform, elastic bodies, 
just above the prostate. These are hot and sensitive to 
the touch. If the patient be instructed to pass the urine 
in three glasses, and between the voiding of the first and 
second specimens the contents of the inflamed sacs be ex- 
pressed by the finger in the rectum, the second specimen 
will contain a larger amount of pus than the first or 
third, and also a number of dead spermatozoa. 
The admixture of any considerable amount of pus 
with the semen almost invariably results in a death of 
the spermatozoa, or, at least, a serious impairment of 
their impregnating ability. This condition is, therefore, 
most important in its relation to marriage. 
Treatment.-In the acute stage marked relief often fol- 
lows the application of leeches to the perineum and hot 
rectal enemata. The bromides, with digitalis and cam- 
phor, in large doses, are useful in subduing the sexual 
hyperesthesia. Absolute rest should be enforced, and ap- 
plications of nitrate of silver be made to the deep urethra. 
In chronic vesiculitis local measures are of little value, 
and dependence must be placed upon hygienic treat- 
ment, including sea-bathing, a change of climate, cod- 
liver oil, iron, and the scrupulous avoidance of stim- 
ulants and sexual excitement. 
George Emerson Brewer. 
GOERBERSDORF. This place is in Silesia, Germany, 
not far from the city of Breslau. It was here that Dr. 
Brehmer started, in 1854, his famous establishment for 
the treatment of consumption by mountain air, cold 
douches, diet, etc. Goerbersdorf is situated in a fairly 
well-sheltered valley, and has an elevation of seventeen 
hundred feet above sea-level. The climate is rather 
severe in winter, but the admirably arranged buildings 
permit exercise in pure air at all seasons. Apart from 
the institution of Brehmer, now in charge of Dr. Ach- 
termann, there are two other sanitaria for diseases of the 
lungs, neurasthenia, etc., one in charge of Dr. Romp- 
ler, the other managed by the Countess of Buckler. 
The good results obtained at Goerbersdorf are now gen- 
erally held to be due quite as much to the careful super- 
vision of every individual and the attention to minute 
details of treatment, as to the climatic advantages of this 
locality. Season, all the year round. 
Edmund C. Wendt. 
GOLD. The use of gold as a remedy in disease is of 
very ancient date, although of late years it has fallen 
into disuse. Very recently it has been revived, and the 
various salts are recommended in many forms of nervous 
disease. Formerly it was used almost solely in the treat- 
ment of scrofulous and syphilitic disease. The action of 
the salts of gold is similar to that of mercury, being even 
more powerful when administered freely ; salivation is 
produced, and prolonged use gives rise to " aurism," with 
sweating, increase of urine and saliva, and mental ex- 
citement, with delirium and intoxication. It is eliminated 
by the liver, intestines, and kidneys. It is still used 
occasionally for syphilitic troubles, and will often pro- 
duce a cure where mercury and the iodide of potassium 
have been used without any apparent benefit. It is said 
to prove most efficient in syphilitic ulceration of the 
throat, ozena, diseases of bones, and syphilitic phthisis. 
Its revival, however, is principally in the treatment of 
the various neuroses, hysteria, ovarian disease, sterility, 
impotence, hypochondria, etc. The beneficial effects of 
the use of the preparations of gold are most evident on the 
brain and nervous system, which is stimulated and ren- 
380 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Ge ni to-ITri nar y. 
Gonorrhoeal. 
dered more active, and, when the use is persisted in, the 
symptoms of this stimulation continue to increase until 
the toxic condition supervenes. The use of gold is indi- 
cated whenever there is depression of the central nervous 
system, and should be avoided when cerebral hyperaemia 
is present. 
Auri et sodii chlor idum, the official salt of the U. 
S. Pharmacopoeia, has shown itself of service in ner- 
vous dyspepsia, in doses of one-twentieth grain, three 
times a" day. Amenorrhoea from torpor of the ovaries, 
and chronic metritis with scanty menses, are often re- 
lieved. Bartholow has recommended it in sterility due to 
functional debility of the sexual organs. It has been 
used in the treatment of progressive general paralysis, in 
which affection it increases the patient's powers of re- 
sistance and retards the progress of the disease. It is 
given in doses of one-thirtieth grain, morning and even- 
ing. Every fortnight the dose is to be increased until 
one-sixth grain is reached. This amount is continued 
for another fortnight and then stopped for a month. 
This salt of gold was recently brought into prominence 
by its reported value as a means of treating pulmonary 
phthisis. Its use for this purpose was introduced by Dr. 
Heneage Gibbs who, with Dr. Shurley, had experimented 
upon animals and used it very extensively in their prac- 
tice, and found it to prove of decided value. Its use is 
combined with the inhalation of chlorine gas and the hy- 
podermic injections of iodine. The chlorine gas may be 
obtained from chlorinated lime by the addition of dilute 
hydrochloric acid, from one-half to six drachms of the 
former and from one to three drachms of the latter, in an 
open vessel in a closed room. Before the gas is produced 
the air should be impregnated with a spray of chloride of 
sodium, about two ounces in a compartment of five hun- 
dred and fifty cubic feet. The patient should only re- 
main in the room for ten minutes at first, but this may 
be increased to twenty or thirty minutes. It may be re- 
peated two, three, or four times a day. In laryngeal 
phthisis, or when it may prove more convenient, the gas 
may be evolved in an inhaler. The iodine and gold 
are introduced by means of an hypodermic syringe 
in the gluteal region. Iodine is used in one-twelfth grain 
doses daily, to begin with, and gradually increased until 
one-half to one grain is reached. The gold and sodium is 
then used, and hypodermics of one-thirtieth to one-twen- 
tieth grain daily are administered at first, the dose being 
gradually increased until one-fifth or one-third grain is 
reached. It is often necessary to discontinue one or the 
other, as " iodism " or "aurism" is threatened. They 
may also be used alternately. It is found that the com- 
bination of gold with the iodine allows a much larger 
amount of the latter drug to be administered without 
causing toxic symptoms. At first, loss of weight and 
increase of temperature and other signs of disturbance 
follow its use, but these soon disappear, and a marked 
improvement takes place. The authors of this remedy 
base their hopes of a successful treatment of this disease 
upon the view that consumption is not the same as gen- 
eral tuberculosis, and is not due to the generally recog- 
nized bacillus. They consider that phthisis pulmonalis 
is a local affection of the lungs of an inflammatory char- 
acter, the progress of which is accompanied by the pro- 
duction of chemical substances which possess a toxic 
action. The object of the treatment is to neutralize these 
poisonous substances, allay the inflammatory process, 
and restore the vital powers. Chlorine, iodine, gold, 
iodoform, liq. potass®, potassic permanganate, iron ar- 
seniate, the mercurial salts, were all found to possess 
these valuable properties, but the first three were se- 
lected as being the most efficacious and least disturbing 
to the system. * 
Auri chloridum occurs in long orange crystals. It is 
very hygroscopic and readily soluble in water, alcohol, 
and ether. It is a powerful caustic and enters into the 
composition of many cancer-pastes. As a caustic for 
epithelioma, one-sixth to one-quarter grain in powder 
may be rubbed into the affected part or applied in solu- 
tion. A case of lupus is reported as having been success- 
fully treated with the hypodermic use of chloride of gold 
(SUPPLEMENT.) 
and cyanide of potassium, a solution of the strength of 
one per cent, of each being employed. Nearly the whole 
face and forehead were involved, and tubercle bacilli were 
found to be present. Six injections were given in the 
course of eleven days, the dose varying from one-thou- 
sandth to one-hundredth grain. On the second day the 
symptoms showed signs of improvement ; on the third 
day the swelling of the face subsided, some old sears 
began to shed cuticle, and a labial ulcer decidedly de- 
creased ; by the twelfth day several ulcers were soundly 
healed, and the remaining ones were clear and covered 
with healthy granulations. On the fourth day of treat- 
ment a mild intoxication, drowsiness, and a slight rise 
of temperature were noticed, but they rapidly disap- 
peared. 
Auri Bromidum.-This combination has been utilized 
to secure the combined effects of gold and bromine on 
the central nervous system. It is a dark brown, non- 
deliquescent powder, soluble in water and ether ; dose, 
one-fortieth to one-hundredth grain, to be increased to 
one-fifth grain, well diluted. The solution should not be 
exposed to light. It has been used in hysteria, epilepsy, 
migraine, and the various affections of the nervous sys- 
tem in which the action of these drugs is indicated. In 
epilepsy it has acted very satisfactorily : the action of the 
drug was rapidly manifested, the fits becoming reduced 
in force and number, and in some cases they were com- 
pletely checked. The introduction of this remedy caused 
Dr. Shtcherbok to undertake a series of experiments with 
the cerebral cortex exposed, to ascertain the action of the 
drug, its effect as compared with other bromides, and in 
what quantities it should be given. The drug was admin- 
istered by intravenous injection, by hypodermic injec- 
tion, and through an oesophageal tube into the stomach. 
It was found that artificially induced epilepsy could be 
averted by the intravenous injection of one-twelfth grain 
for each thirty-two ounces of body weight. Larger doses 
were required when used by hypodermic injection, and 
by the stomach one and one-half to three grains were 
needed. No cumulative action was detected. The drug 
seemed to affect mainly the tracts of communication be- 
tween individual motor-cells, as well as those between 
remote areas of the cerebral cortex. Bromide of gold 
appeared more active than the commonly used bromides 
in the proportion of ten to one. 
Other compounds, as the cyanide, iodide, oxide, etc., 
have also been tried for the treatment of syphilis, but 
with uncertain results. Beaumont Small. 
GONORRHCEAL RHEUMATISM. Since the publica- 
tion of the Reference Handbook many investigations 
and observations have been made to determine more ac- 
curately the pathology of this affection. The results 
have not been very decisive, except, perhaps, to settle 
more firmly the dependence of some of the cases upon 
the gonococcus. A number of investigators have found 
the micro-organisms not only in the urethra but in the 
joints as well, whither they had been carried by means 
of the lymphatics, the blood circulation, and possibly 
the white corpuscles. There is still reason to believe that 
some of the cases partake more of the character of ordi- 
nary septicaemia, although differing from it in certain 
particulars ; while some are still, on any theory so far 
advanced, inexplicable. 
In the management of this affection it has been proven 
more conclusively that it is necessary to remove all points 
of irritation in the urinary mucous membrane, even to 
the relief of stricture, that may have caused the affection, 
as a first step to its cure. Iodide of potassium as an 
internal remedy is still popular, as well as mercurials in 
moderation. Some advocate the latter in quantities suf- 
ficient to produce their constitutional effect promptly, at 
the beginning of the attack. 
Counter-irritation over the inflamed joints by blisters 
and the actual cautery are becoming more popular, as 
are also stimulating embrocations, and heat. 
In the original article on this subject, the violent 
breaking of old, false anchyloses, long after their for- 
mation, was commended as rational. Less has been done 
381 Gonorrhoeal. 
Gout. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
iii this line than was to have been expected. The meas- 
ure deserves to be more often employed. On rational 
grounds it has much to commend it ; the anchylosis is due 
to fibrous deposits ; at most, rupture of this material 
should result in producing some debris of soft substance 
that is readily absorbed, and after it possibly a slightly 
roughened surface ; and roughened joint surfaces after 
the disappearance of causative pathological processes, 
and with good nutrition, tend to disappear. Sepsis is, 
of course, impossible, except with a very low condition 
of vitality of the patient. Dr. B. E. Brodhurst declares 
that he has operated on a large number of cases of fibrous 
anchylosis in this manner without a single accident, such 
as fracture, dislocation, or inflammation. He forcibly 
breaks up the adhesions under chloroform. If contract- 
ures of muscle have occurred, he cuts the tendons before 
forcing the adhesions, and if the contracture is extreme, 
he waits for the skin punctures to heal before doing the 
joint operation. After the operation, passive motion 
must be resorted to to keep what has been gained. 
Norman Bridge. 
GOUT. In attempting to compile, in the form of a 
supplement, such facts and suggestions of importance 
concerning gout as have been developed by clinical and 
experimental investigators since the publication of the 
third volume of the Reference Handbook, containing 
the excellent article by Dr. Mendelson, I find nothing 
necessary to add regarding the history, varieties, and 
symptomatology of the disease. The additional materi- 
als relate almost wholly to its etiology, pathology, and 
therapeutics. To show more clearly the true relations 
and practical bearing of such new materials I have felt 
the necessity of repeating or restating many items that 
are to be found in the original article by Dr. Mendelson, 
instead of making frequent references to the same, which 
would be less convenient for the reader as well as for 
myself. Such restatements are chiefly in the beginning, 
and seemed desirable as an introduction to the mere facts 
that follow. The causes of gout, as of most other dis- 
eases, are conveniently divisible into predisposing and 
exciting causes. The first include all such influences as 
either aid in developing the direct exciting cause or in 
lessening the power of the system to resist the action of 
such cause. The second embraces only such agents or in- 
fluences as are capable of directly exciting the active symp- 
toms of the disease. The more important of the pre- 
disposing influences are : heredity ; alcohol, especially as 
existing in fermented liquors, such as beers and wines ; ex- 
cess of food, especially of the nitrogenous class ; deficient 
physical exercise ; deficient ventilation ; excessive mental 
exertion and depressing emotions, such as grief and anx- 
iety ; and lead. A careful study of the modus operandi of 
these various causes will render it apparent that heredity 
and continued severe mental activity produce their pre- 
disposing influence by increasing the susceptibility and 
lessening the vital resistance of the living tissues ; while 
all the others act chiefly in the direction of lessening the 
internal respiration, or, in other words, the distribution 
of oxygen from the pulmonary to the systemic capillaries, 
and thereby interfering with the metabolic processes on 
which the formation of natural excretory products de- 
pends. That depressing mental emotions, deficient exer- 
cise, and poorly ventilated and overcrowded dwellings 
lessen the fulness and activity of respiration, and in the 
same ratio diminish the internal distribution of oxygen, 
has long been well known. That alcohol, by its action on 
the haemoglobin and albuminous elements of the blood, 
still more directly diminishes the internal distribution of 
oxygen and thereby lessens the natural metabolic process- 
es, has been abundantly demonstrated. It is not, how- 
ever, diminished distribution of oxygen alone that favors 
the development of gout, but it is the co-existence of an 
abundant supply of oxidizable or fermentable material in 
the blood, such as is derived from overeating or the 
drinking of such fermented drinks as contain sugar, free 
acids, and other fermentable materials. Therefore it may 
be correctly stated that it is neither deficiency of oxygen 
alone, nor excess of either alcohol or fermentable material 
(SUPPLEMENT.) 
alone, but the co-existence of all three, that most directly 
favors the formation in the blood and tissues of an excess 
of uric acid and urates, and consequently most actively 
predisposes to attacks of gout. 
The direct exciting cause of gout is very generally con- 
ceded to be the presence in the blood or tissues of an ex- 
cess of uric acid, generally in combination with sodium 
in the form of bi-urate. Since the valuable paper of Dr. 
Garrod in 1848, much additional knowledge has been 
gained through the investigations of J. Mortimer Gran- 
ville, W. Ebstein, A. Haig, Sir William Roberts, Cam- 
merer, and others. As the uric acid in the form of urates 
of sodium and potassium constitutes a natural constituent 
of the fluids of the body, it is of great practical impor- 
tance to know by what processes it is developed, through 
what channels it disappears, and the conditions under 
which it accumulates in abnormal quantities in the sys- 
tem. Uncombined uric acid (CTNHLOs) is a crystalline 
substance, extremely insoluble, and derived from nitro- 
genous metabolism. Whether its evolution and com- 
bination with sodium and potassium takes place at some 
stage of the digestive and assimilative processes, or in 
some part of the retrograde tissue changes, cannot be re- 
garded as definitely determined. Dr. Garrod, and per- 
haps a majority of writers on the subject since his orig- 
inal essay, have regarded the uric acid as only one stage 
of the processes by which nitrogenous tissues are resolved 
into urea for elimination. The uric acid being less oxi- 
dized and much less soluble than the urea, its accumula- 
tion was regarded as the result of incomplete oxidation 
of the products of tissue metabolism ; a view strongly 
supported by the fact that very many of the conditions 
and circumstances that are known to retard the internal 
respiration or distribution of oxygen to the tissues are 
accompanied by an increase of the uric acid or urates. 
J. Mortimer Granville, however, claims that the uric 
acid is formed chiefly in the liver, from imperfect duo- 
denal digestion. Regarding more particularly the clini- 
cal phenomena preceding and accompanying attacks of 
gout, he sees evidence of inactivity of the liver by which 
less bile passes into the duodenum to co-operate with the 
pancreatic fluid in saponifying the food-elements. In 
consequence of this defect the food-elements are taken 
up in only an emulsified condition and carried by the 
portal vessels to the liver, which so alters its glycogenic 
and other functions as to lead either to the "excessive 
formation of uric acid or to the arrest of the subsequent 
processes by which the acid should be converted or de- 
stroyed." On the other hand, W. Ebstein, of Gottingen, 
in his valuable treatise on the nature and treatment of 
gout, claims that the production of the greater part of 
the uric acid found in the living system takes place in 
the muscular structures, and to some extent in the marrow 
of the bones. In support of this claim he refers to the 
fact that such kindred bodies as kreatin, sarkin, and 
xanthin were found in muscular structures; to the de- 
posits of uric acid in birds and reptiles, and to the guanine 
gout in pigs ; and he might have added the presence of 
uric acid in cases of splenic leucocytlnvmia. That the 
production of uric acid in the system is increased by 
nitrogenous food, by such disorders of digestion as are 
accompanied by acid fermentation, and by whatever 
lessens the distribution of oxygen from the pulmonary to 
the systemic capillaries, has been well shown by the re- 
cent investigations of Dr. A. Haig, Lehmann, Sir William 
Roberts, and others ; which renders it certain that it is 
derived from either nitrogenous food-elements or from 
the nitrogenous tissues, or more probably from both. 
And a careful review of all the facts within our reach 
leads to the conclusion that the uric acid is not exclu- 
sively the precursor of urea, but an independent product 
of nitrogenous metabolism undergoing elimination largely 
in the form of soluble urates, but in a lesser degree also 
as urea. The natural or physiological condition of uric 
acid in the body is that of a quadri-urate (Roberts), and 
not in a free or uncombined state. So long as it remains 
in the form of quadri-urate it is freely soluble in the 
blood-serum, synovia, and tissue fluids, and undergoes 
ready elimination through the kidneys, and consequently 
382 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Gonorrhoeal. 
Gout. 
it causes no disturbance or symptoms of disease. Con- 
cerning the history of uric acid in the living body, both 
in the normal and in the gouty state, Sir William Roberts, 
in his third Cro'onian lecture recently delivered before 
the Royal College of Physicians of London, says : " It 
has been shown that in normal urine uric acid always 
exists as a quadri-urate ; and that in animals which eli- 
minate their nitrogen as uric acid, like birds and serpents, 
the urinary secretion is composed entirely of the same 
combination. Proof has also been furnished that in 
liquids containing alkaline carbonates-such as the serum 
of the blood and its derivatives, lymph and synovia- 
uric acid passes into solution in the first instance as a 
quadri-urate. From these considerations it may be in- 
ferred that in the normal state uric acid is primarily taken 
up in the system as as quadri-urate, that it circulates in 
the blood as a quadri-urate, and that it is finally voided 
with the urine as a quadri-urate. In perfect health the 
elimination of the quadri-urate proceeds with sufficient 
speed and completeness to prevent any undue detention 
or any accumulation of it in the blood. But in the gouty 
state this tranquil process is interrupted, either from de- 
ficient action of the kidneys or from excessive intro- 
duction of urates into the circulation, or from some other 
cause, and the quadri-urate lingers unduly in the blood 
and accumulates therein. The detained quadri-urate, 
circulating in a medium which is rich in sodium car- 
bonate, gradually takes up an additional atom of base and 
is thereby transformed into bi-urate. This transformation 
alters the physiological problem. The uric acid, or rather 
a portion of it, no longer circulates as the more soluble 
and presumably easily secreted quadri-urate, but as bi- 
urate, which is less soluble, and probably also less easy 
of removal by the kidneys."-{The Lancet, July 9, 1892.) 
Pathology and Pathological Anatomy.-Assuming the 
correctness of the claim that sodium bi-urate constitutes 
the direct cause or disturbing element on which the vari- 
ous symptoms and forms of gout depend, w'hat are the 
pathological processes and changes induced by its pres- 
ence in the fluids of the body ? It has been shown, both 
by experimental research and clinical observation, that 
the soluble quadri-urate naturally existing in the blood- 
serum and tissue fluids is readily changed into a less 
soluble bi-urate by failure of the kidneys to eliminate it, 
or by whatever will lessen the alkalinity of the blood- 
serum (Roberts), and by such food and drinks as either 
contain an excess of acid material, or give rise to acid 
fermentation in the digestive organs (A. Haig), thereby 
favoring the precipitation of such less soluble bi-urate in 
the tissues which are most favorable for its accumula- 
tion. That such precipitation does take place in all the 
more active forms of gout is readily demonstrable by 
both chemical and microscopic detection of its presence 
in the synovial and tissue fluids of the articulations af- 
fected, in addition to the well-known fact that it is the 
chief constituent of the tophi or gouty concretions found 
in the more chronic cases. According to Sir William 
Roberts, the precipitated bi-urate is always found in 
crystalline form, and is "distributed through the im- 
plicated tissue in the form of delicate needles aggregated 
in tufts, bundles, and stars." And he adds: "The ar- 
thritic incidents of gout may be said, not improperly, to 
be simply incidents pertaining to the precipitation of 
these crystals in the structures of the joints. Without 
the occurrence of this precipitation the gouty paroxysm 
could not take place, nor could the more chronic changes 
in the joints, with their train of attendant symptoms, 
follow after." From this we must infer that the offend- 
ing bi-urate produces its effects by a primary irritating 
action, either upon the nervous structures or the fibrous 
tissues, or by mechanically obstructing the capillary ves- 
sels ; or, perhaps, by all these modes simultaneously. 
When the quantity of bi-urate present is small and 
the precipitation slight, the chief symptoms are those 
of a neuralgic and erratic character without local tume- 
faction or febrile disturbance. If, however, its forma- 
tion takes place more rapidly and it accumulates in 
greater excess, the precipitated crystals appear to pene- 
trate all the tissues of the part involved, and to cause 
rapid tumefaction, intense pain, and general fever. In 
other words, it excites a true inflammation of all the 
structures permeated by its crystals. And if they are 
not subsequently redissolved, they become permanent 
obstructions inducing all the phenomena and changes in- 
cident to chronic gout. While the majority of investi- 
gators, including Garrod, Granville, Haig, and Roberts, 
regard the inflammation and other gouty symptoms as 
the result of the urate precipitation in the part, Dr. W. 
Ebstein claims to have traced, by numerous experiments 
and dissections, evidences of the direct irritative action of 
the sodium urate, both in the kidneys and other internal 
organs, and in the articular cartilages, fibrous structures, 
and the connective tissue between the muscles, thereby 
claiming to have proved the diffused primary action of 
the irritant conveyed in the blood before actual crystalline 
precipitation occurred. Consequently he regards the 
first stage of the disease as " an inflammatory process, set 
up by the uric acid, leading to foci of necrosis, and then 
deposits of urates in the cavities thus formed." He fur- 
ther endeavors to show that inflammatory necrosis in any 
tissue causes an acid reaction in the part, which acidity 
in turn determines the precipitation of urates in the 
necrotic foci. 
The order of development of the pathological processes 
described by Ebstein necessitates a distinct stage of in- 
flammation, or at least tissue poisoning, with its accom- 
panying tumefaction and pain, before the precipitation of 
urates can take place, while careful and multiplied clin- 
ical observations seem to demonstrate the presence of the 
precipitated urate coincidently with the first manifestation 
of local symptoms. It appears, therefore, more correct 
to regard the necrotic foci described by him as resulting 
from the obstruction and irritation of the crystalline pre- 
cipitate, instead of the latter resulting from the former. 
The more remote and full development of tissue changes 
induced by repeated attacks of gout are well set forth in 
the following account of a post-mortem examination by 
Hudelo, presented to the Anatomical Society of Paris 
{Annual of Universal Medical Sciences, vol. i., 1889), the 
subject having died from gout in the Hopital de la Pitie, 
in the service of Troisier: "In the upper extremities 
tophi existed in the right hand at the base of the meta- 
carpo-phalangic articulations of the index, medius, and 
ring fingers, and also at the base of the articulations of 
the second and third phalanges of the index and medius, 
and at the base of the thenar eminence. An incision 
through .the integument near the thenar eminence ex- 
posed a soft, pulpy substance infiltrating between the 
muscles, and at the level of the fingers it filled the sheaths 
of the tendons without communicating with the articula- 
tions. By extending the incisions the uratic infiltration 
was found in the tendon sheaths of the palm of the hand. 
The articular cartilages of the phalanges and the meta- 
carpal phalanges were covered with a whitish layer of 
urates. The periarticular bony contour was uneven, 
ragged, and in places presented osteophytic projections. 
The lesions were greatest at the base of "the radio-carpal 
articulation. At the right elbow a subcutaneous tophus 
of the size of a hen's egg filled the olecranon pocket. 
The elbow-joint was filled with a mixture of synovia and 
urates. The hand, wrist, and elbow of the left extremity 
presented pathological and anatomical changes very simi- 
lar to those described in the right. In the lower extrem- 
ities the phalangic, metatarso-phalangic articulations of 
the tarsus and metatarsus of both feet were affected in 
the same manner as the corresponding parts of the upper 
extremities, the uratic infiltrations being most prominent 
in the articulations of the great toe. Both knee-joints 
were filled with the uratic deposit; the articular surfaces 
of both tibia and femur were diseased, their contour 
rough and irregular, with large osteophytes attached 
to the femurs. The surfaces of the patellas were also 
rough with osteophytic projections. The organs in the 
cranium and thorax were natural except the heart, which 
was large, its walls pale and thin, with dilated cavities, 
but without valvular deposits. Of the viscera of the ab- 
domen, the liver was harder and more granular than 
natural, the pancreas contained a whitish substance re- 
383 Gout. 
Gout. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
sembling the uratic infiltration, but not crystalline, and the 
kidneys were enveloped in an excess of fatty tissue, notably 
diminished in volume, the capsules easily removed, leav- 
ing the surface uneven, but with no appearance of cysts. 
Incisions showed marked atrophy of the parenchyma in- 
closing some fatty tissue. In the centre of the papilla 
was a series of whitish layers parallel to the collected 
tubes of the pyramids, but not extending more than six 
or seven millimetres into the parenchyma." It is thus seen 
that while the characteristic deposits and structural 
changes are most abundant in the less vascular structures 
entering into the articulations of the extremities, they 
may be found in less degree in nearly all the tissues and 
organs of the body. The deposits are always in the crys- 
talline form, and composed almost exclusively of sodium 
bi-urate. Of the internal viscera, the kidneys suffer 
most, particularly from chronic interstitial nephritis char- 
acterized by the existence of an increased amount of in- 
terstitial connective tissue, with a corresponding atrophy 
of the secreting cells, thereby rendering the organs 
progressively less efficient in the performance of their 
natural function. 
The changes in the fluids of the body during the ex- 
istence of gout, are most noticeable in the blood, synovia, 
and urine ; and chiefly consist of an increase of uric acid 
in the form of sodium bi-urate, instead of the natural so- 
dium quadri-urate, as more recently determined by Sir 
William Roberts. Dr. Garrod has shown that an appre- 
ciable quantity of uric acid is pretty uniformly present 
in the blood-serum of chronic cases of gout. And Cam- 
merer (see Deutsch. Medicin. Wochenschrift, March 5,12, 
1891) states that while the amount of uric acid in healthy 
blood is only 2.8 to 100 of urea, in those affected with 
gout it averages 3.1 to 100 of urea. M. Molliere, in a 
communication to the Lyons Medical Society in 1888, 
not only recognizes the increase of uric acid or urates 
in the blood in gout, but claims that it is antagonistic to 
both pyogenic micro-organisms and the bacillus tubercu- 
losis ; and alleges this as the reason why the gouty are so 
generally exempt from tuberculous disease. In most 
cases the haemoglobin and red corpuscles are diminished. 
The synovia in affected articulations is often found 
turbid from the presence of urates. 
The quantity of uric acid excreted in the healthy urine, 
in twenty-four hours, is about 0.5 gramme (grs. viij.), 
the greater part in combination with sodium. It has been 
shown by many investigators that for a day or two pre- 
ceding, and at the commencement of, acute attacks of 
gout the urine is less acid and contains less urates than in 
health, but subsequently they appear in excess, especially 
at the crisis of the disease. Dr. A. Haig suggests that 
the diminished excretion of the urates at the commence- 
ment of acute attacks is owing to the fact that they are 
then being stored or precipitated in the tissues. 
Such diminished excretion, extending even to a few 
days prior to the attack, may be further explained if we 
regard the views of Sir William Roberts as correct, when 
he states that the uric acid in healthy urine exists and is 
excreted in the form of soluble sodium quadri-urate, 
while in gout it has been changed to an insoluble bi-urate, 
and instead of continuing to be excreted, it is first retained 
and then precipitated in the tissues, and can only reap- 
pear abundantly in the urine after resolution, during the 
middle and advanced stages of the disease. To further 
emphasize this order of development, the same active in- 
vestigator has designated the preliminary stage, while the 
quadri-urate is being changed into bi-urate in the blood- 
serum, synovia, etc., as the condition of lithamia, and 
the succeeding precipitation into the tissues as teratosis. 
Emil Pfeiffer, in a communication to the Seventh 
Congress of German Physicians, at Wiesbaden, 1888, 
claimed to have demonstrated that the uric acid in the 
urine of those affected with gout, even in the more 
chronic and latent conditions, could be separated in 
larger quantity by a certain process, while urine from 
non-gouty subjects did not yield any such increase: 
which, if true, would afford a valuable means of diag- 
nosis, especially in the more obscure cases. His method 
consisted in obtaining all the urine passed in twenty-four 
(SUPPLEMENT.) 
hours, filtering it through paper and dividing it into two 
parts. One of the parts was again passed through a 
filter on which had been placed some chemically pure 
uric acid. The other part was not so treated. One 
hundred cubic centimetres from each of these parts 
were taken into separate vessels and acidulated with 
strong hydrochloric acid, and allowed to rest until 
the precipitated uric acid had completely separated. 
Then both precipitates were collected on previously 
weighed filters, washed with distilled water, dried, and 
weighed. If the urine had been passed by a person not 
affected with gout or urolitheemia, the two filters con- 
taining the dried products would show the same amount 
of uric acid ; but if passed by a person affected by any 
stage of gout, the specimen that had been treated with 
the pure uric acid would show a notable increase of 
the dried product. Sir William Roberts subsequently 
repeated the experiments of Pfeiffer, and came to the 
conclusion that the test proposed was entirely unre- 
liable. To this Pfeiffer has replied that the experi- 
ments of Roberts having been made with the urine of 
healthy persons, the results were not applicable, as the 
sole basis of his test was on the greater readiness of 
the urine of persons subject to gout to part with its uric 
acid. And as proof of such greater readiness of separa- 
tion he alleges that, while from one hundred cubic centi- 
metres of the urine of healthy persons the uric acid is 
only extracted by 2.0 or 3.0 grammes (30 to 40 grains) 
of uric acid, from the urine of gouty persons it is with- 
drawn by 0.2 or 0.5 gramme (3 to 8 grains). In this 
connection it is proper to state that Dr. C. J. Rademacher 
(see American Practitioner and Neus, Louisville, Ky., 
June 21, 1890) claims to have discovered a new acid in 
the urine of persons suffering from an attack of gout, 
which is precipitated almost immediately after having 
been voided, and which he regards as the direct exciting 
cause of the disease. He says, " this acid is only found 
in the urine during an attack of gout, and always in a 
free or uncombined state, while the uric acid remains in 
the urine as a urate and in solution." 
His method of obtaining his new substance in separate 
form is as follows : " The precipitate in the urine was 
collected in a filter and washed with distilled water. It 
was then transferred to a beaker and neutralized with a 
dilute solution of caustic soda, and filtered through ani- 
mal charcoal. The filtrate was treated with pure dilute 
hydrochloric acid, the precipitated acid again washed 
with distilled water, redissolved in a solution of caustic 
soda, and again precipitated with pure dilute hydro- 
chloric acid, washed and dried. This acid, prepared by 
the above process, is a white crystalline powder but spar- 
ingly soluble in water. Its aqueous solution has a de- 
cided acid reaction to litmus (which uric acid has not); 
its formula, from ultimate analysis, is C6HBO4N4, its 
molecular weight 200, and it contains 28.28 per cent, of 
nitrogen." The value or correctness of the claim by 
Dr. Rademacher remains to be tested by further investi- 
gation. 
Dr. Edward Grim, in The Lancet, London, January 
23, 1892, makes the statement that " in three consecu- 
tive cases of acute gout he found the blood to be swarm- 
ing with a long encapsuled bacillus, side by side with 
which numerous crystals of bi-urate of soda are to be 
seen," and promises more information in a future com- 
munication. 
Treatment.-If the views presented in the preceding 
pages concerning the etiology and pathology of gout are 
correct, the objects to be accomplished by its treatment 
are easily inferred and capable of being clearly stated in 
few words. 
The first object is to prevent the accumulation or reten- 
tion of an excess of the normal sodium quadri-urate in 
the blood or tissue fluids long enough to favor its con- 
version into the less soluble sodium bi-urate, and thereby 
prevent the formation of the essential cause of the dis- 
ease. The second object is to render the sodium bi-urate 
already formed in the blood and tissues more soluble 
and, consequently, more easy of elimination. The first 
object is essentially prophylactic or preventive, and the 
384 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Gout. 
Gout, 
(SUPPLEMENT.) 
and clinical investigations, that it is not necessary to ad- 
duce the proofs here. 
Neither is it important to enter upon the inquiry 
whether one kind of alcoholic drink is more injurious 
than another. All admit that the use of beers and wines 
is practically more efficient in producing and perpetu- 
ating gout than the use of distilled spirits, and for two 
obvious reasons: First, those who use chiefly the fer- 
mented drinks, use them more uniformly from day to 
day, and in much greater bulk; second, they take with 
them a greater amount of acids, sugar, and imperfectly 
fermented materials that directly encourage gastric, he- 
patic, and renal disorders. It is true, as so fully stated 
by Dr. A. Haig and others, that the use of food or drink 
containing free acids, sugar, and other readily ferment- 
able materials, even without any alcohol, by persons al- 
ready possessed of a strong gouty diathesis, either he- 
reditary or acquired, may be sufficient to provoke a more 
acute attack. But, as already stated under the head of 
^Etiology, there is no proof that the use of any kind or 
amount of free acids, saccharine matter, or nitrogenous 
food will produce an acute attack of gout de novo, or 
develop the characteristic gouty diathesis without the co- 
incident use of alcohol in some form. It is proper to 
insist, therefore, that entire abstinence from alcoholic 
drinks is necessary, both for effectually preventing the 
primary development of gout and for overcoming the 
diathesis when previously established. The medical 
treatment of gout in all its aspects should be directed for 
the accomplishment of three objects : first, to render the 
retained sodium urates more soluble; second, to hasten 
their elimination ; and, third, to lessen the patient's pain 
and suffering while the two preceding objects are being 
accomplished. 
For many years past there has existed a very general, 
belief that certain natural saline or mineral waters, used' 
freely for both drinking and bathing, ■were among the 
most efficient remedies for promoting the solubility of 
the urates concerned in the production of gout. Conse- 
quently several natural springs, both in this country and 
Europe, have become popular places of resort for the 
gouty invalid, and saline waters, artificial as well as nat- 
ural, have been much prescribed by members of the pro- 
fession. 
Some, however, who have had ample opportunities for 
observation, deny their efficiency entirely, and attribute 
the improvements that patients frequently experience 
while attending at some of the most noted places of re- 
sort, to the change of air, diet, exercise, and rest from 
their usual occupations. Sir Mortimer Granville insists 
that the use of the same quantity of pure water is more ef- 
ficacious as a solvent of urates than any water containing 
the salts of sodium, potassium, magnesia, or lithium. 
The correctness of his position is fully demonstrated by 
the results of an extensive series of experiments illustrat- 
ing the chemistry and therapeutics of uric acid gravel 
and gout, by Sir William Roberts, as stated in his third 
Croonian lecture before the Royal College of Physicians 
of London. 1892, to which reference has previously been 
made. It is shown in the lecture that distilled water at 
the temperature of 100° F. will hold in solution 1 part 
of sodium bi-urate to 1,000 of the water, while water at 
the same temperature, holding in solution 0.50 percent, of 
sodium chloride, and 0.20 per cent, of sodium bicarbonate 
-being about the same proportion naturally existing in 
blood-serum and synovia-would hold in solution less 
than 1 part of sodium bi-urate to 10,000 parts of the water. 
The experiments were so varied as to clearly demonstrate 
the fact that, the more salts having for their base sodium, 
potassium, magnesium, or lithium were contained in water 
at a given temperature, the less sodium bi-urate would be 
dissolved or retained in solution. And the result was the 
same whether the saline solutions yielded an acid or alka- 
line reaction with litmus. Similar experiments per- 
formed with the natural blood-serum and synovia led to 
exactly the same results. The important practical infer- 
ence is, that the same liberal use of pure water, both 
for drinking asd bathing, as is now made of the most 
popular mineral waters, would be productive of much 
means for its accomplishment are almost exclusively 
hygienic in their character ; while the second is directly 
curative or to relieve existing attacks, and the means for 
its accomplishment include the administration of such 
remedial agents as will increase the solubility of the bi- 
urate and facilitate its elimination through the natural 
channels, and such as may lessen its irritative action on 
the nervous and fibrous structures of the body. Few 
things within the domain of both clinical and social ob- 
servation are better established than the fact that individ- 
uals and whole communities who have been trained from 
childhood to a fair amount of out-door muscular exer- 
cise, to the use of a fair variety of vegetable and animal 
food, and to total abstinence from alcoholic drinks, both 
fermented and distilled, are absolutely exempt from at- 
tacks of any form of gout. The only apparent excep- 
tions to this rule are found in such individuals as have 
inherited a very strong predisposition from their parents. 
Such individuals, though habitually living within the 
hygienic conditions just stated, may be found to suffer 
occasionally with some form of neuralgic gout, but the 
number is very small. 
The facts presented by Dr. A. Haig in his inaugural 
thesis, as well as those presented by many other writers, 
seem to show conclusively that a diet largely of animal 
food is accompanied by the excretion in the urine of less 
uric acid and urea than a diet chiefly of vegetables. Con- 
sequently the former is supposed to encourage the reten- 
tion and storage in the tissues of the sodium urates, 
while the latter promotes their elimination, and has been 
generally regarded as more efficient in preventing their 
retention in such quantity as to endanger an attack of 
the disease. A careful study of such results of investi- 
gations and clinical observations as are on record seems to 
show that it is not profitable to attempt to adopt an arbi- 
trary rule regarding the quantity, or quality of food, at 
least so far as it relates to its nitrogenous or non-nitro- 
genous character. 
The most important requisite is that the food shall be 
such as the individual eating it can most perfectly digest 
and assimilate without being accompanied with gaseous 
or acid fermentations, and yet will contain all the ele- 
ments necessary for the repair of the solids and fluids of 
the body. That a mixed diet, composed of a reasonable 
proportion of meats, vegetables, and fruits, and taken 
not more frequently than three times in twenty-four 
hours, is that best adapted to promote the health and 
longevity of the human race, admits of little or no doubt. 
The relative proportion of the three kinds of food, and 
the gross quantity to be taken, must be adjusted to the 
needs and capacities of each individual. And even when 
the food is thus adjusted, still another condition is neces' 
sary for its assimilation and normal uses in the living 
system, namely, the reception of the proper quantity of 
pure air, and the active distribution of its oxygen from 
the pulmonary to the systemic capillaries. Without 
this neither the metabolic processes concerned in diges- 
tion and nutrition, nor those of tissue metamorphosis 
and excretion, can be maintained in a strictly natural 
condition. 
Consequently, constant access to fresh air and daily 
muscular exercise, not merely of the back and lower ex- 
tremities, as in walking, but also of the chest and arms, 
by which fulness of respiration and freedom of pul- 
monary circulation are secured, are among the most effi- 
cient means for rendering the internal oxidation pro- 
cesses concerned in retrograde tissue metamorphosis 
complete, and thereby preventing the accumulation of 
an excess of sodium urates in the blood or tissues. 
In addition to the proper regulation of the food, air, 
and exercise, still another hygienic condition is necessary 
to render the development of gout practically impossible, 
namely, the total abstinence,from alcoholic drinks. The 
fact that the presence of alcohol in the blood so modifies 
the haemoglobin as to diminish its internal distribution of 
oxygen and retard tissue metabolism, and so modifies the 
secreting functions of both liver and kidneys as to strong- 
ly favor the formation and retention of sodium urates in 
the system, is so fully established, both by experimental 
385 Gout. 
Guaiacol. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
greater benefit, especially to all invalids of the gouty 
class. 
For the speedy relief of paroxysms of acute gout col- 
chicum has long sustained a high reputation. It should 
be given in as large doses as the stomach and bowels will 
tolerate, and repeated at intervals of from one to three 
hours until the pain and active symptoms begin to abate, 
when the doses may be diminished gradually, and finally 
withdrawn as soon as the relief is complete. If it acts 
too quickly on the bowels, as is sometimes the case, ten 
or fifteen minims of the acetated tincture of opium may 
be added to each dose. On the other hand, if the attack 
has been preceded by constipation, coated tongue, and 
scanty urine, from five to ten grains (0.31 to 0.61 gramme) 
of calomel may be given at once with benefit to the pa- 
tient, As soon as acute symptoms have disappeared the 
further management of the case should be in accordance 
with the hygienic principles already stated for the re- 
moval of the gouty diathesis and the prevention of acute 
relapses, and only such medicines should be continued as 
may be necessary to maintain a healthy condition of the 
digestive and urinary organs. Dr. W. Ebstein, in treat- 
ing acute symptoms gives, instead of colchicum, lithium 
salicylate in doses of 0.66 to 1.00 gramme (grs. x. to xv.), 
every two or three hours, until relief is obtained. Sir 
Mortimer Granville gives preference to the use of iodine, 
either in the form of tincture, iodoform, di-iodo-hydri- 
odide of caffeine, or hydriodic acid, and claims that it 
unites with the sodium of the bi-urate and facilitates its 
elimination from the system. But he very properly says, 
it should not be administered in combination with sodium 
or potassium. Dr. C. J. Rademacher declares that a 
combination of colchicia, decandria, and solanin with 
iodine, constitutes a reliable specific remedy for gout. 
The most recent remedy that has been highly recom- 
mended is piperazine. Dr. Schweninger, of Germany, 
is represented as having obtained most excellent re- 
sults from its use in both acute and chronic cases (see 
Journal of American Medical Association, September 24, 
1892). Drs. Biesenthal and Schmidt (La Semaine Medi- 
cale, No. 4. 1892) bear equally strong testimony as to its 
efficacy. It should be taken in dilute solution in pure 
water. One gramme (gr. xv.) may be dissolved in three 
hundred grammes (1 pint) of water, and the whole drunk 
during the twenty-four hours. At the beginning of 
acute cases, a larger quantity may be taken during the 
first day, but subsequently it should be continued for 
a considerable time in nearly uniform moderate doses, 
as its chief efficacy is supposed to consist in its power 
to increase the solubility and elimination of the sodium 
urates, and thereby counteract the tendency of the dis- 
ease to continue in a chronic form, and to develop per- 
manent arthritic uratic concretions. 
Dr. Thomas A. Edison has reported a case of such 
chronic concretions successfully treated by electricity ; 
while Dr. A. D. Rockwell reports one or more cases in 
which.the use of electricity only hastened the dissolution 
of the tissues covering the concretions, instead of dimin- 
ishing the latter. He Jias found electricity beneficial 
only in the chronic nervous manifestations of the disease. 
Nathan S. Davis. 
GRANVILLE. A sea-bathing resort on the coast of Nor- 
mandy, and facing the shore of Brittany. It is a pictur- 
esque settlement, and, like many of the sea-side resorts in 
France, is divided into an upper new town and a lower old 
one. The principal hotels are the Grand, Hotel du Nord, 
V Hotel des Trois Couronnes, V Hotel de France, V Hotel de 
Paris, VHotel du Soleil, and I'Hotel de la Boule-d'Or, all of 
which are in the Rue Lecampion, and almost all of which 
have the same tariff of prices-viz., from 7 fr. to 8 fr. a 
day. The Casino of Granville is called La Cabane, and 
is a pretty, unpretentious little building in wood, on a 
terrace at the base of a high cliff. The beach, which 
lies immediately below this ten-ace, is of fine white sand, 
and terminates on the town side by a high, sombre-colored 
and picturesquely jagged cliff (Baughan, " The North- 
ern Watering Places of France "). 
Steamboats ply between Granville and the Island of 
Jersey. Season, June to September. There are many 
fine walks and drives at and near Granville. The place 
is French, rather than international. 
Edmund C. Wendt. 
GRASSE. A winter health-resort on the Riviera, 
which has recently been made popular by the sojourn 
there of the Queen of England. The writer, after a per- 
sonal inspection of the place, described it about as fol- 
lows in the Medical liecord of May 28, 1892 : 
Grasse is picturesquely perched on the southern slope of 
Mount Rocavignon, which rises some seven hundred feet 
above it. It is twelve miles by rail in a northerly direc- 
tion from Cannes. The inhabitants, to the number of 
some fourteen thousand five hundred, are chiefly given 
over to the production of perfumery. Rose, cassia, 
heliotrope, violets, jasmine, verbena, jonquil, tuberose, 
orange, mignonette, and other blossoms are made use of 
in vast quantities for the purposes of this industry. 
Grasse gets plenty of sunshine, but being inland and 
about twelve hundred feet above the level of the sea, its 
climate is tonic and soothing, rather than stimulating and 
exciting. It is a little colder than the Mediterranean 
coast places, but the rise and fall of the thermometer is 
less abrupt. It enjoys a more equable temperature than 
do some of .the better known and more fashionable re- 
sorts of the Riviera. Grasse faces the sea, and enjoys a 
charming view over the lowlands running down to 
Cannes. 
Spurs of the Esterel Mountains extend to the north- 
west, and in a northeasterly direction there rise the peaks 
of the Maritime Alps. The dust and mistral are less 
trying at Grasse than at neighboring winter stations, 
though the mountains back of the village fail to give it 
that complete protection which has been claimed for it. 
It will nevertheless be seen that Grasse possesses certain 
advantages that entitle it to be more patronized than it 
has been, at least by real invalids. 
Not much has been done in the way of recent sanitary 
improvements. But the cesspool system is always less 
objectionable in small villages than in large settlements, 
where human beings are herded together in close quar- 
ters. 
The Grasse drinking-water, while not absolutely irre- 
proachable, comes from two good sources. It is con- 
ducted in canals, one of which is covered. It is safer to 
boil it before drinking, but it is less calcareous than much 
of the Riviera water. The two sources are known as 
La Foux and Le Foulon, and the supply is more than 
abundant. From the excellent little guide to Grasse, pub- 
lished by " An English Resident," the following table is 
taken : 
Analysis of Grasse Drinking-water,-One litre of 
water taken at the sources contains : 
Foux. Foulon. 
Degree hydrometric 18.2 c.c. 18 c.c. 
Organic matters calculated as oxygen from 
]>ermangnnate of potash 7.2 mg. 0.48 mg. 
Chlorides traces traces 
Nitrites and nitrates nil very slight traces 
Combined ammonia and albuminoids.... 0.2 mg. 0.003 mg. 
Oxygenation 8.5 c.c. 8.22 c.c. 
The Grand Hotel has been quite recently put in good 
sanitary condition by Mr. Best, of London. Board and 
lodging are cheaper in Grasse than at the more favored 
resorts. Many interesting walks and excursions offer 
themselves to the tourist. But apart from that there 
is very little "going on." It may be for this reason, 
perhaps, that so few Americans spend the winter at 
Grasse. 
Invalids who do not prosper at the sea-side will do well 
to try the inland air of Gn\sse ; and for some cases of 
nervous break-down the very dulness of the place should 
be a strong recommendation. 
Cases of chronic laryngitis, pharyngitis, chlorosis, anae- 
mia, and early cases of phthisis generally do very well at 
Grasse. Asthmatics and gouty patients are also benefited 
there. Edmund C. Wendt. 
386 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Gout. 
Guaiacol, 
GROUND ITCH. A disease so often met with de- 
serves, at least, to be described and named. We can find 
no reference to it in the workmen practice, on skin diseases, 
in encyclopaedic handbooks, or the "Index Catalogue" 
of the Surgeon-General's Office ; yet there is scarcely a 
boy raised in the coast districts of South Carolina who 
has not been a sufferer from this affection. 
As it involves invariably one or more of the toes, sel- 
dom extending beyond them, and possesses the charac- 
teristics of eczema, there need be no difficulty in giving 
it its correct scientific designation. We would suggest 
the compound name, Eczema phalangis pedis. 
Cause.-It is generally found in those going without 
shoes, and is popularly ascribed to walking barefoot in 
the sand, dew, and wet grass, and therefore generally 
affects boys. 
It is met with extensively along the seaboard, in the 
Pineland residences, and elsewhere, also on Sullivan's, 
Pawley's, and other islands ; and in these localities are 
found certain grasses armed with spines or prickles, 
which are highly irritating, though no complaints are 
made of them. "^Those of cleanly habits are not exempt 
from the disease. 
Symptoms.-There may be at first moderate redness or 
subacute inflammation, followed by papules or vesicles 
which burst. This is accompanied by intense itching 
and burning, only partially relieved by scratching ; the re- 
sult being a sore with whitish ulceration around and be- 
tween the toes, with a moisture characteristic of eczema. 
There is no rash, fever, or chill; no extreme swelling or 
sloughing. 
It is analogous with an affection known as "stone 
bruise," quite common in the upper and more rocky dis- 
tricts. 
The disease we are describing is neither camp nor 
prairie itch, nor is it embraced under any of their syno- 
nyms, which are all contagious and generalized over the 
whole surface of the body, whereas ground itch is strictly 
localized and never contagious. 
A correspondent who is a high authority on dermatol- 
ogy suggests that " it is possible that it may be due to 
the attack of the pulex penetrans (sand-flea or jigger). 
This attacks the neighborhood of the toes, but is not 
commonly met with outside of tropical countries, 
although it has been reported from time to time as met 
with in the Southern States. Even though it be an 
eczema, it must, from your note, have peculiar features." 
We are inclined to dissent from this opinion, though we 
have heard the affection ascribed to some minute insect. 
Were the pulex the cause, it would be more readily rec- 
ognized, for the female, which is generally regarded as a 
true flea, penetrates the thin skin between the toes or 
about the toe-nails, and then swells up to the size of a 
flea, forming a bag of eggs, and this becomes plainly vis- 
ible. This causes much irritation, which often results in 
suppuration, followed by open ulcers. 
Treatment.-There are many popular remedies, as, for 
example, bread-and-milk poultices in the early stages ; 
soaking the feet in hot water is said to arrest the disease ; 
applications of the leaves of the gourd or calabash (Cu- 
curbita lagenaria) heated ; a hot decoction of the yellow 
gerardia (Gerardia flavd), which grows abundantly here 
and is considered a sovereign remedy. We have experi- 
enced good results from the application of a powder of 
aristol, bismuth, and oxide of zinc, equal parts. A com- 
bination of campho-phenique and oil or vaseline, equal 
parts, also gives great relief, and we have seen benefit fol- 
low the application of an ointment given us by the late 
Dr. Valentine Mott, of New York, for eczematous affec- 
tions, viz.: 
I). White precipitate of mercury 3 j. 
Oil of tobacco gtt. x. 
Lard | j. 
Iodoform in the moist stage is a useful application ; 
and a strong solution of soda, frequently applied, re- 
lieves the itching temporarily. 
When the suppuration is subsiding any drying powder, 
(SUPPLEMENT.) 
such as calamine, subnitrate of bismuth, oxide of zinc, 
or powdered cinchona bark, will prove useful. A med- 
ical friend finds equal parts of ichthyol and vaseline the 
most efficient remedy. Carbolic acid is sometimes em- 
ployed as an ointment, with lard or vaseline. 
The disease is often very refractory, the itching and 
burning being very severe. A patient, under constant 
supervision, is now in the sixth week of the disease. 
F. Peyre Porcher. 
GUAIACOL. This compound constitutes from sixty 
to ninety per cent, of creasote, and may be separated by 
fractional distillation; the portion passing over between 
200° and 205° C. being collected. Chemically it is mono- 
methyl pyrocatechin, with the formula of C6H4OHOCH3. 
It is a colorless liquid with a strong, aromatic odor, very 
slightly soluble in water, 1 part in 85, but readily soluble 
in alcohol and ether. Specific gravity at 60° F., 1.117 ; 
boiling-point, 200° to 202° C. Guaiacol may also be 
formed from guaiacum resin by distillation. Many of 
the guaiacols of commerce are contaminated with various 
impurities, which give it a lower specific gravity and 
boiling-point ; they are darker in color, and spoil by ex- 
posure to light. With concentrated sulphuric acid the 
pure guaiacol gives a faint yellow coloration, which is 
changed to a yellow red by the addition of a small quantity 
of acetone ; the impure guaiacol gives a more or less red 
color with the acid alone. A characteristic test for guaia- 
col is the addition of a trace of ferric chloride to an 
alcoholic solution : this gives a blue color which changes 
to green with the presence of a greater proportion of the 
salt. Guaiacol is excreted with the urine, the saliva, and 
the perspiration, and may be detected as early as half an 
hour after its administration. It may be demonstrated by 
distilling the secretion with diluted sulphuric acid. The 
product is placed in a test-tube and to it is added a small 
quantity of highly dilute solution of liquor ferri sesqui- 
chlor. (two or three drops to a test-tube of water). In 
the presence of guaiacol a reddish-brown color is grad- 
ually developed, the intensity of which is in proportion 
to the amount present. 
The value of guaiacol in the treatment of tubercular 
disease was pointed out by Professor Max Schueller, of 
Berlin, in a work published in 1880.1 The author had 
made numerous trials, with various drugs, upon animals 
affected with tuberculosis. Extract of guaiacum wood, 
guaiacol, creasote, benzoate of sodium, and many other 
substances had been experimented with, and he had se- 
lected guaiacol as the most serviceable. In 1891 a second 
treatise was issued,'2 reviewing his work during the inter- 
vening years and explaining in detail his method of em- 
ploying the drug in general and in surgical tuberculosis. 
Dr. Schueller administers it continuously for a long 
period in moderate doses ; he does not think large doses 
are of any special value. An improvement shows itself 
quickly, but the remedy must be continued throughout 
the course of the disease, and when recovery takes place 
its use must be persisted in for some time longer. He 
particularly insists upon it being given for some months, 
after the bacilli have disappeared. He has recorded 
eighteen cures of pulmonary tuberculosis ; some of the 
patients have been free from symptoms of returning dis- 
ease after several years have elapsed. 
In pulmonary tuberculosis he gives it in doses of two 
or three drops to children, and three to five drops to 
adults, four times daily. He gives the drug without any 
preparation, in a glass of water, to which a little table 
salt has been added to facilitate solution and cover the 
taste ; or it may be given in milk, wine, or spirits. He 
does not like the use of pills or capsules. This method, 
he thinks, allows it to be present in the stomach in a too 
concentrated state, but where such are given, large quan- 
tities of water should be used before and after to facilitate 
solution and dilution. Guaiacol is well borne by the 
stomach, and its disagreeable odor and taste are soon 
overcome to such an extent that patients rarely com- 
plain. 
Dr. Schueller has also used it extensively in surgical tu- 
berculosis with equally satisfactory results. It is admin- 
tions, viz.: 
387 Guaiacol. 
Headache. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
istered internally as in pulmonary disease, and injected 
into the site of the local trouble. He also uses the guaia- 
col in combination with iodoform for the local treatment. 
Enlarged glands, tubercular deposits, and skin affections 
in which caseation has not commenced, he has seen dis- 
appear with simply the constitutional treatment, and 
many threatened joint affections have been averted. In 
tubercular disease of the bones, when caseation and de- 
struction have taken place, he considers that the diseased 
tissue should be removed, and the local use of guaiacol 
and iodoform then proceeded with to promote repair and 
prevent the return of the disease. 
Guaiacol has been very extensively used as a substitute 
for creasote, and has been found to be easily taken and re- 
tained. It is also of a more definite strength than crea- 
sote, and free from any deleterious effects. The dosage 
varies, and many follow the method of Sommerbrodt 
with creasote, in giving large doses and pushing it with 
the idea of saturating the system. It is generally given 
in solution in preference to other ways, and tincture of 
gentian, tincture of cinchona, and wine, are favorite men- 
strua with which it may be combined, to disguise its taste 
and increase its tonic action. If for any reason it cannot 
be administered in the ordinary way, it may be given in 
the form of an enema, and for this purpose the follow- 
ing formula may be adopted : Guaiacol, 7 grains ; sweet 
almond oil, drachm ; gum acacia, f drachm ; distilled 
water, | pint. 
Iodoform in combination with guaiacol, as an improve- 
ment upon the latter alone, was introduced by Professor 
Picot, of Bordeaux.3 A solution of the two drugs in ster- 
ilized olive oil is prepared and used subcutaneously. The 
dose he advocated was very small, viz., one-sixth grain of 
iodoform and one grain of guaiacol, daily, to be increased 
gradually until three times that amount is reached. lie 
selected the supra-spinous fossa as the most suitable place 
for the injection, as it does not bear the weight of the 
body when the patient lies on his back. No local reaction 
followed its use, but from twenty to thirty minutes after 
the injection signs of a general reaction were evident ; 
there was profuse perspiration of the face and chest, which 
was followed by a lowering of temperature. The diges- 
tion was not affected, but in some cases colic and diarrhoea 
were complained of. No effect on the urine was noticed. 
Twenty.-five cases of tubercular phthisis and pleuritis 
were treated, and Professor Picot had never obtained such 
favorable results in any other line of treatment as he ob- 
served in these cases. He sums up as follows : The in- 
jections improve the general condition, and lessen cough 
and expectoration. In certain cases they dry up cavities 
and favor their cicatrization. In the second stage of 
phthisis they make cough and expectoration disappear, 
while causing the cessation of fever and night-sweats. 
They also diminish the number of bacilli in the sputum. 
Professor Picot, at a later date,4 reported the results of 
forty-two cases treated with the same satisfactory results, 
and without any unfavorable symptoms accompanying 
the injections. 
Dr. R. Robertson, at the British Medical Association, 
1891,6 gave the result of his experience. He used it 
after the manner of Professor Picot. The small dose 
was commenced with, at the seventh day it was doubled, 
and at the twenty-first day the full quantity was begun. 
He employed the remedy in twenty-five cases of con- 
sumption and three of empyema. He concludes, 1, 
that in empyema with free drainage the treatment does 
good in improving the general condition and in dimin- 
ishing the discharge from the pleural cavity, but that 
without free drainage it is of uncertain value ; 2, that in 
pyrexic phthisis, whether the disease is small in extent 
or so extensive that the case seems almost hopeless, it is 
not an absolutely certain antipyretic, but it is commonly 
of decided advantage, if persevered with, in reducing the 
fever, and by so doing in diminishing the activity of the 
disease ; 3, that even where it fails within a reasonable 
time to modify the fever, it is still serviceable in most 
cases in diminishing expectoration and in modifying the 
cough ; 4, though it is serviceable in limiting waste by re- 
ducing temperature and by diminishing expectoration, 
(SUPPLEMENT.) 
it cannot be said that this treatment is specially favorable 
to increase in body weight; 5, the treatment is without 
risk with ordinary precautions ; 6, its use does not pre- 
vent the development of other tuberculous outbreaks or 
extensions of tuberculous mischief, for meningitis, pleu- 
risy, haemoptysis, have been shown to occur after many 
injections; 7, in interpreting the mode of action of 
these remedies, their antiparasitic action should not ex- 
clusively be thought of ; it must not be forgotten that 
both remedies act upon the patient himself, even in small 
doses, as a sedative, as a stimulant of the mucous mem- 
brane, and as an astringent. 
Benzosol.-A crystalline salt of guaiacol in which an 
hydrogen atom of the hydroxyl group is replaced by 
benzoyl. It is the benzoate of guaiacol. The chem- 
ical formula is C6H4OCH3OCOC6H5. It is a colorless 
crystalline powder, almost devoid of taste and odor, 
insoluble in water, readily soluble in alcohol, ether, and 
chloroform. It contains fifty-four per cent, of guaiacol. 
The boiling-point should not be below 44° C. 
Benzosol is acted upon by the alkaline secretions and 
gradually decomposed, guaiacol and benzoic acid being 
formed. It does not cause any irritation to the diges- 
tive tract nor give rise to eructations or any other disa- 
greeable symptom. Its advantage over guaiacol is the 
absence of any odor and taste. In addition to its use 
as a substitute for guaiacol in the treatment of phthisis, 
it is also recommended as an intestinal antiseptic where 
such is required. The dose is four grains, to be gradu- 
ally increased to twelve grains, three times daily. 
Guaiacol Carbonate was also introduced 6 because 
it afforded a better means of administering guaiacol than 
the employment of the parent liquid afforded. It has 
the advantage of being more definite in composition and 
perfectly free from any adulteration. Although termed 
a carbonate its formula is CO(OC6H4OCH3)2. It forms 
in neutral crystals, is tasteless and without odor, and is 
insoluble in water. Its melting-point is 86° to 90° C. It 
is not affected by the gastric juices, but in the alkaline 
secretions of the intestines it is decomposed and guaiacol 
set free. If the stomach is deranged and the seat of putrid 
fermentation, the decomposition of the salt will take place 
and produce its beneficial action. It is also used to re- 
place guaiacol and creasote in phthisis. The dose is six 
to eight grains, gradually increased, three times a day. 
As much as ninety grains have been given without pro- 
ducing disturbance of the digestive organs. 
Guaiacol Salicylate, also called guaiacolic salol. 
Its chemical formula is C6H4OHCOOCH4OCH3. It oc- 
curs in white, odorless crystals, with a melting-point of 
65° C. It is insoluble in water. This compound is in- 
troduced for the same purpose as the above salt, and is 
also said to be much superior to salol for all purposes in 
which that salt is employed. The dose and modes of 
administering are the same as for salol. 
Beaumont Small. 
1 ExperimentelJe und Histologische Untersuchungen, etc. Stuttgart: 
F. Enke, 188V. 
2 Eine neue Behandlungsmethode der Tuberkulose, besonders chirur- 
gischen Tuberkulosen, von Professor Max Schueller. Wiesbaden: J. F. 
Bergmann, 1891. 
3 La Semaine Medicale. March 4, 1891. 
4 La Semaine Mfidicale, August 5, 1891. 
5 British Medical Journal, November 14, 1891. 
8 Berlin, klin. Wochen., 1891, No. 52. 
H7EM0GALL0L. A patented article prepared by the 
reducing action of pyrogallol on the coloring matter of 
the blood, It is a brownish-red powder, very soluble, 
and more readily absorbed than any other preparation of 
iron. It is very well borne by the most delicate stomach, 
and when absorbed is easily transformed into the blood 
coloring matter. The dose is from two to eight grains, 
three times a day. As much as fifteen to thirty grains 
have been given without any inconvenience. 
This compound was introduced by Professor Robert, 
Director of the Pharmacological Institute of Dorpat Uni- 
versity, as the result of a series of experiments upon the 
assimilation of iron salts, lie considers that ferruginous 
preparations, if they are of any value, should be excreted 
388 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Guaiacol. 
Headache. 
with the urine, not immediately, but after the lapse of a 
few days, and should appear as a definitely formed urate 
of iron. None of the usual preparations of iron answer 
to these conditions. When introduced into the blood 
they are excreted to the extent of forty per cent, in an 
unchanged condition, which would indicate that the as- 
similation of these salts is very uncertain. The new 
preparation answers to all the above conditions, and clin- 
ical experience has shown the most favorable results, 
both in chlorosis and anaemia. 
Hoe mol is a similar preparation, obtained by using 
zinc-dust in the place of pyrogallol as the reducing agent. 
The dose is the same as that of haemogallol, the action is 
very similar, and the same favorable results have been 
obtained. This preparation contains a trace of zinc, 
which is considered a rather desirable combination, as it 
exerts a beneficial action where there are lesions of the 
stomach or intestines. Beaumont Small. 
HAND, DEFORMITIES OF. Athetosis.-No local 
treatment, either mechanical or operative, of the deform- 
ity associated with athetosis has given satisfactory re- 
sults. Relapses have invariably occurred after even pro- 
longed immobilization, and after section of the tendons 
deformity has soon recurred and become steadily worse. 
Only excision of the cerebral cortical centres, which, of 
course, paralyzes the part, affords any relief to the de- 
formity. 
Drop-wrist.-Very many cases of drop-wrist that 
obtain little, if any, benefit from other forms of treat- 
ment, go on to a partial, and not infrequently complete, 
cure when the nerve inflammation has subsided, by being 
persistently kept for a very long time in an over-corrected 
position. 
(SUPPLEMENT.) 
resorts, although the beach is remarkably fine. Accord- 
ing to Black ("Watering-places of England, Scotland, 
and Ireland") the "ridge of hills that runs through the 
centre of Sussex dividesat Hastings, as it approaches the 
sea, into several spurs, enclosing valleys, from within 
which begin the houses of Hastings and St. Leonard's, 
and extend to the beach, where they all join into one al- 
most continuous frontage of about two miles. This front- 
age begins at St. Leonard's on the west, with one range 
after another of fine mansions, till Hastings is reached. 
Along the whole of this front extends one almost un- 
broken promenade. Behind, at various distances, are the 
cliffs, which are much lower at St. Leonard's ; but from 
thence, gradually though irregularly, they increase in 
height till they attain the magnificent elevation, at or lit- 
tle beyond the eastern extremity of Hastings, of five hun- 
dred and sixty feet." 
The east winds are at times very trying, but in gen- 
eral the climate is mild and equable, and for this rea- 
son many consumptives spend the winter there. There 
is comparative absence of fogs, and the porous soil quick- 
ly absorbs moisture. The drainage and drinking-water 
are good. The sanitary condition of the towns is excel- 
lent, the annual death-rate being only about sixteen to 
seventeen per thousand. There is a large pier at Hast- 
ings, with conveniences for exercise under glass-covered 
promenades. According to Savery (" Hastings and St. 
Leonard's, their Meteorology and Climate"), the whole 
number of tine days is 189. They advance with great 
regularity from their minimum in January to their max- 
imum in July, and then as steadily decrease. The cloudy- 
fine days number 46 ; the cloudy, 52; the fine-rain, 42; 
and the cloudy-rain, 30.5 ; while the rainy days only 
amount to nine in the year. From this it is evident that 
the number of days on which the invalid can- 
not get out on account of the weather is very 
small; and those on which he may en joy the 
rays of the sun, so conducive to health and 
vigor, are 280. To these must be added 52, 
which are dry though overcast; hence there are 
332 days in which a person may enjoy a walk. 
The regularity of these results, and the small 
amount of variation year after year, is very re- 
markable, and has much surprised him, as the 
fickleness of the weather in England has passed 
into a proverb. Dr. Mantell claims that it is 
not necessary for the invalid, however delicate, 
to be confined to the house for any length of 
time. Apart from Torquay, few English resorts are 
better adapted for an invalid's winter residence than 
Hastings and St. Leonard's. Many excursions can be 
conveniently undertaken from these resorts. There are 
the usual concerts^ assemblies, and other amusements. 
The hotels are good ; the Queen's on the Parade, facing 
the sea, the Albion, and the Castle are the best. At St. 
Leonard's, the Hoyal Victoria and South Saxon are the 
best. Edmund C. Wendt. 
HEADACHE. Since the appearance of the Reference 
Handbook very little has been added to our knowledge 
of the pathology of headache. There has been a good 
deal of speculation, and some ingenious theories have 
been suggested in explanation of some of the phenomena ; 
many facts have been observed and classifications made 
without giving grounds for much change of views as to 
the nature of the trouble. 
It is pleasant to note that so painstaking a student as 
C. L. Dana, after a thorough review of the whole subject, 
holds, with the original article on this subject, that we 
have no proof that headache may have its seat in the 
brain, although there is no proof that it may not. The 
cortex "may be the seat of headache, but then it is a 
psychical pain and in the nature of an hallucination." 
There can be no subjective difference between a genuine 
pain and one founded on an hallucination ; to the pa- 
tient they are identical. 
Most headaches are doubtless in the nature of neural- 
gias of the nerves of the dura mater or of the tissues cov- 
ering the skull. Of course this includes the tri-facial 
Fig. 210. 
Figs. 210 and 211.-Splint for Drop-wrist. 
Fig. 211. 
The hand is fully extended on the forearm and held by 
a simple metal splint applied to the palmar aspect, from 
the elbow to the carpo-phalangeal articulation. This 
position is maintained, without being even once relaxed, 
for from twelve to eighteen months. Structural short- 
ening, the result of the position, seems to take place in 
the extensor muscles, and even if voluntary motion in 
them is not regained, the deformity is cured, and the 
flexor muscles act io a greater advantage, while a more 
comely and useful hand is the result. 
Infantile Hemiplegia.-In some cases treatment is 
of no avail ; in others much restoration of function can 
be gained. If the deformity can be readily overcome, 
and the hand placed in the extreme opposite deformity 
without discomfort to the patient, it should be so placed 
and held by a suitable splint, without change of position, 
for from twelve .to eighteen months. This overcomes 
the shortening of the flexor muscles and permits the 
slack of the extensor to be taken up by structural short- 
ening. If the hand cannot be easily and comfortably 
placed in hyper-extension, division of all shortened tis- 
sues should be made, and the hand at once placed in the 
desired position and held there as already directed. A 
permanent gain in position may always be anticipated, 
and in a few cases there has been considerable restoration 
of voluntary movement. John Ridlon. 
HASTINGS AND ST. LEONARD'S. Popular sea-side 
resorts and winter stations in Sussex, England. Hastings 
and St. Leonard's are practically one. They are at 
present fashionable winter stations rather than summer 
389 Headache. 
DEFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Heart. 
(SUPPLEMENT.) 
nerves, the upper cervical nerves, and some sensory 
branches of the vagus. 
The explanation of reflex headache has, like that of all 
reflex phenomena, been unsatisfactory. Why, for ex- 
ample, does an irritation of the stomach produce head- 
ache, instead of a pain in the foot ? Dr. Dana suggests 
the theory that the first irritation being received by the 
vagus and transmitted to the brain is easily " shunted off 
or^liffused " from the seat of original irritation to the 
nerves most obnoxious to pain. This theory is rational 
so far as it goes, but does not explain the special irrita- 
bility of the headache nerves. 
The explanation of migraine is still sought in the 
assumed discharge of nerve-force occurring periodically, 
a most unsatisfactory theory, but perhaps the best one at 
present. As illustrating the protean forms in which 
migraine appears, one author quotes ten cases-cases oc- 
curring at random-in which were represented the fol- 
lowing symptoms : Concentric retraction of the field of 
vision, aphasia, hemianopsia superior, numbness of one 
arm, vertigo, agraphia, scintillating scotoma, hemipare- 
sis, hemianaesthesia, difficulty of speech, amaurosis, and 
epileptiform convulsions. 
Dana classifies two hundred cases of non-migrainous 
headache, and attributes thirty-five per cent, to poisons 
and poverty of the blood, such as anaemia, dietetic states, 
infections, uraemia, lead, alcohol, tobacco, etc. ; twenty- 
five per cent, to reflexes from the digestive organs; ten 
per cent, to other reflexes ; five per cent, to local organic 
disease, and twenty per cent, to neurotic states. 
Much has been insisted of late on dull frontal and dif- 
fuse headache as resulting from catarrhal states of the 
upper part of the nasal passages, but I am satisfied that 
this is a much over-estimated cause. 
The character of the headache doubtless indicates to 
some degree the causation ; for example, the throbbing 
headache, aggravated by a jarring of the body, is more 
likely to be migraine, while the dull, steady pain is more 
likely to result from dyspeptic disturbance and toxaemia. 
The hot, burning, sore headache is often alleged to be 
due to anaemia, but frequently results from neurotic con- 
ditions incident thereto, and to uterine disorders. The 
intense, boring pain (clavus) is nearly always a hysterical 
symptom ; while the occipital pain is often caused by 
eye-strain. 
Weir Mitchell has wisely emphasized the fact that 
headaches probably often persist long after the causes of 
them, such as eye-strain, have been removed, as though 
from a habit of pain. They are more likely to persist 
when they have come on during the period of youth. 
Sunstroke leads often to persistent tendency to head- 
ache, always aggravated by heat, and especially by the 
sun's heat. There can be no doubt that in some of these 
cases, as well as in cases following injuries, spots of 
meningeal thickening occur which through pressure on 
nerve-fibres and abbreviation of the movements of the 
brain substance, as well as possibly by reflex action, lead 
to almost constant pain. 
Each year fresh evidence develops of the manifold 
headaches due to eye-strain from various optical defects 
of the organs of vision, the variations of hypermetropia 
and astigmatism being the most common. Defects of the 
extra-ocular muscles probably also cause headache. Ob- 
servers differ as to the proportion of cases due to these 
causes all the way from a modest figure up to seventy- 
five per cent, or more. A misleading circumstance is 
the fact that in some of the worst of such cases there are 
no ocular symptoms of pain or discomfort. 
Experience shows that oculists have not yet found the 
way to correct by glasses all cases of headache due to 
optical defects. Many cases must be tested repeatedly and 
experimented with in the use of various degrees of cor- 
rection before the right fit is found ; and sometimes the 
right fit is not found, suggesting that such cases are not 
due to the eyes. This conclusion is less tenable since 
numerous such cases have, by later1 methods and more 
careful testing, been entirely relieved. 
The claim has been lately put forth, and defended with 
zeal, that headaches, as well as other nervous troubles, 
including epilepsy, are often clue to inequality or asym- 
metry in tension of the extra-ocular muscles, for which 
graduated tenotomy is recommended. Many operations 
of the kind have been made, but the results have not been 
such as to commend either the theory or the remedy to 
the majority of students of the subject. That there is a 
measure of truth in the theory is probable, but its advo- 
cates have unquestionably claimed too much for it. 
Within a few years a remarkable series of coal-tar prod- 
ucts of the chemical laboratory have come into use in 
the treatment of headaches, as well as of neuralgias in 
general. Antipyrine has been used most extensively, 
while antifebrin, or acetanilid, and phenacetine, have 
been used very widely. Exalgine has been used to a 
limited extent. Various secret and proprietary prepara- 
tions, which are mostly compounds of some of these 
medicines with various modifying agents, have also been 
extensively employed. So common has the use of this 
new class of agents come to be in the United States, that 
many people purchase and use them on their own re- 
sponsibility as freely as quinine is used for so-called mal- 
aria. Notwithstanding the wholesale use of such medi- 
cines, very few unfortunate results have been recorded. 
Antipyrine is a fine crystalline white powder, highly 
soluble in water, while antifebrin is offered in coarser 
crystals, and is sparingly soluble in water ; phenacetine 
is similar in appearance, and is also sparingly soluble in 
water. 
These agents were first introduced as antipyretics, but 
were found to exercise a potent influence upon the ner- 
vous system, particularly in the presence of simple neu- 
ralgias, especially those that are produced by reflex in- 
fluences and aggravated by the lowering of vital tone. 
Antipyrine has been used in doses of two to twenty 
grains, and but few instances have been recorded of in- 
jury from this larger dose. Occasionally a large dose 
produces a sense of prostration, evidence of heart weak- 
ness or some skin eruption, but in general it may be said 
that in tentative quantities the drug is a safe one, even in 
the hands of the laity. The proper dose of antipyrine 
for headache in an adult is five grains, which may be 
repeated every half hour or hour until relief has been 
obtained, or until enough doses have been taken to prove 
that the drug is ineffective. 
People differ widely in their susceptibility to the reme- 
dial influence of the drug for headache, but most per- 
sons experience benefit from one to three doses of five 
grains each ; but some seem not to be affected by any 
safe quantity of the drug. Doubtless the cause of the 
headache determines to some degree the susceptibility 
to the remedy ; thu® true migraine headaches, produced 
by digestive derangement and fatigue of the eyes, are 
more likely to be benefited than headaches due to nephri- 
tis, anaemia, nervous exhaustion, and cerebral syphilis. 
One trial of the drug will nearly always determine for 
each patient its constant effect upon him. A headache 
relieved by a certain dosage for a particular patient may 
be expected thereafter to yield, to some degree, to the 
remedy, but migraine patients have found that they ac- 
quire a tolerance for the drug that makes it, after re- 
peated trials, ineffectual except in large quantities ; so 
that many, after a year's trial of it and more or less 
benefit, have rejected it as unsatisfactory. This has 
been, however, the experience of such patients with 
every drug known to affect the disease. 
Antipyrine seems specially applicable to cases of head- 
ache produced by gastric disturbance ; in many cases it 
corrects the stomach disorder as well as the headache ; 
and if taken at the first appearance of the premonitions 
of a migraine it may cut these symptoms short and pre- 
vent the appearance of the paroxysm. An effective and 
convenient way to administer the drug is by means of 
compressed tablets. 
Antifebrin should be given in smaller doses than anti- 
pyrine. It produces much the same effect, but is less 
soluble in the stomach, and, given in large quantities, as 
twenty or thirty grains within a few hours, it is liable to 
produce a cyanosis, due to an effect upon the superficial 
capillaries. This condition is known not to be specially 
390 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Headache. 
Heart. 
dangerous, but is generally alarming to lay people who 
observe it. This drug has not given the satisfaction to 
patients with headache that has been experienced from 
antipyrine and phenacetin. Probably one explanation of 
this fact is the sparing solubility of the remedy. The 
drug is much more soluble in hot water than in cold, and 
may well be given in a hot solution where its prompt ac- 
tion is important. 
Phenacetin produces fewer unpleasant symptoms than 
antifebrin, is very popular with patients who have used 
it for headache and neuralgias, and may be given in 
about the same doses as antipyrine. It produces more 
perspiration in febrile cases than either of the other 
drugs named ; and in large doses may produce decided 
cyanosis. It is unwise, however, because of its sparing 
solubility, to give this drug in the shape of compressed 
tablets, if there is any considerable' catarrh of the stom- 
ach. I have known such tablets given in typhoid fever 
for headache to pass in large number through the ali- 
mentary canal undissolved. 
Just how these drugs act is something of a mystery. 
Antipyrine is believed by some to reduce intra-cranial 
blood-pressure, and that it should never be used when 
spasm of the blood-vessels exists-if it can be known 
certainly when that occurs, of which there is often some 
doubt. 
There is no reason to think that any of these new rem- 
edies induces a lessening of the tendency to regular re- 
currence of migraine paroxysms. Norman Bridge. 
HEART, THE. The vertebrate heart arises in tw'o dis- 
tinct ways, each of which is intimately associated with the 
origin of the blood-vessels in general. In the lower ver- 
tebrates its first appearance is in the form of a single tube 
on the ventral median line of the embryo, quite near the 
head. Fig. 212 is a section of a salamander embryo in 
which the heart is just beginning to form. The body 
cavity Ih is composed of two lateral halves (see Ccelom) 
separated from each other by a median septum. It is in 
this septum that the heart first makes its appearance. 
The two layers which contain this septum become sepa- 
hearts. Fig. 214 is a section through an embryo of 
the same stage as that pictured in Fig. 213. The 
neural canal, rf, is just beginning to close and in the 
splanchnopleur on either side there is a large fold, ahh. 
Fig. 213.-Rabbit Embryo of the Ninth Day. (After von Kolliker.) 
X 10 times, A, double origin of the tieart; nb. optic vesicle ; th, fore- 
brain ; mh, mid-brain; hh, hind-brain ; rf, medullary groove ; uw, 
myotomes ; h, heart; to, vena omphalo-mesenterica. 
which already contains the endothelial tube com- 
ing from the omphalo - mesenteric vein. The 
tubes grow toward the median lines, but before 
uniting each has its descending aorta, as shown in 
Fig. 215. The rudimentary hearts are formed 
between the splanchnopleur and entoderm, and 
as the former surrounds the heart to form its 
muscular layer the heart protrudes into the coe- 
lomic cavity (Fig. 214), much as does the unilat- 
eral heart of lower vertebrates (Fig. 212). Soon 
the two halves unite as indicated in Fig. 215, and 
then we have a single heart with two veins enter- 
ing from behind and two arteries, aortae, leaving 
from in front. Although this primary division 
has nothing whatever to do with the later sepa- 
ration of the heart into its two halves, yet before 
the two primary hearts are united into a single 
tube the position of the ventricle is already 
marked (Fig. 215, h). So, to sum up, in the lower verte- 
brates the heart appears as a single tube which in general 
remains such during the life of the animal, and it must 
be viewed as the prima- 
tive form of heart. 
Fig. 212-Section through a Salamander Embryo, to Show the Origin of the Heart. 
(From Hertwig, after Rabi.) d, yolk; vm, pericardium: M, body cavity; end, 
endocardium; p, muscle layer of the heart; ep, epidermis. 
rated, and the opening soon becomes lined with a layer of 
cells, end, the endocardium. The cells of the septum 
surrounding the opening give rise to the muscle-walls of 
the heart. 
In higher vertebrates the heart 
is first formed by the union of two 
tubes arising from what might 
practically be called the outside 
of the body. Fig. 213 is a sur- 
face view of quite a young rab- 
bit embryo in which the heart is 
beginning to form on either side. 
The omphalomesenteric veins on 
either side run toward the ventral 
median line, and later on unite. 
Their appearance is such, how- 
ever, that before they are united 
they may be spoken of as two 
Fig. 214.-Section through the Embryo Pictured in 
Fig. 213. 'After von Kolliker.) The bilateral 
hearts are cut transversely, rf, medullary groove; 
h, ectoderm: men. mesoderm; (id, entoderm; dd'. 
chorda : muscle-wall of the heart; ihh, endo- 
thelial lining of the heart. 
391 Heart. 
Heart. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Higher up the scale the heart arises before the foregut is 
formed, from that portion of the splanchnopleur which 
later on lies in the median line of the embryo. It is this 
part which is to give rise to the heart, and in the higher 
its walls have also become thickened. Figs. 219 and 220 
are ventral and lateral views of a reconstruction at this 
stage. The profile view again gives a cast of the heart 
cavity, which now shows the beginning of the auricle 
Fig. 215.-Sketches Showing the more Advanced Condition of the Bi- 
tubular Heart of the Rabbit. X 22 times. (After Allen Thomson.) 
C is more advanced than B. FF, omphalo-mesenteric veins ; h, heart; 
«, aorta ; the arrows indicate the direction of the circulation. 
animals the heart arises before the lateral parts have 
reached the median line (Hertwig). The two hearts 
then unite into a straight tube which is destined to be- 
come separated into the right and left hearts of the adult. 
Fig. 218. 
Figs. 217 and 218.-Ventral and Profile Reconstructions of His's Human 
Embryo. Lg. X 40 times. (After His.) In the profile view only the 
outline of the cavity of the heart is shown. F., ventricle ; A. b., bul- 
bus aortic. 
Fig. 216.-Outlines of the Anterior Half of the Chick Viewed from the 
Ventral Side, Showing the Heart in its Earlier Stages of Development; 
X 20 times. (From Quain, after Remak.) A, thirty hours; B, forty 
hours ; a, anterior cerebral vesicle ; b, myotomes; c, cephalic fold ; 1, 
omphalo-mesenteric veins; 2, 3, 4, the heart. 
(V.h.) At this time the heart is partly tilted over and 
the veins enter on the dorsal side. Viewed from in front, 
the auricles, which are just appearing, cannot be seen 
because they now lie on the dorsal side. A stage later 
Fig. 216 is a ventral view of two chicks just after the 
two primary tubes of the heart have united. It is seen 
that the veins (1) enter from behind, but the relation is 
soon changed by the heart becoming bent as is already 
indicated in Fig. 218. 
Fig. 217 shows the general form of the 
heart in a very young human embryo. 
The front of the thorax has been cut 
away, cutting also through the transverse 
septum and opening the body cavities. 
The entrance of the veins still lies be- 
hind, and the aorta in front, but the heart 
has already formed one complete loop, 
making of it an S. Fig. 218 is a profile of 
the same embryo, ami the heart is indi- 
cated as a cast of its cavity. It shows the 
variations in calibre of the tube through- 
out its length. At a somewhat later stage 
the heart is bent upon itself more, and 
Figs. 219 and 220.-Ventral and Profile Reconstruction of His's Embryo, Lr. X 40 times. 
(After His.) V, ventricle; Vh, auricle; 4. b., bulbus aorta;. 
Fig. 219. 
Fig. 220. 
392 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Heart. 
Heart. 
(Figs. 221 and 222), the adult form can already be recog- 
nized. The heart has undergone a half revolution in ad- 
dition to the S-formation. The veins enter nearer the head 
and the artery arises behind, or away from the head. The 
aorta lies upon the ventral side and the auricles clasp it 
from the dorsal. Fig. 222 
X shows the great irregu- 
f ik larity of the cavity. 
(SUPPLEMENT.) 
the heart is much as it is in the Fig. 224, only that the 
auricles are " shoved " into the ventricle. This is of con- 
siderable importance, as we shall later on see. In both 
cases the aorta arises from the right side of the ventricle, 
and in its further development one-half of it must be 
transferred to the left side in order to produce the aorta 
proper, while the half which remains becomes the pul- 
monary artery. 
Figs. 221 and 222.-Ventral and Profile Reconstruction of His's Embryo, Bl. X 40 
times. Ho, auricle ; C.a, auriculo-ventricular canal; Tr, aorta. 
Fig. 221. 
Fig. 222. 
A profile view of a heart, of this stage is shown in Fig. 
223, which shows the relation of the heart to the sur- 
rounding organs. The auricle (A) is now in front and 
the ventricle (V) behind. The larger veins enter on the 
dorsal side by one common opening into the right side of 
the auricle, the future right auricle. 
After the heart has once reached this stage it is only 
to be separated into its right and left tubes to produce 
the mammalian heart. In some of the lower animals this 
never takes place, and in others it is only partial. In 
Fig. 224. 
Fig. 223.-Reconstruction of a Human Embryo enlarged sixteen times, 
and viewed from the left side. H, hypophysis ; 1, 2. 3, and 4, branchial 
pockets; M, mouth ; A, auricle ; F. ventricle; AD, descending aor- 
ta ; L, lung; S, stomach ; P, pancreas. 
Figs. 224 and 225.-Two Stages in the Formation of the Septum Inter- 
medium in the Heart of the Human Embryo. (From Quain, after His.) 
In A the septum is represented as growing from a triangular area to 
the left of the sino-auricular orifice ; in ZZ it has coalesced with the en- 
docardial cushions, and lies like a stopper in the auricular canal. 
r.a. and l.a., right and left auricle ; r.v. and l.v., right and left ven- 
tricle ; s.r., sinus renniens ; Eu.v., Eustachian valve ; s.sp., septum 
spuriuni : s.s., septum superior; s.inf., septum inferior; s.i., septum 
intermedium ; v.c.s., vena cava superior dextra. 
Fig. 225. 
cases of arrested development the human heart in the 
adult may show any of its embryological forms, as, for 
instance, an open foramen ovale. 
Figs. 224 and 225 show the interior of two stages of 
early human hearts, taken from models made by His. 
In Fig. 224, the auricle is quite enlarged and the vein 
enters on the right side. The ventricle is considerably 
smaller and its walls are much thicker than those of the 
auricle. This is usually the case with the hearts of em- 
bryos, as they die with the ventricles contracted and the 
auricles filled with blood. Between the two there is a 
narrowed auriculo-ventricular canal and with a corre- 
sponding constriction on the outside of the heart. Fig. 
225 shows a more advanced stage. The general state of 
The first important change in the separation of the 
heart into its two lobes is the formation of two septa, 
one arising in the auricle, S.8., which grows backward, 
and one in the ventricle, S.inf., which grows forward. 
At the same time that these are growing toward each 
other, a cushion of connective tissue, s.i., is formed upon 
the two lips of the slit-like auriculo-ventricular opening 
393 Heart. 
Heredity. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
which aids to complete the septum of the heart. This 
cushion, or septum intermedium, soon separates the au- 
riculo-ventricular opening into two canals, the right and 
the left, to become the right and left auriculo-ventricular 
canals, respectively. 
The septum of the auricle is completed by the septum 
superior growing backward to unite with the septum in- 
termedium. Before this takes place, however, several 
changes take place in the septum (Figs. 226, 227, and 228). 
the former it is multiple, and in the latter, as a rule, 
single. It is therefore seen that the formation of a sec- 
ondary or true foramen ovale, as described by Born, is 
confirmed by the comparative anatomical evidence (see 
Born, Arch. f. mik. Anat., Bd. 33, and Rose, Morph. 
Jahrbuch, Bd. 15 and 16). 
The opening of the vein is guarded by two folds of 
the walls of the heart, which really form a complete bi- 
cuspid valve (Fig. 225). An additional fold extends to 
Figs. 226, 227, and 228.-Side views of three stages, to show the formation of the foramen ovale. (After Born.) S', first portion of the superior 
septum; S", second portion of the superior septum; O', first foramen ovale; O", secondary opening or true foramen ovale; E.p., endothelial 
cushion in the auriculo-ventricular opening. 
Fig. 226. 
Fig. 227. 
Fig. 228. 
These figures represent three stages of a lateral view of 
the two septa above named, with the opening between 
them. In Fig. 226, the septum superior is forming, but 
the S. intermedium is not yet complete. It was at first 
thought that the opening between them, O', produced 
the foramen ovale, but later observations by Born show'ed 
that there is a secondary rupture in the septum superior 
which is destined to become the true foramen ovale (Fig. 
227, 0"). The portion of the septum superior which has 
been cut off by the formation of the foramen ovale, unites 
with the septum intermedium as shown in Fig. 227. The 
secondary septum, S", later on forms the limbus of Vieus- 
sens, and the first, S', the valve of the foramen ovale. 
A partial septum of the heart is first met with in cer- 
tain classes of ganoid fishes (Dipnoi), where it arises by a 
union of muscle-columns in the auricle. This is a very 
incomplete septum, which is gradually increased in the 
amphibia. In neither of these cases has the septum 
reached the auriculo-ventricular opening. This gives us 
this from in front, the septum spurium, S.sp. Later on, the 
orifice enlarges to incorporate a portion of the veins into the 
auricle, but the right lip of the opening remains perma- 
nently as the Eustachian valve. The pulmonary veins are 
formed later. They grow from the lungs to the left auricle. 
Returning to a stage of heart as represented in Fig. 
225, we notice that the common ventricle shows a con- 
striction on the outside which corresponds to a septum 
forming on the inside. As this septum from the inside, 
the septum inferius, grows toward the S. intermedium, it 
must also grow toward the aorta to join a septum aorti- 
cum which is forming there. Figs. 229-231, show how 
this is brought about. Fig. 229 represents a stage in 
which the auricles empty wholly on the left side and the 
aorta arises wholly on the right. As the inferior septum 
arises the auriculo-ventricular opening moves, as it were, 
toward the aorta ; and when the septum inf. unites with 
the S. intermedium it cuts the auriculo-ventricular open- 
ing in such a manner, that the blood coming from the 
Fig. 229. 
Fig. 230. 
Fig. 231. 
Figs. 229, 230, and 231.-Diagrams to Show the Formation of the Septum of the Ventricles and Bulb, and the Mode of Division of the Common 
Aunculo-ventricular Aperture. (From Quain, after Born.) r.v. and l.v., right and left ventricles ; s.inf., inferior septum ; b., bulb of aorta ; s.b., 
septum bulbi; au.vc., auriculo-ventricular canal; ao., aorta ; /J.a., pulmonary artery. 
an auricle partly divided, both compartments commu- 
nicating with each other, and through a common opening 
with a single ventricle, much as is shown in the heart of 
the human embryo pictured in Fig. 224. In the reptiles 
the septum is complete, and we have two distinct auricles 
communicating independently with the ventricle. We 
can view this as the completion of the second stage, i.e., 
a complete union of the septum superior and the septum 
intermedium. In birds and mammals, however, there 
is a secondary rupture of the septum of the auricle ; in 
right auricle passes to the right ventricle, and the blood 
from the left auricle to the left ventricle. A small open- 
ing exists for quite a while between the twp ventricles, 
but, later on, this is closed by a membrane of connective 
tissue. Before the ventricles are completely separated 
from each other, a view of the septum appears much as 
is shown in Fig. 232. The aorta is already completely 
separated into two vessels : the one which communicates 
with the right ventricle, communicating above with the 
fifth aortic arch, and the one from the left with the 
394 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Heart. 
Heredity. 
fourth. The fourth is destined to become the aorta, and 
the fifth the ductus arteriosus from which the pulmo- 
nary artery arises. 
At an early stage the tissue of the ventricle walls be- 
comes spongy on the inside. These meshes and columns 
play a very important part in the formation of the valves, 
the figure indicates, the primitive chordae tendinese are 
formed. Soon, however, the bands lose their muscle- 
fibres, in the portions which form the chordae, and in 
other portions, farther away from the valve, the muscle- 
fibres increase to form the papillary muscle. The valves 
have therefore a double origin : (1) Peripheral, and (2) 
from the septum intermedium. According to His, the 
tendons attached to the valves arising from the periphery, 
have their permanent attachment to the valve from the 
beginning, while a portion of those passing to the valve 
and arising from the septum intermedium may possibly 
shift their valvular attachment. 
The muscle-walls of the two ventricles are at first of 
the same thickness, but later on that of the left becomes 
heavier than that of the right. The spongy layer in the 
ventricle is covered with endocardium, and from this 
layer the column® earnest arise. 
Distinct muscle tissue is not present until the heart is 
quite well formed, although it begins to beat long before 
this. The nerves grow into the heart from the spinal 
ganglia, at a much later period, as shown by Onody and 
by W. His, Jr. Franklin P. Mall. 
HEREDITY. The progress of our knowledge in pathol- 
ogy and etiology constrains me to curtail the boundary 
of hereditary diseases since the former article under the 
above title was written. I am now satisfied that leprosy 
should be dropped from the list, and that heredity figures 
little in tuberculosis. Bacteriology has made good its claim 
on both diseases, and both are found to be transmissible 
in direct ratio with facilities for communication in the 
recognized habit of contagious maladies. The bacilli of 
the two diseases are strikingly similar, both morphologi- 
cally and in tardiness of growth and multiplication. 
Leprosy is never congenital and is never developed 
until months, and sometimes years, after contagion has 
had time to do its work. It is most prevalent among 
people whose habits of life bring them into closest social 
relations, and segregation of those affected is the most 
effectual mode of checking its spread. There is even less 
difficulty in tracing the probable or possible source of 
contagion than exists in the case of scarlatina and measles, 
though it is vastly less communicable. 
Congenital tuberculosis has been found in a very few in- 
stances within the last five years, and congenital pneumo- 
nia has been reported in at least one instance. The bacillus 
tuberculosis is sometimes found in the blood, associated 
with diffused miliary tuberculosis as causative of the lat- 
ter. It is conceivable that a woman affected with this form 
of the malady might communicate it to her unborn child 
through the placenta ; but it is not in accordance ■with 
the accepted etiology and known progress of tubercu- 
losis, to presume that its bacilli, taken into the blood of 
a foetus, may remain latent, with or without reproduc- 
tion, and the usual local effects be postponed for many 
years. It is quite reasonable that the opportunities for 
infection afforded by the close social relations of kin- 
dred dwelling together have been mistaken for heredity 
in this disease, as in leprosy. On the other hand, we 
have the experiment of Sanchez-Toledo, of Paris, who 
has injected pure cultures of Koch's bacillus tuberculosis 
into the jugular vein of pregnant guinea-pigs, but failed 
to find the bacilli in the blood or organs of the progeny, 
though the mothers became tuberculous. 
Uncured syphilis in either parent at time of procrea- 
tion, or during gestation in the mother, is quite apt to be 
transmitted to the foetus, but may be controlled by active 
treatment of the mother before parturition. Thorough 
eradication of the syphilitic virus by prolonged treatment 
terminates its transmissibility. 
As to gout, rheumatism, goitre tending to cretinism, 
scrofula, cancer, and the various neuroses, heredity figures 
as a predisposing factor in some obscure way. In the case 
of tuberculosis, predisposition probably means unusual 
susceptibility to the admission or action of the bacilli; 
perhaps extraordinary delicacy of epithelium in the res- 
piratory or intestinal tract,which may be inherited. We 
might even suppose a duplex inherited predisposition to 
syphilis, consisting in a delicate epithelium associated 
Fig. 232.-Opened Heart of a Human Embryo Seen in Profile. X 33 
times. (After His.) p., pulmonary artery; a., aorta; S.a., septum 
aorticum; S.inf., septum inferior ; S.s., septum superior; S.int., sep- 
tum intermedium; v.e., Eustachian valve; S.r., sinus reuniens; 
V.c.i., vena cava inferior ; Lb., liver ; D., diaphragm. 
muscle-columns, and the tendons to the valves. We have 
seen that the septum intermedium is formed in the 
auriculo-ventricular canal and divides it into a right and a 
left half. When this is complete a section of the heart 
gives a picture as shown in Fig. 233. At the same time 
Fig. 233.-Section through the Heart of a Human Embryo to Show the 
Formation of the Column® Carne®. X 36 times. (After His.) Oe., 
oesophagus; Lg., lung; M.pp.. membrana pleuro-pericardiaca ; 
S.r.d. and S.r.s., right and left horns of the sinus reuniens; F. E., 
Eustachian valve ; S.int., septum intermedium ; S.inf., septum infer- 
ior ; S.a., septum aorticum. 
a portion of the auricle is, as it were, pushed into the 
ventricle, as the figure shows. This invagination takes 
with it a portion of the epicardium, to be incorporated in 
the formation of the valve. Connective tissue is incor- 
porated in the formation of the valve at its beginning, 
although the great bulk of the valve is at this time com- 
posed of muscular fibres. The burrowing of the ven- 
tricle walls includes also the valves, and in this way, as 
395 Heredity. 
Heredity. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
with a propensity for promiscuous sexual indulgence. 
Whether such conjunction be most apt to occur in the 
sanguine temperament, is a point for investigation by the 
numerical method. S. S. Herrick. 
" Pan genesis of Germ-cells " and " Continuity of Germ- 
cells," according to the dominating idea in each. 
a. Pangenesis.-The idea pervading pangenesis was 
first expressed by Democritus that the " seed " of animals 
was derived by contributions of material particles from 
all parts of the bodies of both sexes, and that like parts 
produced like. Two thousand years later, Buffon revived 
this conception of heredity in his "molecules orga- 
niques." In 1864 Herbert Spencer suggested the ex- 
HEREDITY IN THE OVUM AND SPERMATOZOON.1 
The purpose of this article is to give a summary of recent 
researches upon the structure and relations of the male 
and female germ-cells in connection with the phenomena 
of reproduction and heredity. 
Much progress has been made of 
late years in the knowledge of the 
stages through which the ovum and 
spermatozoon pass before and after 
union, and in the abnormal effects 
produced by experimental, chemical, 
and mechanical disturbances. The 
latter bear directly upon teratology. 
Speculation and investigation upon 
heredity have kept pace with em- 
bryological research, and at the 
present time the marvellous trans- 
formation of an infinitesimal speck of 
protoplasm (the fertilized ovum) in- 
to the adult body with its hereditary 
structure and tendencies, is under 
the focus of researches in the follow- 
ing branches of biological science : 
A. Development of the Race. 
-Heredity.-1. Speculative, includ- 
ing theories of Pangenesis and Con- 
tinuity of Germ-plasm, Darwin, 
Weismann, etc. 
2. Anthropological, including data 
from human anatomy and anthro- 
pology, teratology, etc. 
3. Comparative, including data 
from the evolution of lower types 
of animals (palaeontology). 
4. Experimental (or experimental 
evolution), including influences upon 
offspring of experiments upon the 
structure, function, or environment 
of parents. Systematic researches 
in this line have just begun. 
B. Development of the Indi- 
vidual.-Embryology. 5. Normal, 
including the phenomena of ovogen- 
esis and spermatogenesis, fertiliza- 
tion, histogenesis, intercellular ac- 
tion, as derived from study of lower 
types of animals and plants. 
6. Experimental, the diversion of 
normal phenomena by mechanical, 
chemical, and thermal experiments 
upon different stages of development. 
It will be seen that the two objects 
of investigation are 
The Body-cells, or Soma, - the ex- 
pression of Heredity. 
The Germ-cells = the potential 
vehicles of Heredity. 
The many problems resolve them- 
selves into the simple questions : 
How do the parent germ-cells trans- 
form into the offspring body, and how 
does the latter influence the new germ- 
cells, or, what are the total relations 
between the body-cells and germ-cells ' 
A. Development of the Race.-1. Speculative He- 
redity.- In a valuable summary of the past theories of he- 
redity 2 J. A. Thomson distinguishes three general prob- 
lems, which are often confused. 1st. What characters dis- 
tinguish the germ-cells from other cells of the body ? 2d. 
How do the germ-cells derive these distinguishing charac- 
ters ? 3d. How shall we interpret " particulate " inheri- 
tance, or the reappearance of single peculiarities in the 
offspring ? 
The various theories may be grouped under two heads, 
First generation. Second generation. Third generation. 
Fig. 234.-Illustrating, I. Normal Histogenesis ; II. Theory of Pangenesis; III. 
Theory of Continuity of Germ-plasm. The fertilized ovum (f.o.) contains the ma- 
ternal and paternal characteristics. This expands into the adult body, or Soma (S'), composed of 
somatic cells (n, s, m, d. v) constituting the nervous, secretory, muscular, digestive, and other tis- 
sues, besides the germ-cells (G) of the reproductive organs. I. Histogenesis.-Showing the succes- 
sive rise, G, and union, f.o., of the maternal and paternal germ-cells by direct histogenesis. II. 
Pangenesis.-Showing the tissues of the body N, contributing to the germ-cells G, so that each 
f.o. is composed of elements (gemmules) from both the somatic and germ-cells. III. Continuity 
of the Germ-plasm.-Showing the division of the embryo, f.o., into somatoplasm, s (from which 
arise the body-cells), and germ-plasm, G (which passes direct to the germ-cells), establishing a 
direct continuity. 
istence of " physiological units," derived from the body- 
cells of the parent, forming the germ-cells and then 
developing into the body-cells of the offspring. This the- 
ory is designed to explain how changes in the body-cells 
of the parent can be transmitted to the offspring. ("Use- 
inheritance, or "inheritance of acquired characters "). 
It is interesting to note the course of Darwin's thought 
upon this matter in his published works and in his " Life 
and Letters." He was at first strongly opposed to the 
views advanced by Buffon, by Erasmus Darwin, and ex- 
396 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Heredity. 
Heredity. 
panded by Lamarck, that changes in the parents are 
transmitted to offspring, as the main cause of evolution. 
But gradually becoming convinced that his own theory 
of natural selection could not account for all the facts of 
evolution, he unconsciously became a strong advocate of 
Lamarck's theory and contributed to it a feature which 
Lamarck had entirely omitted, namely, a theory of he- 
redity expressly designed to explain the transmission of 
acquired characters. Darwin's " provisional hypothesis 
of pangenesis "3 postulated a material connection between 
the body-cells and germ-cells by the circulation of mi- 
nute buds from each cell; each body-cell throws off a 
"gemmule" containing its characteristics; these gem- 
mules multiply and become especially concentrated in the 
germ-cells ; in the latter they unite with others like them- 
selves ; in course of development they grow into cells 
like those from which they were originally given off 
(see Fig. 234). 
Galton,4 who has always been doubtful in regard to use- 
inheritance, while advancing a theory of " continuity," 
partly approved Darwin's pangenesis idea in the cautious 
statement: "Each cell may throw off a few germs that 
find their way into the circulation and thereby have a 
chance of entering the germ-cells." At the same time 
Galton contributed very important experimental disproof 
of the existence of " gemmules," and, in fact, of the 
popular idea of the circulation of hereditary characters 
in the blood, by a series of careful experiments upon the 
transfusion of blood in rabbits ; he found that transfused 
blood did not convey with it even the slightest tendency 
to transfer normal characteristics from one variety of 
rabbit to another. 
Professor Brooks,6 of the Johns Hopkins University, 
then contributed an original modification of pangenesis in 
which the functions of the ova and spermatozoa were 
sharply differentiated. (1) He regarded the ovum as a 
cell especially designed as a storehouse of hereditary 
characteristics, each characteristic being represented by 
material particles of some kind ; thus hereditary charac- 
ters were handed down by simple cell division, each 
fertilized ovum giving rise to the body-cells in which its 
hereditary characters were manifested, and to new ova in 
which these characters were conserved for the next gen- 
eration (this portion of Brooks's theory is very similar to 
Galton's and Weismann's). (2) The body-cells have the 
power of throwing off " gemmules," but this is exercised 
mainly or exclusively when its normal functions are dis- 
turbed, as in metatrophic exercise or under change of en- 
vironment. (3) These gemmules may enter the ovum, 
but the spermatozoon is their main centre. According 
to this view the female cell is rather conservative and the 
male cell progressive ; the union of these cells produces 
variability in the offspring, exhibited especially in re- 
gions of the offspring corresponding to the regions of 
functional disturbance in the parent. This hypothesis 
was well considered, and while that feature of it which 
distinguishes the male and female germ-cells as different 
in kind has been disproved, and the whole conception of 
gemmules is now abandoned, the fact still remains that 
we shall nevertheless be obliged to offer some hypothesis 
to explain the facts disregarded by Weismann for which 
Brooks provides in his theory of the causes of variation. 
b. Continuity of Germ-cells.-The central idea here is 
an outgrowth of our more modern knowledge of embry- 
ogenesis and histogenesis, and is, therefore, comparatively 
recent ; it is that of a fundamental distinction between 
the "germ-cells," as continuous and belonging to the 
race, and the " body-cells," as belonging to the individual. 
Weismann has refined and elaborated this idea, but it 
was not original with him. 
Richard Owen," in 1849, Haeckel,7 in 1866, Rauber,8 
in 1879, in turn, dwelt upon the distinction which Dr. 
Jaeger, now of manufacturing fame, first clearly stated : 
" Through a great series of generations the germinal 
protoplasm retains its specific properties, dividing in every 
reproduction into an ontogenetic portion, out of which 
the individual is built up, and a phylogenetic portion, 
which is reserved to form the reproductive material of 
the mature offspring. This reservation of the phylo- 
(SUPPLEMENT.) 
genetic material I- described as the continuity of the 
germ protoplasm. . . . Encapsuled in the ontoge- 
netic material the phylogenetic protoplasm is sheltered 
from external influences, and retains its specific and em- 
bryonic characters." The latter idea has, under Weis- 
mann, been expanded into the theory of isolation of the 
germ-cells. 
Galton introduced the term "stirp" to express the 
sum total of hereditary organic units contained in the 
fertilized ovum. His conception of heredity was derived 
from the study of man, and he supported the idea of 
continuity in the germ-cells in order to account for the 
law of transmission of "latent" characters ; it is evident 
from this law that only a part of the organic units of the 
" stirp " become " patent " in the individual body ; some 
are retained latent in the germ-cells, and become patent 
only in the next or some succeeding generation. For 
example, the genius for natural science was "patent" 
in Erasmus Darwin, grandfather of the great naturalist, 
•it was " latent " in his son, and reappeared intensified 
in his grandson, Charles Darwin. 
Weismann has carried the hypothesis of continuity to 
its extreme in his simple and beautiful theory of heredity, 
which is founded upon the postulate that there is a dis- 
tinct form of protoplasm, with definite chemical and molecu- 
lar properties, set apart as the vehicle of inheritance ; this 
is the germ-plasm, G, quite separate from the protoplasm 
of the body-cells or somatoplasm, S. Congenital characters 
arise in the germ-cells and are therefore blastogenetic, 
while acquired characters arise in the body-cells and 
may be called somatogenetic. 
To clearly understand Weismann's hypothesis, let 
us follow his history of the fertilized ovum in the forma- 
tion of the embryo. It first divides into somatoplasm 
and germ-plasm (see Figure 234, III.) ; the somatoplasm 
supplies all the tissues of the body-n, s, m, d, v, ner- 
vous, muscular, vascular, digestive, etc.-with their 
quota of hereditary structure ; the germ-plasm is kept 
distinct, throughout this early process of embryonic cell- 
division, until it entei's into the formation of the nuclei 
of the new reproductive cells, the ova or spermatozoa of 
the next generation. Here it is isolated from the changes 
of function in the somatoplasm, and in common with all 
other protoplasm is capable of unlimited growth by cell- 
division without loss or deterioration of its past store of 
hereditary properties ; these properties are lodged in the 
nucleus of each ovum and spermatozoon, and these two 
cells, although widely different in external accessory 
structure (because they have to play an active and pas- 
sive part in the act of conjugation), are exactly the same 
in their essential molecular structure, and the ancestral 
characters they convey differ only because they come 
along two different lines of descent. When these cells 
unite they carry the germ-plasm into the body of another 
individual. Thus, while the somatoplasm of each indi- 
vidual dies, the germ-plasm is immortal and simply 
shifts its abode from one generation to another ; it con- 
stitutes the chain from which the individuals are mere 
offshoots. Thus the germ-plasm of man is continuous 
with that of all ancestors in his line of descent, and we 
have an explanation of the early stages observed in de- 
velopment in which the human embryo passes through a 
succession of metamorphoses resembling the adult forms 
of lower types of animals (Von Baer's law). 
In order to emphasize, as it were, the passage of the 
germ-plasm from one generation to another without de- 
terioration in its marvellous hereditary powers, Weismann 
added the idea of its physiological isolation. Not only 
does he repudiate the pangenesis notion of increment of 
germ-plasm by addition of gemmules, but he believes 
that it is unaffected by any of the normal changes in the 
somatic or body-cells. As this continuity and isolation 
would render impossible the transmission of characters 
acquired by the somatoplasm, Weismann began to ex- 
amine the evidence for such transmission, and coming to 
the conclusion that it was insufficient, in his notable 
essay on " Heredity," in 1883, he boldly attacked the 
whole Lamarckian theory, and has continued to do so in 
all his subsequent essays. 
397 Heredity. 
Heredity. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Being forced to explain evolution without this factor, 
he claimed that variation in the germ-plasm was con- 
stantly arising by the union of plasmata from different 
lines of ancestral descent which occurs in fertilization, 
and that these variations are constantly being acted upon 
by Natural Selection to produce new types. He thus re- 
vived Darwin's earlier views of evolution, and this in 
part explains his strong support by English naturalists. 
Weismann admits the general principle of ovumsanum 
in oorpore sano, but denies that any local specific disor- 
ders or changes in the parent body which- are not congen- 
ital (i.e., in the parental germ-plasm) ever result in sim- 
ilar specific localized disorders or changes in the offspring 
body. The mutilation of a parent will not reappear in 
the loss or abnormal development of the same structure 
in the child. The effects of use and disuse are not in- 
herited. In these opinions of Weismann, Kolliker, His, 
Pfluger, Ziegler, and other eminent anatomists and phy- 
siologists concur. 
Speculative Heredity has not yet produced a satisfac-» 
tory theory of hereditary transmission. Weismann's 
"germ-plasm," as a distinct substance, is disproved by 
recent embryology-there is no such continuous and 
specific form of protoplasm confined to certain cells. (See 
Histogenesis.) 
We conclude this section by a brief statement of what 
is required in a complete working theory of heredity. 
The matter of first importance in life is the repetition and 
preservation of type, the principle which insures the un- 
erring accuracy and precision with which complex organs 
are built up from the germ-cells ; the force of regression 
and the more remote forces of reversion all work in this 
conservative direction. 
The matter of second importance, but equally vital to 
the preservation of races, in the long run, is the forma- 
tion of new types adapted to new circumstances of life. 
In the following table are placed some of the facts of 
human evolution, and as they are part of inheritance, 
they also constitute the main external phenomena of 
heredity . 
renewed interest. I would first call attention to the fact 
that this matter has only an indirect bearing, for a mutila- 
tion is something impressed upon the organism from with- 
out ; it is not truly " acquired ; " the loss of a part by 
accident produces a sudden but a less profound internal 
modification of the organism than the loss of a part by 
degeneration. Most of the results are negative; many 
of the so-called " certain " cases prove upon investigation 
to be mere coincidences. Weismann9 himself experi- 
mented upon white mice, and showed that nine hundred 
and one young were produced by five generations of ar- 
tifically mutilated parents, and yet there was not a single 
example of a rudimentary tail or of any other abnormality 
in this organ. The cases of cleft ear-lobule have recently 
been summed up.10 Israel reports two cases of clefts in 
which the parents' ears were normal. Schmidt and Orn- 
stein report affirmative cases. His shows that an affirm- 
ative case, cited by V. Zwiecki, is merely an inherited 
peculiarity. The entire evidence is unsatisfactory, and, 
upon the whole, is decidedly negative. 
Not so, however, in cases where the mutilation results 
in a general disturbance of the normal functions of dif- 
ferent organs, as in the experiments conducted by Brown- 
Sequard 11 upon guinea-pigs, in which we see " acquired 
variation" intensified. In these, abnormal degeneration 
of the toes, muscular atrophy of the thigh, epilepsy, ex- 
ophthalmia, etc., appeared in the descendants of animals 
in which the spinal cord or sciatic nerve had been severed, 
or portions of the brain removed. It was also shown that 
the female is more apt to transmit morbid states than the 
male ; that the inheritance of these in juries may pass over 
one generation and reappear in the second ; that the 
transmission by heredity of these pathological results may 
continue for five or six generations, when the normal 
structure of the organ reappears. These cases, which 
are incontestable, at first sight appear to establish firmly 
the transmission of acquired characters ; they were so 
regarded by Browm-Sequard. These lesions act directly 
upon the organs, and the abnormal growth in these or- 
gans appears to be transmitted. But can they not be in- 
terpreted in another way, namely, that the pathological 
condition of the nerve-centres has induced a direct dis- 
turbance in those portions of the germ-cells which repre- 
sent and will develop into the corresponding organs of 
the future offspring ? 
b. Previous Fertilization.-Consider next the influence 
exerted upon the female germ-cell by the mere proximity 
of the male germ-cell, as exhibited in the transmission of 
the characteristics of one sire to the offspring of a suc- 
ceeding sire, observed in animals, including the human 
species, also in plants. The best example is the oft- 
quoted case of Lord Morton's mare, which reproduced 
in the foal of a pure Arab sire the zebra markings of a 
previous quagga sire. 
Some physiologists have attempted to account for 
these remarkable indirect results from previous fertil- 
ization or impregnation, by the imagination of the 
mother having been strongly affected, or from inter- 
change between the freely inter-communicating circula- 
tion of the embryo and mother, but the analogy from the 
action in plants (in which there is no gestation but early 
detachment and development of che fertilized cells) 
strongly supports the belief that the proximity of male 
germ-cells acts directly upon the female cells in the 
ovary. All that we can deduce from these facts is that 
in some manner the normal characteristics and tenden- 
cies of the ova are modified by the foreign male germ- 
cells without either contact or fertilization. 
c. Maternal Impression.-The influence of maternal im- 
pressions in the causation of definite anomalies in the 
foetus is largely a matter of individual opinion. 
It is denied by some high authorities, led by Bergmann 
and Leuckart. Many medical practitioners, however, 
believe in it, and I need hardly add that it is a very gen- 
eral popular belief, supported by numerous cases. The 
bearing which this mooted problem has upon the discus- 
sion is this : if a deviation in the development of a child is 
produced by maternal impression, we have a proof that 
deviation from normal hereditary tendencies can be pro- 
Phenomena of Heredity. 
Conservative 
(toward past type). 
Neutral. 
Progressive 
(toward future type). 
a. Repetition of parental 
type. 
Fortuitous 
and 
a. Definite Variation in 
single characters, 
by accumulation =: 
b. Regression (in many 
characters) to con- 
temporary race 
Indefinite 
b. Definite Variation in 
m a n y characters 
(from contemporary 
type. 
race type). 
c. Reversion (mainly in 
single characters) 
to past race type. 
Variability. 
2 and 3. Anthropological and Comparative Heredity.- 
The bearing of these branches of study upon heredity is 
as follows : Is there any proof that definite changes in 
the body, whether due to physiological and anatomical ef- 
fects of certain trades or occupations, or to accidents, or 
to pathological changes, produce corresponding changes 
in the ova and spermatozoa, so as to reappear in offspring. 
The supposed influences of certain occupations has, for 
example, been discussed by Arbuthnot Lane, in a series 
of papers in the Journal of Anatomy and, Physiology ; he 
maintains the theory of inheritance of functionally pro- 
duced modifications. 
If such inheritance does take place there must be some 
interchange of material (as implied by Pangenesis) or of 
forces between the parent body and the reproductive cells. 
a. Physiological Data.-There are three phenomena 
about which there is much scepticism, to say the least, 
which bear upon the question of a possible interchange 
of forces between the body and the germ-cells. These are 
the inheritance of mutilations, the influence of previous 
fertilization, and the influence of maternal impressions. 
They are all in the quasi-scientific realm, which embraces 
such mental phenomena as telepathy. That is, we incline 
to deny them simply because we cannot explain them. 
a. Mutilations.-Since the publication of Weismann's 
essays the subject of inherited mutilations has attracted 
398 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Heredity. 
Heredity. 
(SUPPLEMENT.) 
duced without either direct vascular or nervous con- 
tinuity. 
We see that there exists an analogy between the experi- 
ments of Brown-Sequard and Obersteiner, the influence 
of the previous sire and the influence of maternal im- 
pressions. These three classes of phenomena all tend to 
show that the hereditary forces which normally repro- 
duce organs in their typical and perfect form may be 
checked or diverted by other forces which exert a pro- 
found abnormal influence upon the body, chiefly through 
the nervous system. This diversion of the normal direc- 
tion of heredity, in the opinion of the writer, compels us 
to assume that there is some functional and structural 
connection between the body-cells and the germ-cells, the 
nature of which is at present wholly unknown. Our 
ignorance as to the nature of this connection between the 
body-cells and germ-cells does not compel us to deny that 
it exists. To discover this link is now one of the chief 
ends of biology. 
3 Morphological Data.-We must keep in mind that 
the body-cells (somatoplasm) and germ-cells (germ-plasm) 
were originally one, as in all single-celled organisms like 
the amoeba. In course of evolution the separation of 
these two kinds of cells proceeded gradually, and com- 
parative heredity shows that the power of reproduction 
may not be confined to the germ-cells but may extend in 
a feebler degree into the body-cells as well. 
a. The separation of the germ-cells is in the regular 
order of evolution upon the principles of physiological 
division of labor. The unicellular organisms combine 
all the functions of life in a single mass of protoplasm, 
that is, in one cell. In the rise of the multicellular or- 
ganisms the various functions are distributed into groups 
of cells, which specialize in the perfecting of a single 
function. Thus the reproductive cells should fall into 
the natural order of histogenesis, and the theory of their 
entire separation is more consistent with the laws govern- 
ing the other tissues than the theory which we find our- 
selves obliged to adopt, that while separate they are still 
united by some unknown threads with the other cells. 
(Fig. 234, I.) 
The structural separation of what we may call the race- 
protoplasm becomes more and more sharply defined in 
the ascending scale of organisms. Weismann's conten- 
tion as to the absolutely distinct specific nature of the 
germ-plasm and somatoplasm has, however, to meet the 
apparently insuperable difficulty that in many multi- 
cellular organisms, even of a high order, the potential 
capacity of repeating complex hereditary characters, and 
even of producing perfect germ-cells, is widely distri- 
buted through the tissues. 
For example, cuttings from the leaves of the well- 
known hot-house plant, Begonia, or portions of the stems 
of the common willow-tree, are capable of reproducing 
complete new individuals. This would indicate either 
that portions of the germ-plasm are distributed through 
the tissues of these organisms, or that each body-cell has 
retained its potential quota of hereditary characters. 
Among the lower animals we find the same power; if 
we cut a hydra or bell-animalcule into a dozen pieces, 
each may reproduce a perfect new individual. As we 
ascend in the animal scale the power is confined to the 
reproduction of a lost part in the process known as re- 
crescence. As we well know, in the group to which the 
frog and salamande? belong, a limb or tail, or even a 
lower jaw, may be reproduced. The only logical inter- 
pretation of these phenomena is, that the hereditary 
powers are distributed in the entire protoplasm of the 
organism, and the capacity of reproduction is not ex- 
hausted in the original formation of the limb, but is 
capable of being repeated. 
There has been considerable discussion of late as to the 
seat of this power of recrescence. It seems not impossible 
that, in the vertebrates, it may be stored in the germ-cells, 
and it would be very interesting to ascertain experi- 
mentally whether removal of these cells would in any 
way limit or affect this power ; we know that such re- 
moval in castration or ovariotomy sometimes profoundly 
modifies the entire nature of the organism, causing male 
characters to appear in the female, and female characters 
to develop in the male. 
So far as man is concerned it has been claimed by sur- 
geons that genuine recrescence sometimes occurs; for 
example, that a new head is formed upon the femur after 
exsection ; Dr. V. P. Gibney informs the writer that this 
is an exaggeration, that there is no tendency to reproduce 
a true head, but that a pseudo-head is formed, which may 
be explained upon the principle of regeneration and in- 
dividual transformism by use of the limb. 
Pfliiger's opinion is that recrescence does not indicate 
a storage of hereditary power, that there is no pre-exist- 
ing germ of the member, but that the re-growth is due to 
the organizing and distributing power of the cells at the 
exposed surface, so that, as new formative matter arrives, 
it is built up gradually into the limb. This view would 
reduce recrescence to the level of the regeneration pro- 
cess which unites two cut sections of the elements of a 
limb in their former order. It is partly opposed to the 
facts above referred lo, which seem to prove the distri- 
bution of the hereditary power. Yet it seems quite con- 
sistent to consider these three processes-a, reproduction 
of a new individual from every part; b, recrescence of a 
new member from any part; c, regeneration of lost tis- 
sues-as three steps indicating the gradual, but not entire 
withdrawal of the reproductive power from the body-cells 
into the germ-cells. 
Among the reasons for believing in the complete separa- 
tion of the germ-cells in man are the following : The very 
early differentiation of these cells in the embryo, observed 
with a few exceptions in all the lower orders of animals, 
and advancing so rapidly in the human female that 
several months before birth the number of primordial 
ova is estimated at seventy thousand, and is not believed 
to be increased after the age of two and a half years. 
The most patent practical proof is that we may remove 
every portion of the body which is not essential to life 
and yet the power of complete reproduction of a new in- 
dividual from the germ-cells is unimpaired. Among the 
many reasons advanced for pensioning the crippled 
soldiers of our late war we never hear it urged that their 
children are incapacitated by inheritance of injuries. 
The strongest proof, however, rests in the evidence which 
may be cited from heredity of the extraordinary stability 
of the germ-cells which is the safeguard of the race. 
b. The specific nature of the germ-plasm must be con- 
sidered before we consider its relations. Wherein lies 
the conservative power of the germ-plasm, and in what 
direction shall we look Tor its transforming forces ? You 
see at once that marvellous as is the growth of cells in 
other tissues, the growth of the germ-cell is still more so. 
We find it utterly impossible to form any conception 
of the contents of the microcosmic nucleus of the human 
fertilized ovum, which is less than of an inch in di- 
ameter, but which is, nevertheless, capable of producing 
hundreds of thousands of cells like itself, as well as all 
the unlike cells of the adult organism. We can only 
translate our ideas as to the possible contents of this 
nucleus in the terms of chemistry and physics.1 
According to the general law the germ-cell is consid- 
ered as matter potentially alive and having within itself 
the tendency to assume a definite living form in course of 
individual development. The nucleus must be extraor- 
dinarily complex, for it contains within itself not only 
the tendencies of the present type, but of past types far dis- 
tant. The supposition of a vast number of germs of struct- 
ure is required by the phenomena of heredity; Nageli 
has demonstrated that even in so minute a space as took 
cub. millimetre, 400,000,000 micellae must be present. 
Speculation has also been active in this field. Spencer 4 
assumed an order of molecules or units of protoplasm 
lower in degreethan the visible cell-units, to the internal 
or polar forces of which, and their modification by ex- 
ternal agencies and interaction, he ascribed the ultimate 
responsibility in reproduction, heredity, and adaptation. 
This idea of biological units seems to the writer an es- 
sential part of any theory; it is embodied in Darwin's 
" gemmules," in Haeckel's " plastidules," yet, as Lankes- 
399 Heredity. 
Heredity. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
ter says, the rapid accumulation of bulk is a theoretical 
difficulty in the material conception of units. In the 
direction of establishing some analogy between the repe- 
tition power of heredity and other better-known func- 
tions of protoplasm, Haeckel and Hering have likened 
heredity to memory, and advanced the hypothesis of per- 
sistence of certain undulatory movements ; the undula- 
tions being susceptible of change and therefore of pro- 
ducing variability, while their tendency to persist in their 
established harmony is the basis of heredity. Berthold, 
Gautier, and Geddes13 have speculated in the elaboration of 
the idea of metabolism ; the former holding the view that 
"inheritance is possible only upon the basis of the funda- 
mental fact that in the chemical processes of the organism 
the same substances and mixtures of substances are repro- 
duced in quantity and quality with regular periodicity." 
We have merely touched upon these speculations to 
show that the unknown factors in heredity are also the 
unknown factors in operation in living matter. All wTe 
can study is the external form, and conjecture that this 
form represents matter arranged in a.certain way by forces 
peculiar to the organism. These forces are exhibited or 
patent in the somatic cells ; they are potential or latent in 
the germ-cells. 
4. Experimental Heredity.-We must refer here again 
to the experiments of Brown-Sequard and of Obersteiner 
upon guinea-pigs, and to work which is now being in- 
stituted in France, and to some extent in England and 
Germany. This promises to be a most fruitful field of 
research by which the truth or falsity of Weismann's 
theory of heredity will be finally established. 
Experimental evolution or heredity seeks to determine 
chiefly whether modifications produced in the parent, or 
a series of parents, are transmitted to offspring. To test 
the supposed inheritance of mutilations, Weismann has 
cut the tails off nine successive generations of mice 
without producing the slightest diminution of the tail in 
later generations. It will be possible to test the problem 
of maternal impressions, and the firmly established be- 
lief of breeders, that an ill-bred sire injures all the subse- 
quent offspring of well-bred sires. Thus far no abso- 
lutely satisfactory results of this kind of experimental 
work have been recorded. 
B. The Development of the Individual. - 5. 
Normal Embryology.-The structure and physiology of 
the germ-cells will ultimately yield the physical basis of 
the science of heredity. After all, the data which may 
be gathered from the four branches of heredity above 
considered are only indirect, the direct data must come 
from embryology. In the actual material and dynamics 
of the germ-cells and their relation to body dynamics we 
look for the physical basis of the following phenomena : 
a, Repetition of parental characters ; b, variations from 
parental characters ; c, reversion to ancestral characters ; 
d, prepotency of one sex over the other ; e, causes of de- 
termination of sex ; f, causes of anomalies, monstros- 
ities, abnormal births, multiple births. Some of these 
latter phenomena («,/,) occur in course of development 
of the embryo ; others can be traced directly back to the 
germ-cells in their earliest stages. 
The Sexes.-We have naturally come to look upon the 
two sexes as fundamentally distinct. As regards hered- 
ity and our present study, they are fundamentally sim- 
ilar. Unlike as the male and female, the ovum and 
spermatozoon, are in external appearance, all the ma- 
terial and mechanism of inheritance is exactly the same 
in each. Sex is a secondary distinction, both in evolu- 
tion and in the development of the individual. 
The causes finally determining sex may come surpris- 
ingly late in development, and, according to the investi- 
gations of Diising, and the experiments of Yung and of 
Giron,13 are directly related to nutrition. High feeding 
favors an increase of the percentage of females, while, 
conversely, low feeding increases the males. In Yung's 
experiments with tadpoles the following results were ob- 
tained : 
Females. Males. 
Normal percentage 57 43 
High nutrition 92 8 
(SUPPLEMENT.) 
Geddes expresses this principle in physiological terms 
of metabolism, that anabolic (constructive) conditions 
produce females, while katabolic (destructive) conditions 
produce males. 
I think we may now safely eliminate the factor of sex 
from our calculations upon the problem of heredity, and 
thus rid ourselves of one of the oldest and most wide- 
spread fallacies. We shall thus, in using the terms " pa- 
ternal" and "maternal," imply merely the distinction 
between the qualities of two lines of ancestral descent. 
Asexual Conjugation. - Let us, therefore, first con- 
sider Reproduction (Conjugation and Development) in 
those lower single-celled organisms in which there is no 
sex-such as the Amoeba, or the somewhat higher types 
of Ciliated Infusoria. Of the forms described below, 
Stylonichia is an animalcule varying in diameter from 
one-eleventh to one-third millimetre ; it is free, swimming 
in stagnant water, or it sometimes creeps on the surface 
of plants. Glaucoma is also found in ponds, and swims 
by means of five cilia upon its ventral surface. 
Maupas on Conjugation among the InfusoriaN-Among 
the newer researches which throw light upon this old 
problem, those of Maupas are certainly the most brill- 
iant. After a most exact and arduous research, extend- 
ing over several years, he collected his results in two 
memoirs, published in 1889 and 1890. 
His experiments were first directed upon the laws of 
direct multiplication by fission, or direct division of the 
cell. These revealed a complete cycle of life without 
conjugation in the single-celled Infusoria, and showed 
that after a long period this mode of reproduction be- 
comes less vigorous, then declines, and finally ceases 
altogether unless the stock is rejuvenated by union with 
individuals of different broods, or conjugation. In other 
words, these broods of minute organisms grow old and 
die unless they are enabled to fertilize each other by an 
exchange of hereditary substance altogether analogous 
to that observed in the higher multicellular organisms. 
The cultures were made in a drop of water upon a 
slide, and feeding was adapted either to the herbivorous 
or carnivorous habits of the species. Under these condi- 
tions it was found that the rate of fission, or direct repro- 
duction by division, varied directly with the temperature 
and food, rising in some species (Glaucoma scintillans) to 
five bipartitions daily. With the optimum of condi- 
tions this rate, if sustained for thirty-eight days, would 
produce from a single individual a mass of protoplasm 
equivalent to the 'volume of the sun. This rate was, 
however, found to be steady for a time, and then the off- 
spring decline into "senescence," in which they appear 
at times only one-fourth the original size, with reduced 
organs and degenerate nuclear apparatus. This is reached 
sooner in some species than in others ; Stylonichia pus- 
tulata survives three hundred and sixteen generations by 
fission, while Leucophrys patula persists to six hundred 
and sixty generations. Finally, even under the most fa- 
vorable conditions of environment, death ensues. 
Death does not ensue where conjugation is facilitated 
by mingling the offspring of different broods in the same 
fluid, as in the natural state. Maupas soon discovered 
that exhaustion of food would hasten conjugation be- 
tween members of mixed broods. He thus could watch 
every feature of the conjugation process, and determine 
all the phases in the cycle of life. These differed, as in 
the longevity of the species. In Stylonichia, for example, 
" immaturity " extended over the first one hundred bipar- 
titions ; "puberty," or the earliest phase favorable to con- 
jugation, set in with the one hundred and thirtieth bipar- 
tition ; "eugamy," or the most favorable conjugation 
phase, extended to the one hundred and seventieth ; then 
"senescence" set in, characterized by a sexual hypencs- 
thesia in which conjugation was void of result or rejuve- 
nescence, owing apparently to the destruction of the 
essential nuclear apparatus. 
Conjugation begins with the approach of two individ- 
uals, and adhesion by their oral surfaces. There is no 
fusion, but an immediate transformation in the cell 
contents of each individual sets in, concluding with an 
interchange of nuclear substance. In each cell Maupas 
400 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Heredity. 
Heredity. 
distinguishes between the (M) meganucleus (Fig. 235 ; the 
macronucleus, nucleus, endoplast of authors), which pre- 
sides over nutrition and growth, and divides by constric- 
tion, and the (m) micronucleus (paranucleus, nucleolus of 
authors), which presides over the preservation of the 
species. The latter contains chromatin ; it is the seat of 
rejuvenescence, the basis of heredity, it divides by mitosis, 
showing all the typical stages of karyokinesis excepting 
the loss of the cell membrane. 
The transformation in each of these copulating cells 
first affects the centres of hereditary substance, viz., the 
micronuclei ; they divide three times ; thus the micro- 
nuclear substance is reduced to one-fourth of its original 
bulk. It is contained in two surviving micronuclei (the 
others being absorbed or eliminated), one of which mi- 
grates into the adjoining cell ; the other remains station- 
ary. This migration is followed by a fusion of the 
migrant and stationary micronuclei; this fusion effects a 
complete interchange of hereditary substance, after which 
of two individuals. 2. That before union the hereditary 
substance in each is greatly reduced. 3. That there is 
no real line between male and female, the conjugating 
cells are simply in a similar physiological condition 
wherein a mingling of hereditary characteristics affords 
a new lease of life. As Maupas says : 
" Les differences appelees sexuelles portent sur des faits 
et des phenomenes purement accessoires de la feconda- 
tion. La fecondation consiste uniquement dans la re- 
union et la copulation de deux noyaux semblables et 
equivalents, mais provenus de deux cellules distinctes." 
In this conclusion as to the secondary and superficial, 
rather than fundamental, difference between the two 
sexes, Maupas simply confirms the views of Strassburgcr 
the botanist, Hensen, R. and O. Hertwig, Weismann, 
and others, namely, that sex has evolved from the necessity 
of cell conjugation ; that even in the higher forms the cells 
born by the two sexes are absolutely neutral so far as sex is 
concerned ; the wide difference of form of the germ-cells is a 
Fig. 235.-The Conjugation of Infusoria. (From Weismann, after Maupas.) 1, Two infusoria copulating; M. meganucleus : m, micronucleus ; 2-5, 
successive divisions of micronuclei; 6, fertilization by the migration of one of the persisting micronuclei from each infusorian into the other; 7, 
union of the interchanged micronuclei. 
the two infusoria separate and enter upon a new' life cycle. 
Meanwhile the meganucleus breaks up and is reconsti- 
tuted in each fertilized cell. 
Maupas gathers from these interesting phenomena ad- 
ditional proof that the chromatin of all cells bears the 
inherited characteristics, and that the cytoplasm and nu- 
cleoplasm, or achromatin, is the dynamic agent, because 
the micronuclei bearing the chromatin * are the only 
structures which are permanent and persistent, all the 
other structures - nucleoplasm, cytoplasm, etc. - being 
replaced and renewed. The reduction of the chromatin 
is purely quantitative, the eliminated and fertilizing 
micronuclei being exactly equivalent ; after the chro- 
matin has been quartered the cell becomes incapable of 
further activity until it is reinforced by chromatin from 
the other copulating cell. 
No Distinction between the Sexes in Heredity.-The three 
laws which underlie these phenomena are: 1. That fer- 
tilization consists in the union of the hereditary substance 
result of physiological division of labor-the mass and yolk 
of the ovum having been differentiated to support the early 
stages of development, while the spermatozoon has dis- 
pensed with all these accessories and acquired an active 
vibratile form for its function of reaching and penetrating 
the ovum. The evidence of the Infusoria is paralleled 
among some of the plants, in which conjugation between 
entirely similar cells is observed. 
Sexual Conjugation.-As noted above, in higher types 
of animals in which the sexes are different, the ovum 
and spermatozoon differ widely in external form ; this 
is because the ovum is a food-carrier and is passive 
while the spermatozoon is active, and, so far as we know, 
merely a carrier of hereditary substance. The ovum is 
sometimes found a million times larger than the sperma- 
tozoon, but the materials concerned in heredity in each 
are now believed to be exactly equal. 
The various processes through which these two cells 
pass before and after conjugation are technically known 
as : 
1. Ovogenesis and Spermatogenesis-Reduction of Here- 
* For the meaning of these terms see the following section. 
401 Heredity. 
Heredity. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
ditary Substance: Preparation of male (sperm) and 
female (ovum) cell for conjugation. 
2. Fertilization-Union of Hereditary Substance: Union 
of certain elements in male and female cells into a new 
single cell. Or union of maternal and paternal hereditary 
elements. 
3. Embryonic Development-Distribution of Hereditary 
(SUPPLEMENT.) 
cells; they are now believed to represent the active 
dynamic and regulative material of the cell. The centro- 
some is apparently the active agent in every cell division 
throughout life. 
We may begin at any point in the cycle of develop- 
ment. In order to understand most clearly the respective 
HEREDITARY 
SUBSTANCE 
Fig. 236. 
Fig. 238.-Typical Cell Division, showing the Distribution of Chroma- 
tin. (From Parker, after Carnoy.) A-C, arrangement of the chroma- 
tin ; D-E, formation of the chromosome rods and loops ; F, splitting of 
the loops ; G-H, retraction of the chromatin into the two daughter- 
cells. 
Substance : Division of the fertilized ovum (oosperm) into 
the cells of the tissues. 
This is a complete cycle of changes, for among the 
embryonic cells from the oosperm soon appear the germ- 
cells in which we observe a fresh ovogenesis or spermato- 
genesis. Now what elements enter into these changes ? 
The older topography of the ovum as a typical cell is 
very well known ; there is first the (a) cell-wall, and with- 
in this the cell-protoplasm or (b) cytoplasm. In the centre 
of the cell is the (c) nucleus, containing its protoplasm 
or (d) nucleoplasm. Flemming was the first to show that 
suspended in the nucleoplasm is a special highly staining 
form of protoplasm which he called [e) chromatin, and still 
more recently it has been found that on one side of the 
nucleus, in the cytoplasm, are suspended one or two small 
special centres or (f) centrosomes. 
functions of the chromatin and centrosomes let us first 
consider embryonic development and observe the mech- 
anism by which the chromatin is evenly distributed to 
every ceil of the body. 
a. Distribution of Hereditary Substance.-The starting- 
point of distribution is the oosperm (fertilized ovum). 
This contains chromatin and centrosome elements from 
each parent, as shown in the accompanying figure. The 
chromatin is contained in four chromosomes (the number 
characteristic of the species); two of these chromosomes 
come from the sperm-cell and two from the ovum-cell. 
These chromosomes are kept separate in the first stages, 
and then united in one coil, Fig. 239. The centrosomes 
Cell-wall 
Maternal 
centrosonu 
Nucleus 
Two mater- 
nal chro--; 
mosomes 
Sperm nu- 
■ cleus. 
Paternal and ma- 
ternal chromatin coil 
Nucleoplasm 
Two pater- 
.:>■ nal chro- 
mosomes. 
Direction sphere 
Paternal 
centro- 
some. 
Centrosome dividing 
Cytoplasm 
Fig. 237.-Oosperm prior to Union of Maternal and Paternal Elements. 
Fig. 239.-First Stage after Union of Maternal and Paternal Elements. 
The chromatin presents the appearance of a fine net- 
work in the interior of the nucleus when the cell is quies- 
cent, but when the cell is dividing it is drawn out into a 
number of fi ne compact threads or chromosomes (Waldeyer), 
as shown in the accompanying figures. An equal quantity 
of chromatin is found in the ovum nucleus and sperm 
nucleus, and this is now believed to be the material basis 
of heredity. The chromosomes are concerned in all cell 
life, and are considered qualitative. 
The centrosomes are specific bodies lying in the cyto- 
plasm outside of the nucleus, and moving to its opposite 
poles only during division. As proved in " polyspermy," 
these bodies are also found in both ovum and sperm- 
are believed to unite and combine maternal and paternal 
elements from the start. 
The phenomena of karyokinesis which attend the divis- 
ion and distribution of this hereditary substance through- 
out the whole course of embryonic and adult develop- 
ment are well illustrated in Carnoy's figures (Fig. 238). 
First we have the quiescent period, in which the chro- 
matin presents the appearance of a coiled, tangled thread ; 
surrounding this is the clear nucleoplasm (or achromatin) 
bounded by the nuclear membrane ; the extra-nuclear 
substance, or cytoplasm, is apparently undifferentiated. 
As soon as cell division sets in, however, radiating lines 
are seen in the cytoplasm above and below the nucleus, 
these are called the centrosomic filaments, since they pro- 
402 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Heredity. 
Heredity. 
(SUPPLEMENT.) 
ceed from the two centrosomes (Fig. 240). As the activ- 
ity becomes more intense the filaments are seen to diverge 
from a centre-the plasmic centrosome-which lies just 
without the nucleus at either pole ; this radial display of 
finally a number of distinct vertical rods, chromatin 
rods, or chromosomes, are formed. 
A remarkable and significant fact may be noted here, 
that the number of chromosomes varies in the cells of 
different species, and even in the cells of different varie- 
ties (as in the thread-worm of the horse-Ascaris megalo- 
cephalaf but in each variety the same number is constant 
in all the cells of each individual through all stages; thus 
the same number of chromosomes appears in the first 
segmentation of the fertilized ovum as in all the subse- 
quent cell division in the tissues. 
Carnoy next indicates the vertical splitting of each rod 
into a loop or link preceding the horizontal splitting ; 
thus we may conceive of a thorough redistribution of the 
chromatin before it passes into the daughter-cells. The 
split loops are each retracted toward a centrosome, sug- 
gesting to some authors a contractile power in the centro- 
somic filaments; each chromasome being apparently 
withdrawn by a single filament. The chromatin is 
again retracted into two coiled threads, each the centre 
of the daughter nucleus with a single centrosome beside 
it. But when the line of cleavage is drawn between the 
two cells (Fig. 238), the single centrosome in each cell 
divides so that each daughter-cell is now complete with 
its chromatin coil and two centrosomes. This process 
has been well figured by Watase 1 (Figs. 240 and 241). 
It thus appears that both the chromatin and centro- 
some are permanent elements of the cell, such as we for- 
merly considered the nucleus ; the apparently passive 
chromatin is divided with great precision by the active 
centrosomes, then the centrosomes simply split in two to 
resume their cleavage function. Each chromosome and 
each centrosome is separate-these two elements are ap- 
parently passed down distinct from generation to gener- 
ation. 
The theoretical meaning of this distribution process 
will now be discussed. The whole process can be very 
clearly followed in Figs. 237, 239, 240, 241, 242, 243. 
Fig. 240.-The Central Portion of a Tissue-cell during Division. Differ- 
entiation of the Cytoplasm and Nucleus of a Squid Embryo, Loligo. 
(After Watase.) M. the nuclear membrane ; F, achromatin or nucleo- 
plasm; C, cytoplasm or protoplasm outside of the nucleus; A-A, the 
two centrosomes; B, extra nuclear centrosome filaments ; E, intra- 
nuclear centrosome filaments attached to n, n', the chromatin rods. 
cell-forces suggested the term "asters" to Fol, and 
" spheres attractive" to Van Beneden ; they may here be 
called direction spheres. The behavior of the chro- 
matin, or hereditary substance, under these forces, is 
Chromosomes 
Centrosomes 
Fig. 242.-Second Stage. Division of Centrosome. 
The Nature of the Hereditary Substance in each Body- 
cell.-There still remains to be considered the relation of 
the hereditary substance to the future development of the 
individual. There is some reason to believe that each 
cell of the body contains not only the characters of the 
special tissue to which it belongs, but other characters. 
There is first the astonishing fact that, as the chromatin 
goes on dividing, its mass or volume remains apparently 
undiminished. That is, there is apparently as much 
chromatin in one of the many million active cells of the 
body as in the original fertilized ovum, and we face 
still the enigma as to the nature of this chromatin and 
its functions. 
1st. In plants De Vries 16 and others believe that all or 
by far the greater number of cells in the plant body con- 
tain the total hereditary characters of the species in a la- 
tent condition. Kolliker11 has fully discussed this ques- 
tion and called attention to Muller's early views that, in 
spite of the physiological division of labor producing the 
tissues, the properties of all the tissues can be derived 
Fig. 241.-After Division. Interior of a Daughter-cell in the Squid. 
(After Watase.) Division has just taken place and the daughter- 
nucleus, N, shows the chromatin coil. The daughter centrosome is 
just forming two new centrosotnes, A-A, by direct division. 
shown in Carnoy's diagrams (Fig. 238). First, the 
nuclear wall breaks up, then the chromatin coil unfolds 
into lines of vertical striation which become thread-like 
(hence the term mitosis), and then more compact, until 
403 Heredity. 
Heredity. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
from the nuclear substance of a single tissue, as proved 
by experiments upon the lower animals. According to 
this idea there is only a quantitative distribution, the 
chromatin increases in bulk, and each tissue only calls 
forth certain of its powers. Weismann, on the other 
hand, has held that the course of development is marked 
by a constant qualitative distribution of his germ-plasm or 
hereditary substance, so that each tissue finally contains 
only the hereditary substance which belongs to it and 
the total hereditary substance or germ-plasm goes only to 
the new ova and spermatozoa. Kolliker opposes this idea 
and maintains that the hereditary substance, or " idio- 
plasm,'' passes into all cells, in which it divides in course 
of development ; step by step, from the embryonic layers 
to the tissues, the constructive processes are under the 
direction of the nuclei containing this hereditary sub- 
stance ; it remains in every nucleus for a long period un- 
altered. in order to finally, here earlier, there later, im- 
press its peculiar constructive forces. In certain ele- 
ments, as in blood-corpuscles, epidermal scales, etc., it 
disappears, as the last product of division. 
(SUPPLEMENT.) 
by this theory, for he regarded the germ-cells as herma- 
phrodite until one sex was eliminated. But now that the 
researches of Hertwig have given the last blow to Van 
Beneden's theory, and it follows that there can be no 
sexual difference in chromosomes, there remains room 
for the analogous view that the maternal and paternal 
chromosomes remain distinct throughout the course of 
development, not as sexual elements but as substances 
with different hereditary tendencies. Babi, an eminent 
embryologist, shares this view, and it is supported by 
Boveri upon the observation that in each division the 
paternal and maternal elements are kept distinct, and in 
Ascaris, for example, two of the chromosomes of each 
division figure are paternal and two are maternal. In 
favor of this hypothesis we may place the following 
facts : 1st, That there are an even number of chromosome 
rods in all cells ; 2d, that the number is constant through- 
out all the subsequent changes in the tissues; 3d, that 
the number is fixed for each species or variety ; 4th, that 
the number is the same in each sex. 
Against this non-furion hypothesis we must consider 
Centrosome 
Centrosome 
dividing 
Chromo- 
somes 
Line of 
- cell division. 
Chromo- 
somes 
Centrosome 
Centrosome 
dividing 
Fig. 244.-Fourth Stage. Division of Cell-wall. 
Fig. 243.-Third Stage. Division of Chromosome. 
Hertwig takes a similar view; since embryonic and 
adult cell division is differential there must be a form of 
differentiation in the nucleus, but this does not consist in 
the total elimination of some qualities and survival of 
others, nor of a reduction in mass. The mass and the 
properties remain the same in every cell, the differ- 
entiation consists in the activity of certain elements in 
certain tissues. The potential of the nuclear substance 
is differently exerted at different points. Here, again, 
we have the idea of patent and latent hereditary elements, 
such as appear in the entire individual upon a larger 
scale. 
In the following paragraph Hertwig expressed his 
view of nuclear control and cytoplasmic differentiation : 
" As I saw in the transformation of the nucleus during 
fertilization proof that it is the bearer of hereditary sub- 
stance I recognized a great advance in the fact that the 
nucleus leaves in the same form in every cell, and in its 
vesicular capsule is somewhat removed from the meta- 
morphoses of the cells. As Nageli spread his idioplasm 
as a net-work throughout the whole body, so, according 
to my theory, every body-cell contained in its nucleus 
its quota of hereditary substance, while its specific histo- 
logical peculiarities were to be regarded as its plasma- 
products." 
2d. The next question is the fate of the maternal and 
paternal contributions to the embryo : are they fused or do 
they lie side by side ? Here there is a wide difference of 
opinion. 
We have seen that in the oosperm (Fig. 237) the 
maternal and paternal chromosomes are entirely separ- 
ate, but as soon as this cell divides into two, the mater- 
nal and paternal chromatin forms an intimate net-work. 
On the one side Van Beneden is the leader of those who 
regard each cell of the body as in a sense hermaphrodite ; 
as we have seen, his views of maturation and the signifi- 
cance of the exclusion of the polar bodies were colored 
the extreme complexity of the division process, and the 
long-intermediate resting, or thread stage, in which the 
chromatin lies in a confused coil. Ilertwig advocates a 
fusion hypothesis and argues that if the elements are dis- 
tinct we should find some evidence that the maternal 
or paternal part is atrophied or replaced, or excluded 
from the nucleus, for both parts cannot share alike in 
the control of the cell. Such are his grounds for sup- 
porting the " Verschmelsungstheorie," or fusion theory, 
also advocated by Waldeyer, to the effect that by the 
complete upion of the maternal and paternal substance 
a new product is formed ; in this fusion the law of pre- 
potency may come into play, causing one or other of the 
parental tendencies to predominate, or there may be an 
even redistribution, whereby, as expressed by Hensen, 
" the hereditary substance of the son is not that of the 
father plus that of the mother, but is his own, with a 
new hereditary form resulting from the combination." 
While suspending judgment between these two views 
as to the fusion or non-fusion of the hereditary sub- 
stances, we may appeal to the external phenomena of 
heredity for light upon the probabilities in the question. 
First, we have the very decided opinion of Francis Gal- 
ton in regard to particulate inheritance ; he is so im- 
pressed with the fact that we are made up bit by bit of 
separate structures derived from different ancestors that 
he has even suggested that the skin of the mulatto may 
represent not a fusion of white and black but an exces- 
sively fine mosaic in which the colors are so distributed 
as to give the appearance of blending. We do some- 
times observe patches of color as evidence of uneven 
distribution. As Galton distinguishes two types of struct- 
ures with reference to inheritance, viz., those which 
blend and those which do not blend, we might correlate 
these types with prepotency, replacement, and fusion. 
Where characteristics do not blend, as in eye-color, it is 
evident that, while the offspring must receive from both 
404 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Heredity. 
Heredity. 
parents the material basis for the formation of the com- 
plete color of the eye, either the maternal or paternal 
material must be prepotent and exclude the development 
of the other ; the logical inference is that the former 
actively replaces the latter ; but it is not necessary that 
exclusion from the cell-chromatin should follow. Now, 
while some blends seem to support the theory of fusion, 
the sum total of facts of heredity are strongly against 
this as a universal principle, for many maternal and pa- 
ternal structures are preserved in their absolute integrity 
for generations without the least indication of mixture. 
b. Reduction of Hereditary Substance.-By the above 
"distribution" the chromatin is constantly increasing 
in quantity, because an equal amount passes into every 
cell of the body. The embryonic sperm and' ovum 
cells receive their share, it follows that originally each 
has the chromatin complement of a complete cell ; 
part of this must be gotten rid of, otherwise the oosperm 
will represent not one cell but two cells. It has 
long been known that the ovum is prepared or " ma 
tured" for the reception of the sperma- 
tozoon by the extrusion of two small 
"polar bodies," containing both chroma- 
tin and hyaline protoplasm, and separat- 
ing off by karyokinetic division. From 
this it appears that before fertilization 
the original amount of chromatin is re- 
duced in quantity. For twenty-five 
years speculation has been rife as to why 
the ovum should extrude a portion of its 
substance in two small cells. Why not 
in one cell ? why not in a larger num- 
ber ? Thanks to the intense curiosity 
which these polar bodies have aroused, 
and to the great variety of explanations 
which have been offered for them, we 
have arrived to-day at a solution which 
links the higher animals with the lower, 
breaks down the supposed barrier be- 
tween the sexes, and accords with the 
main external facts of heredity. 
It seems best to disregard tlie order of 
discovery, and to state the facts in the 
most direct way. First, a few words as 
to the speculations upon the meaning of 
the polar bodies. 
The early theories of the meaning of 
sexual congregation or fertilization 1 were 
naturally based upon the apparent signif- 
icance of this process in the human 
species, in which the sexes are sharply 
distinguished from each other in their 
entire structure, and the reproductive 
cells are also widely 'differentiated in 
form, the ovum large and passive, the 
spermatozoon small and active. It wras 
most natural to regard these elements as representing 
distinct physiological principles, corresponding to the 
essential sexual characteristics-in short, as male and 
female cells, the former vitalizing and rejuvenating the 
latter. Thus one of the earliest definite " polar-body" 
theories was that the embryonic ovum was hermaphro- 
dite, and contained both male and female principles, and 
that it was necessary to get rid of the male substance 
before the spermatozoon could enter. 
As Von Siebold and Leuckart had demonstrated that 
some ova reproduce parthenogenetically, that is, without 
fertilization by spermatozoa, Weismann turned to such 
forms for the solution of this problem, and was surprised 
to find that parthenogenetic ova only extrude one polar 
body; this led him to attach one meaning to the first 
polar body, and another meaning to the second, which he 
viewed as designed to reduce the hereditary substance in 
the ovum without regard to sex. Thus both this and the 
older theory conveyed alike the idea of reduction, but 
with an entirely different supposition as to the nature of 
the material reduced or eliminated. 
The Modern Theory of Reduction.-Van Beneden's dis- 
covery that these bodies contained chromatin led gradu- 
ally to the view that they were not fragments of the ova, 
but represented minute, morphologically complete, cells. 
Biitschli showed that they were given off independently 
of, and prior to, the contact of the spermatozoon, and, 
finding in the leeches that the first polar body subdivides 
to form two bodies, he considered them as formed by 
true cell division, and containing both nucleoplasm and 
chromatin. Giard independently reached a similar opin- 
ion, assigning an atavistic meaning to the polar cells. 
Whitman, in 1878, advanced the idea that they repre- 
sented vestiges of the primitive mode of reproduction by 
fission, while Mark described them as "abortive ova." 
At this point speculation subsided until it was revived 
by Weismann's attempt to connect these bodies with his 
theory of heredity,19 already referred to. The whole his- 
tory is clearly given in R. Hertwig's masterly memoir 
upon Ovo- and Spermatogenesis in the Nematodes.20 Tak- 
ing advantage of Boveri's discoveries in staining tech- 
nique, and stimulated by Weismann's prediction that 
spermatozoa would also be found to extrude polar bodies. 
Fig. 245.-The Maturation of Ova, or Formation of Polar Bodies in Ascaris. (From Weismann, 
after Hertwig.) A, original germ-cell in embryonic germ-layer-4 chromatin rods ; B, ovum 
mother-cell-8 rods; C-D, first polar body extruded ; E, splitting of first polar body-ovum 
still contains 4 rods ; F, second polar body extruded-ovum mature with 2 rods. 
this author examined all stages in the peculiarly favor- 
able germ-cells of the thread-worm of the horse (Ascaris 
megalocephala'). 
He made the surprising discovery that ova and sper- 
matozoa are formed in a substantially similar manner by 
repeated divisions, the single difference being that the 
last products of division among the sperm-cells are 
effective spermatozoa, capable of development in fertili- 
zation, while the last products of division in the ovary 
are, first, the true ova, and second, the abortive ova 
(polar cells) incapable of development. In both ova and 
spermatozoa, when ready for union, the nucleus contains 
but one-half the chromatin which a typical nucleus con- 
tains ; in the case of A. megalocephala (see Fig. 245) each 
of the germ-cells contains but two chromosomes, while 
the normal body-cells contain four. The manner in 
which this maturation of the germ-cells for conjugation 
is brought about is beautifully shown in these diagrams, 
taken from Weismann's essay, "Amphimixis." We ob- 
serve that the number of chromosomes in the primary 
germ-cells is four (Figs. 245 and 246, A). Then are 
formed by subdivision the ovum and sperm "mother- 
cells," in which the chromatin substance is doubled, so 
405 Heredity. 
Heredity. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
that we observe eight chromosomes. The mother-cells 
then divide and the chromatin is reduced to four rods ; a 
second division rapidly follows, whereby the chromatin is 
reduced to two rods, or half the original quantity. These 
last divisions take place by karyokinesis, but, as Hert- 
wig points out, they differ from typical karyokinesis in 
the fact that the divisions follow so rapidly upon each 
other that the vesicular resting-period of the nucelus is 
omitted. Thus, he suggests, is prevented an over-accu- 
mulation of chromatin substance prior to the fusion of 
the ovum and sperm. 
It is evident that the polar-cells are rudimentary ova, 
which do not possess the yolk-mass, etc., essential to de- 
velopment, and are divided off at a very late stage, some- 
times after the egg has left the ovary, but are in other 
respects analogous to the spermatozoa. The reason why 
these polar-cells have not disappeared altogether in either 
plants or animals is that they originally possessed a deep 
physiological importance. As the first polar-cell subdi- 
vides and forms two, it follows that from both ovum and 
sperm mother-cells four daughter-cells are formed, each 
containing half the chromatin substance of a normal 
nucleus. In the ovary three of these daughter-cells abort 
and the fourth forms a true ovum ; in the sperm-gland, 
however, all four daughter-cells form spermatozoa. 
We may thus consider the polar-cell problem as in all 
based upon the observed fact that the two pairs of rods 
do not fuse, but lie side by side, and upon the assump- 
tion that these pairs are kept distinct in each cell through 
all the subsequent stages of embryonic and adult devel- 
opment. If this is the case, the hereditary substance 
contributed by the father would remain separate from 
that contributed by the mother, throughout. 2. " Each 
of these pairs would be made up of the collective pre- 
dispositions which are indispensable for the building up 
of an individual, but each possesses an individual charac- 
ter, for they are not entirely alike. I have called such 
units ' ancestral plasms,' and I conceive that they are 
contained in numbers in the chromatin of the mature 
germ-cells of living organisms, also that the older nuclear 
rods are made up of a certain number of these. . . . 
Obviously these units cannot become infinitely minute ; 
however small they may be they must always retain a 
certain size. This follows from the extremely compli- 
cated structure which we must without any doubt ascribe 
to them." These units are not, however, ultimate, they 
are in turn extremely complex, and are composed of 
countless biological units of the kind conceived of by 
Nageli and others. 3. The reduction of the chromatin 
only acquires a meaning when taken in connection with 
the above supposition of distinct ancestral plasms, and 
has no meaning if we accept Hertwig's view that there 
is a complete fusion of maternal and paternal germ- 
plasm. This meaning is that reduction in the maturation 
of germ-cells is sui generis, it does not divide the ances- 
tral plasms into two similar groups, but one daughter- 
cell receives one set of germ-plasms or hereditary pre- 
dispositions, and another daughter-cell receives another ; 
reduction is thus differential. According to this view 
the four sperm and ovum daughter-cells would each con- 
tain a different set of ancestral plasms. 4. The fact that 
the chromatin substance is doubled in the sperm and 
ovum mother-cells, so that we observe double the num- 
ber of rods characteristic of the species, is to be ex- 
plained as an adaptation to the requirements of natural 
selection, for this doubling and subsequent double divis- 
ion render possible an infinite number of combinations 
(as many, in fact, as there are individuals) for Selection 
to operate upon. 
This explanation of Weismann's is an example of his 
apotheosis of the theory of natural selection. Every pro- 
cess is made to suit this theory, which, as we have seen 
in the section on Speculative Heredity, is, in his opinion, 
the exclusive factor of evolution. But this very high de- 
gree of mingling and remingling of ancestral predisposi- 
tions would be fatal to evolution, for after a combination 
favorable to survival had been established in one gener- 
ation it would be broken up into a new combination, 
perhaps unfavorable to survival, in the next generation. 
His entire essay upon "Amphimixis," or the theory 
of mingling of reduced hereditary substance, marks a 
turning-point to decline in Weismann's influence as a bi- 
ologist. His whole reasoning is now in a circle around 
the natural-selection theory. 
C. Union of Hereditary Substance-The Meaning of 
Conjugation.-Weismann looks upon sexual reproduction 
as designed to mingle hereditary tendencies and to create 
individual differences whereby natural selection may 
form new species. It is evident that such combinations 
must be mainly fortuitous and productive of indefinite 
variations. 
The fact, however, that variability and evolution by 
the accumulation of certain variations in successive gen- 
erations is also observed in organisms which reproduce 
asexually, both among plants and animals, shows that 
we must look in another direction for the underlying 
cause or purpose of sexual reproduction. Weismann 
rightly combats the old idea of ritalization of the ovum 
by the spermatozoon, and it is perfectly evident from 
the researches of Maupas and Hertwig that the ovum 
may as accurately be said to vitalize the spermatozoon 
as the reverse. Conjugation is simply the approxima- 
tion of two hereditary substances of distinct origin 
and their incorporation into a single cell destined to give 
rise to a new individual. The action and reaction of 
Fig. 246.-Spermatogenesis in Ascaris. (From Weismann, after Hert- 
wig.) A, original germ-cell-4 chroma'in rods ; B, sperm mother- 
cell-8 rods ; C-D, first daughter-cells, with 4 rods each ; E-F, forma- 
tion of second daughter-cells, or mature spermatozoa, with 2 rods 
each. 
probability settled ; the whole process is probably an 
inheritance or survival of a primitive condition in which 
all four ova, like all four spermatozoa, were fully func- 
tional. 
The Relation Between the Reduction of the Chromatin 
Substance and Heredity.-We have just seen that the last 
stages in the preparation of the ova and spermatozoa for 
conjugation result in halving the number of rods in the 
original germ-cells. Now, as Hertwig and Weismann 
point out, one point is still left in doubt. Why is the chro- 
matin substance doubled in the mother-cells so that two 
successive subdivisions are necessary to reduce it to half 
the original quantity ? Hertwig has not attempted to 
answer this question, as he prefers to wait for further 
research. Weismann, however, who is unfortunately 
cut off from research by failing eyesight, has offered a 
speculative solution to this problem which he trusts may 
guide future investigation. 
This leads to a few words in regard to bis concep- 
tion of the relation of the chromatin to heredity. 1. 
His first premise is that in fertilization there is not a 
fusion of chromatin, but that a certain independence is 
preserved between the maternal and paternal elements, 
406 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Heredity. 
Heredity. 
these substances may be considered equal and mutual, 
so far as we now know. 
The remarkably ingenious experiments of Hertwig and 
Boveri, above alluded to, strengthen this idea. Some 
years ago Weismann wrote : "If it were possible to in- 
troduce the female pronucleus of an egg into another 
egg of the same species, immediately after the trans- 
formation of the nucleus of the latter into the female 
pronucleus, it is very probable that the two, nuclei would 
conjugate just as if a fertilizing sperm-nucleus had pene- 
trated. If this were so, the direct proof that egg-nucleus 
and sperm-nucleus are identical would be furnished." 
Boveri succeeded in accomplishing a similar feat by 
shaking an ovum and thus depriving it of its nucleus and 
subsequently admitting a spermatozoon which fertilized 
the de nucleated ovum and produced a complete individual! 
Weismann goes further, and maintains that there is 
nothing in the nature of vitalization or "rejuvenes- 
cence " in conjugation-that, given proper environment, 
protoplasm is immortal and runs upon a course of un- 
diminished activity. This we have seen is not the case 
in the infusoria, and, as recently remarked by Hartog, 
there is only one class of organisms which, according to 
our present knowledge, are completely agamous and im- 
mortal, namely, the group which includes the bacteria. 
It may in future appear that even in these minute organ- 
isms there is a cycle of development in which conjuga- 
tion plays its part. 
Maupas's experiments seem to establish the interpreta- 
tion of the purpose of conjugation as well as of sex, the 
latter being a consequence of the former, namely, that 
after a long period of direct subdivision of hereditary 
material from a single individual, a limit is reached be- 
yond which the forces of heredity are not reproduced in 
their original intensity unless combined with another set 
of similar forces of different origin. This combination 
restores the original intensity. It is objected to this that 
two sets of feeble forces cannot constitute one vigorous 
force, but this is met by the observed fact that such 
union does start a new life cycle, and is therefore reju- 
venescent. We may regard this as the fundamental 
meaning of conjugation and the production of variations 
as entirely secondary. 
6. Experimental Embryology.-Experimental em- 
bryology plays the role of experimental physiology and 
vivisection upon the ovum, spermatozoon, oosperm, and 
embryo. The idea is to discover normal laws and rela- 
tions by setting up abnormal relations. Thus the Hert- 
wig brothers for many years experimented upon the 
ovum during the conjugation period with drugs and ex- 
tremes of temperature and found that when the regu- 
lating forces in the ovum are artificially suspended 
abnormal conjugation and development results. Follow- 
ing the gravity experiments of Pfluger, Roux has opened 
up a new branch of embryology in his " Entwickelungs- 
mechanik," or the science of the combinations of vital 
energy which produce development by studying the in- 
fluence of gravitation, light, heat, and magnetism upon 
the embryo.21 Roux has also practised the extirpation 
method by removal of portions of the embryo. Verworn 
has also practised extirpation upon the infusoria, or 
single-celled organisms. A third line of experiments 
has been introduced by Driesch and Wilson by shaking 
the embryo in the two- and four-cell stage, and thus pro- 
ducing out of a single oosperm from two to four complete 
individuals. Some of the results of these various meth- 
ods may now be briefly summarized. 
a. Relation of Nucleus to Cell.-After a long series of 
experiments, Verworn reaches the conclusion that the 
nucleus is not a dynamic or force centre, either auto- 
matic or regulating, but the nucleus combined with the 
extra nuclear protoplasm must be the seat of heredity. 
He compares the role of the nucleus with that of a cell 
organoid, like the chlorophyll of plant-cells, as not con- 
stantly present but as necessary to activity. This con- 
clusion coincides with the prevailing theory we have 
outlined as to the relations between the chromatin (with- 
in the nucleus) and centrosomes (without the nucleus), 
although Verworn, working upon living cells, naturally 
(SUPPLEMENT.) 
could not separate either of these elements, which are 
only brought out by staining.22 
b. Abnormal Fertilization or Polyspermy.-In the nor- 
mal state the entrance of a single spermatozoon produces 
a reaction in the ovum-wall preventing the entrance of 
other spermatozoa, but when the ovum is weakened 
by chloroform solution, also by morphine, cocaine, cu- 
rare, and other poisons, two or more spermatozoa enter 
before the reaction appears ; in fact the degree of poly- 
spermy is directly proportional to the intensity of the 
chemical, thermic, or mechanical disturbance of the 
ovum. Nicotine and strychnine seem to increase the 
activity of the spermatozoa. Double fertilization or over- 
fertilization has not in a single case resulted in the pro- 
duction of twins, so that Fol's supposition is negatived, 
although other forms may behave differently. Fol sup- 
posed that single, double, or multiple births might be 
proportionate to the number of spermatozoa entering the 
ovum. The effect of over-fertilization is to produce a 
number of karyokinetic figures, or spindles (see Fig. 
238, illustrating " typical cell division ") within the 
oosperm instead of one ; the normal cell division runs 
riot, and no complete individuals are produced. The 
cell-division may be arrested at any stage by thermic in- 
fluences ; thus two pronuclei, paternal and maternal, 
about to unite can be held apart in an oosperm, by lower- 
ing the temperature. Polyspermy also results from a 
lowered temperature. It is noteworthy that the con- 
ditions of bastard fertilization (fertilization by sperm of 
another variety of animal) and polyspermy are different ; 
chloroform produces the latter, but not the former. 
The latest researches upon polyspermy are those of 
Ruckert. He has made the surprising observation that 
in some fishes the penetration of more than one sperma- 
tozoon into the ovum is a normal process. But a single 
sperm nucleus unites with the ovum nucleus to form the 
main tissues of the body, while the other sperm nuclei 
combine with certain elements in the ovum and form the 
parablast, an embryonic layer whose history has always 
been doubtful. 
c. The Production of Twins and Double Monsters.-See 
Driesch in the embryos of starfish, Hertwig in the same 
form, and Wilson in the embryos of the lancelet (Am- 
phioxus, the lowest animal in the vertebrate scale). Wil- 
son's experiments are the latest. He produced, with 
perfect ease, embryos from one-half to one-eighth the 
natural size, and corresponding in number from two to 
eight, by shaking the early embryo in its various stages 
of division from two to eight cells. Thus just after the 
oosperm has divided into two cells, shaking produces 
two quite separate and independent twins of half the 
normal size. These embryos develop into free swim- 
ming larvae, but do not live more than a day. Shaking 
in the four-celled stage produces embryos which live a 
much shorter time. In the eight-celled stages the em- 
bryos develop but die before invagination. If the embry- 
onic cells are more or less incompletely separated, we find 
a series leading from scarcely bilobed forms to those in 
which two nearly perfect bodies are joined by only a nar- 
row bridge of tissue. 
Here we have a hypothetical key to the mode of forma- 
tion, both of twins and of double monsters.24 
d. Dynamics of Embryonic Development.-This line of 
research has not as yet been brought to a stage in which 
its bearings upon heredity are so obvious as in the above 
phenomena. The main conclusions from the researches 
of Pfluger, Born, Hertwig, and Roux are that develop- 
ment is due to forces within the oosperm, which are 
powerful and independent enough to readjust themselves, 
if artificially thrown out of their normal relations, to 
external physical forces, such as gravity, light, heat, mag- 
netism, etc. Yet there are two sets of forces to be con- 
sidered in development: first, the internal self-differ- 
entiating, second, those interacting with the external 
environment. 
The self-differentiating forces are very powerful in the 
early stages, and the ability to produce a whole is not 
divided between single cells. As we have seen above 
that each of the four cells of a single embryo lancelet is 
407 Heredity. 
Hernia. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
capable of producing a complete lancelet, so Roux finds 
that when a portion of an embryo is destroyed, say by 
thrusting in a hot needle, this wound is healed, the part 
removed is regenerated, and a complete, though sickly, 
individual is produced. To take another case, if the 
embryonic region destined to form the tail is split in 
two, a pair of complete tails are sometimes produced, not 
two half tails. 
On the other hand, Roux finds in some cases that if 
the cells are injured in early stages and not detached, the 
remaining healthy cells will produce only the regions of 
the body which they were normally destined to produce. 
Thus the four-celled stages mark a division into the four 
quarters of the future body, the right and left head end 
and the right and left tail end ; suppose the right head 
and tail ends are injured, then the left head and tail ends 
produce a perfect half embryo. In some cases a more or 
less complete individual is produced by post-generation. 
Similar experiments have been conducted by Chabry25 
and reviewed by Andrews, who concludes that each half 
cell in the two-celled stage of embryonic division has for 
the main part all that the other has, and if the other be 
killed, not a half larva but a whole larva, deficient in only 
a few organs, will be produced. 
e. Cross Fertilization.-Interesting experiments have 
been made by Boveri upon the production of bastards, 
or fertilization between ova and spermatozoa of different 
varieties. This was done by depriving the ovum of a 
sea-urchin of its nucleus by shaking in a test-tube ; from 
the denucleated ovum of one genus [echinus) and the 
spermatozoon of another (sphcerechinus) a larva of middle 
form is produced. But when a fragment of an ovum is 
fertilized, and this is found possible, a larva is produced 
with the character of the sperm only. This appears to 
prove that the spermatozoon conveys the power of form- 
ing a complete individual. These few examples of the 
kind of progress which is now being made in experi- 
mental embryology are sufficient to prove that the phe- 
nomena of teratology are largely seated in the conditions 
under which the ovum and spermatozoon unite, that 
fertilization during periods of alcohol, morphia, or nico- 
tine poisoning may produce in the offspring of man re- 
sults altogether analogous to those which we observe in 
these lower organisms. 
Conclusions. 
Heredity.-Perhaps the most impressive result of 
this review of recent researches in heredity is the uni- 
formity of life-processes throughout the whole scale of 
life from the infusoria to man. Such uniformity fur- 
nishes a powerful argument for the advocates of the 
study of biology as an introduction to the applied sci- 
ence of medicine. Much that is now entirely omitted 
from medical education, because it is considered too re- 
mote, is in reality at the very roots of the science. To 
understand the disorders of life we should first thor- 
oughly understand the essential phenomena of normal 
life. Of course we shall never see life as it really is, be- 
cause there is always something beyond our highest 
magnifying powers ; but we come nearest to this invisi- 
ble form of energy when, with such investigators as 
Van Beneden, Hertwig, Boveri, and Maupas, we strip 
the life-processes of all their accessories and view them 
in their simplest external form. 
The problems of evolution are found to be inseparably 
connected with those of heredity. No theory is at all 
adequate which does not explain both classes of facts, 
and we have seen that the explanations of hereditary pro- 
cesses offered by those who believe in the transmission of 
acquired characters and those who do not, are directly 
exclusive of each other. We should gather from every 
quarter facts which bear upon the most important and 
central problem of the transmission of acquired charac- 
ters. Medical practitioners enjoy exceptional opportuni- 
ties of contributing evidence upon this mooted question. 
It must not be forgotten that while the inheritance of the 
changes observed during life caused by various habits is 
the simplest method of explaining the evolution of man, 
we know absolutely nothing of how such changes can be 
(SUPPLEMENT.) 
inherited through the germ-cells. We cannot at present 
construct even any form of working hypothesis for the 
process which 
" shapes our ends, 
Rough-hew them how we will." 
The Germ-cells.-1. The material substance of heredi- 
tary transmission is the highly coloring protoplasm, or 
chromatin, in the nucleus of the germ-cells, probably con- 
nected with the activity of the centrosome containing a cer- 
tain form of dynamic protoplasm, outside of the nucleus. 
2. Before conjugation and fertilization the hereditary 
substance of both the male and female cells is reduced to 
one-half that found in a typical cell. The substance is, 
however, first doubled and then quartered, the meaning 
of which process is not understood. 
3. There is a difference of opinion as to whether the 
paternal and maternal hereditary substances, during fer- 
tilization, are fused or lie side by side ; also as to how 
the substance is distributed through the tissues, whether 
en masse or by qualitative distribution. The balance of 
evidence seems to favor the view that the chromatin of 
each cell contains, besides its special characters, some 
of the general characters of the entire organism. 
4. No physiological connection between the germ-cells 
and body-cells is known, but the facts of heredity seem 
to render such a connection theoretically necessary. 
Several classes of facts connected with reproduction 
seem to support this theory. 
5. The facts of heredity support the theory of a con- 
tinuous hereditary substance in protoplasm, as the basis 
of repetition of type, but do not favor Weismann's hy- 
pothesis that the germ-cells alone contain this hereditary 
material. 
Bibliography. 
Hertwig, O. and R. : Untersuchungen zur Morphologie und Physiologic 
der Zelle, Parts 1 to 6. 1884-99. Gustave Fischer, Jena. 
Boveri, Th. : Article II. Befruchtung. Ergebnisse der Anatomie und 
Entwickelr.ngsgeschichte, edited by Merkel und Bonnet. Wiesbaden, 
1892. 
Maupas : Le Rajeunissement Karyogamique chez les Cilies, Arch, de 
Zool. Experimentale, Bd. vii., 1889. 
Weismann : Essays upon Heredity and Kindred Problems. Clarendon 
Press, Oxford. Two vols. (Translation by Schdnland, Shipley, and 
Poulton.) 
Henry Fairfield Osborn. 
1 This article is largely a revision of the Third Cartwright Lecture be- 
fore the Alumni of the College of Physicians and Surgeons, with new 
material added. 
2 See Proc. Roy. Soc. Edin., 1888, p. 93. 
3 See Animals and Plants under Domestication, 1875, vol. ii., p. 349. 
4 Contemporary Review, vol. xxvii., pp. 80-95. 
6 The Law of Heredity, 1883. 
6 See Parthenogenesis, in his Anatomy of Vertebrates. 
7 Generelle Morphologie, vol. ii., p. 170. 
8 Zool. Anz., vol. ix., p. 166. 
9 Biological Memoirs, p. 432. 
10 Journal of Anatomy and Physiology, 1891. p. 433. 
11 Comptes-Rendus, March 13, 1882. These experiments have been 
confirmed by Obersteiner. 
13 See Huxley, Article Evolution, Enc. Britannica, p. 746. 
13 See Geddes and Thomson : The Evolution of Sex. 1891 ; also Diising: 
Die Reguliernng des Geschlechtsverhaltnisses bei d. Vermehrung der 
Menschen. Tiere und Pflanzen, Jen. Zeit. f. Natur., Bd. 17, 1884. 
14 Sur la multiplication des Infusoires Cilies, Archiv. de Zoologie ex- 
pdrimentale, Ser. 2, vol. vi., pp. 165-273 : Le Rajeunissement Karyo- 
gamique chez les Cilids, vol. vii., pp. 149-517. See also Hartog, Quart. 
Journ. Microscop. Science, December, 1891. 
16 See Marine Biological Laboratory Lectures, 1889. Boston: Ginn & 
Co. 
16 Hugo de Vries : Intracellulare Pangenesis. Jena, 1889. 
17 Die Bedeutung der Zellkerne fiir die Vorgange der Vererbung, Zeit. 
f. Wiss. Zool., 1885. And, Das Karyoplasma und die Vererbung, op. 
cit.. 1886. 
18 See also the introduction of Weismann's last essays on Heredity 
(Macmillan & Co., 1892), especially the article " Amphimixis." 
19 On the Number of Polar Bodies and their Significance in Heredity. 
1887. 
20 Ei und Samenbildung bei Nematoden, Archiv. f. Mikr. Anat.. Bd. 
26. 189(1. This species is found in abundance in the intestines and fasces 
of the horse. 
21 See a summary of this whole subject in American Naturalist, May 
and June 1892, " Experimental Embryology," by E. A. Andrews. 
22 Max Verworn: Die Physiologische Bedeutung des Zellkerns, 
Archiv fiir Physiologie. 1891. pp. 113-115. 
23 Untersuchungen zur Morphologie und Physiologie der Zelle, O. and 
R. Hertwig. Fischer. Jena. 1890. 
24 E. B. Wilson : On Multiple and Partial Development in Amphioxus, 
Anatomischev Anzeiger, 1892, p. 732. 
25 Contribution a 1'Embryologie normale et t6ratologique des Ascidies 
simples, Journ. de l'Anatomie, 1887. 
408 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Heredity. 
Hernia. 
HERNIA. In Vol. VIII. of this work the writer dis- 
cussed first the subject of strangulated hernia and its 
treatment, and then the accepted modern methods in at- 
tempting radical cure of hernia ; a previous volume con- 
taining other methods than these more recent ones. 
Since the time when the article in Vol. VIII. was com- 
pleted there have been devised in various parts of the 
world yet other hernial operations of interest. These 
and a few modifications of the thoughts which I for- 
merly expressed render a further study of these subjects 
advisable. 
Regarding strangulated hernia I have little to add. 
I endeavored in my previous article to point out, and 
wish here again to emphasize, the fact that the peril lies 
in delay and repeated and prolonged taxis, and not in 
the simple cutting operation to give relief. The patients 
who die do so not through any fault of the surgeon, but 
from the procrastination of the physician, who counsels 
waiting " just a little longer." 
After a few hours have elapsed it is in most instances 
no longer a question between the surgeon and the physi- 
cian, but between the surgeon and the undertaker. 
I think it rather a common error in the profession to 
estimate the degree of the strangulation by the severity 
of the pain and tenderness. This rule is an unsafe 
guide. 
I still think an hour sufficient time to devote to taxis 
and the various devices calculated to promote the suc- 
cess thereof. 
Among these, one that I can recommend as sometimes 
of more value than application of ice, is spraying the 
swelling with ether. If no spray apparatus is at hand, 
pouring the ether on, a little at a time, and vigorously 
fanning, will also cause intense cold, and this acts favor- 
ably both by contracting the bulk of any gas within 
the strangulated loop of bowel and by relieving mus- 
cular spasm. The latter factor, considering the aponeu- 
rotic nature of the stronger constricting fibres-those of 
the external oblique muscle,-is not, at least commonly, 
of importance. Perhaps spasm of the internal oblique 
or transversalis muscles, at or near the deep ring, may 
occasionally be present and be relieved by the cold. 
Poulticing and hot baths can hardly do good in any 
other way than this ; and as they must necessarily in- 
crease the bulk of the gas, I now substitute the cold (by 
ether spray) instead. 
It need hardly be said that aspiration of gas and of 
fluid faeces, through an aspirating-needle, might so 
readily be followed by septic infection in the track of the 
withdrawn needle as to make this plan a dangerous one. 
Recent experience has inclined me to advise against 
the use of morphine in any cases of strangulation. Like 
the hot baths and poultices, morphine can only be of use 
by relieving a doubtful muscular spasm. And too often, 
by making the patient entirely comfortable, it seals his 
death-warrant. He cannot-in some instances-be made 
to realize that the unreduced bowel, now so free from 
pain and tenderness, is rapidly dying from obstructed 
circulation. 
Indeed, the family doctor has not always, in such a 
case, the courage of his convictions, and either delays- 
where delay is a crime-or but half-heartedly advises a 
cutting operation; which suggestion the comfortable pa- 
tient promptly rejects. He is no more enthusiastic for 
the knife than is his doctor ; probably even less so. 
In my previous article I described the case of an el- 
derly lady in whom I found the strangulated gut dead, 
and removed thirteen inches, with immediate end-to-end 
reunion of the sound bowel. I then claimed that this 
was the largest amount ever successfully removed in 
America ; though in a few instances in Europe more 
has been sacrificed with recovery-notably a case of Koe- 
berle's, from whom 2.05 metres were excised. Since the 
publication of Vol. VIII., however, I have learned of an 
instance in which Dr. G. D. Beebe, of Chicago, removed 
four feet ten inches with success. Upon ascertaining 
this to be true, I published a statement of the facts in the 
New York Medical Record for December 5, 1891. 
It is possible that in my previous article upon hernia 1 
did not sufficiently emphasize the point regarding opera- 
tion upon strangulation, that, with the rarest exceptions, 
it is advisable, should dead gut be found, to make an arti- 
ficial anus and await a return of the patient's strength- 
delaying some weeks if need be-rather than to attempt 
a restoration of continuity, by any plan, at the time of 
operation for relief of strangulation. The patient is al- 
most always in so weak a state-from postponed opera- 
tion-that the mere relief of the strangulation is all that is 
wise, and the added time needed to perform either lat- 
eral anastomosis or end-to-end reunion may well turn 
the scale against him so that he will "die cured." On 
the other hand, after some weeks of vigorous alimenta- 
tion, the patient will probably be so strong, in spite of 
the artificial anus, that the chances of recovery from the 
kelotpmy will be much better than they would have 
been in the first instance. 
It should clearly be understood, too, in a case of artifi- 
cial anus, that, by whatsoever technique the restoration 
of the bowel-continuity is performed, it is never easy. 
No man can conscientiously attempt it who has not prac- 
tised it a considerable number of times on the dog, or 
the human cadaver, or both. On the other hand, the 
general practitioner need not fear to operate for strangu- 
lation. If he is cleanly of person and patient and boils 
his instruments and dressings ; if he makes an abun- 
dantly long cut, thereby seeing what he is about; if he 
always cuts until he sees the bowel, and freely relieves it 
where pinched ; and if he treats it, when dead or doubt- 
ful, as described in the article in Vol. VIII.,-he is doing 
all that the most expert surgeon could do. 
No one to-day advocates that relic of the dark ages, 
replacing the gut in the abdomen without opening the 
sac ; for that means putting back a loop which may still 
be strangulated within the sac, or ruptured from the 
taxis, or ulcerated, dying, or dead. It is simply trusting 
to luck, and is bad surgery. 
Neither can a conscientious man permanently replace 
a loop of doubtful vitality and sew up his wound. If it 
dies, what chance of recovery has his patient ? The 
proper technique required under these circumstances I 
have already published in Vol. VIII. 
Though 1 have just said that if the loop of intestine 
be dead, giving relief to strangulation and escape to fae- 
ces is commonly doing all that is wise at that time in an 
operative way, this remark does not apply to the much 
more common cases in which the bowel quickly begins 
to regain its normal color after cutting the constriction. 
Here we always, as a matter of course, devote from five 
to ten minutes to the necessary steps in attempting rad- 
ical cure by one or another of the plans which I have 
either described or am about to detail. It would indeed 
be a pity to lose this opportunity to prevent, by good 
surgery, at one stroke, the possibility of another strangu- 
lation and the necessity for a truss thereafter. 
Since my former article was published the technique 
of kelotomy for restoring' continuity in a bowel badly 
torn, wounded, or dead, has been greatly discussed ; and 
it cannot be said that to-day surgeons are united in opin- 
ion as to what method is best. 
Were I again to meet a case such as the interesting one 
which I described in Vol. VIII., I should certainly not 
adopt the plan used then. I should to-day be able, by 
lateral anastomosis with plates cut from raw vegetable 
tissue (potato, for example), to complete the union in 
twenty minutes, or less in certain cases; and this saving 
of time would, of course, greatly improve the patient's 
prospects of recovery. 
It is quite generally admitted, now, that statistics, so 
far as they can be trusted, favor lateral anastomosis as 
against any of the end-to-end plans, though sometimes a 
lack of room compels us to use one of the latter. The 
deadly mesenteric junction is where leakage so often 
occurs, following operation by the terminal methods; 
and from the very first the new opening is of necessity 
smaller than the normal, and still further to be reduced 
when the plastic exudate covering the line of union is 
changed, as finally it must be, into scar-tissue, and this 
undergoes the inevitable shrinkage. 
409 Hernia. 
Hernia. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
The very small opening that exists during the days be- 
fore sloughing carries it away with the faeces, is the ob- 
jection, too, to the recently devised and most ingenious 
button of Dr. J. B. Murphy, which in cholecysto-enteros- 
tomy seems destined to be a brilliant success. 
If oblique division of the bowel-ends be done, then, to 
be sure, the lumen is larger, but there is often a conse- 
quent bending or knuckle of the gut at that point, and 
the mesenteric danger remains. By any "stove-pipe" 
method, such as Jobert's or Robinson's, mistaking the 
proximal for the distal end would be fatal. And though 
Nothnagel's salt-test, as to direction of the peristaltic 
wave, seems an unsafe guide, we do not wish to start at 
the caecum and handle perhaps ten or fifteen feet of 
bowel to make sure which end is proximal. Then, too, 
by any "stove-pipe" plan, if much is excised, we are 
met with the difficulty that the proximal end is distinctly 
the larger. 
By lateral anastomosis, on the other hand, the operation 
is done at least as quickly, and it makes no difference 
thereby which end is proximal. The danger of leakage 
at the mesenteric junction with the bowel is removed ; 
and an abundantly large incision-four inches or so, 
which is now always a point to be insisted upon,-permits 
a free canal, even if with time the new opening contracts 
one-half, which it will probably do. The blind ends, 
which theoretically might be expected to give trouble 
and accumulate faeces, practically do not do so, and 
quickly atrophy. 
At the present date a majority of surgeons advocate 
lateral anastomosis ; and, following the lead of the Ger- 
mans, they have made what I believe to be a distinct 
backward step in laying aside all plates, rings, or other 
devices for aiding rapid work, and have returned to the 
older and certainly slower plan of suturing without such 
aids. 
Since time is so tremendous a factor in success in 
bowel-work,-inasmuch as a difference of five or ten 
minutes with the peritoneum exposed may make all 
the difference between life and death,-I cannot too 
strongly oppose the present tendency to leisurely sewing. 
Speed, breathless speed, is, next to cleanliness and thor- 
oughness, the keynote which cannot too often be sounded 
here. 
In discussing the various mechanical means of rather 
recent device, I cannot but think that the best of these, 
for reasons purely logical, are plates with a narrow, four- 
inch long, opening cut from raw vegetable tissue ; for in- 
stance, raw potato or turnip. These I devised and experi- 
mented with (trying also a number of other kinds of 
vegetable and fruit tissue) in the physiological laboratory 
of the College of Physicians and Surgeons, New York, 
during the whole winter of 1890-91, with the result that 
the last seventeen dogs subjected to kelotomy and the use 
of such plates recovered. 
Upon the living human subject this material-raw 
vegetable tissue-has been submitted to the hardest test 
in Germany, where, in the summer of 1892, Dr. R. von 
Baracz, of Lemberg, and subsequently Dr. Richard 
Heigl, of Coblentz, each performed abdominal section 
for gastro-enterostomy, both patients recovering. Dr. 
Heigl, in his published comments, praises these plates 
(in these instances cut from raw Swedish turnip) as bet- 
ter than Senn's bone plates. 
It is evident that if at any point the danger exists that 
such material might be digested and absorbed too soon, it 
would be in the stomach. Hence the value of these tests 
by the German surgeons named. 
When soaked for an hour or two in warm or tepid 
water (not in carbolic solution, which softens it) these 
raw vegetable plates-I still prefer white potato-be- 
come as rigid almost as wood. This is probably due to 
swelling of the starch-granules ; but is not accompanied 
by any marked change in shape of plates already cut 
out. After remaining for a few hours exposed to the 
digestive fluids of either stomach or bowel the plate begins 
to soften, while retaining its shape. At length it is com- 
pletely digested and disappears, this occurring at a period 
of time varying according to what part of the alimentary 
(SUPPLEMENT.) 
canal it occupies. But always during the first ten or 
twelve hours at least-the time in which, most of all, we 
fear leakage at our anastomosis-it holds the peritoneal 
surfaces smoothly in contact. 
In this length of time, or even half of it (if we have 
lightly scraped the surfaces to be apposed), we may be 
sure of firm agglutination. And after these hours of 
peril the softened plates yield to peristalsis, and quite 
easily cut free from their plate-sutures, taking them- 
selves out of the way. 
Contrast this with Senn's bone plates, which occa- 
sionally slide on each other and obstruct the opening, 
and require at least, a week or so to be removed after 
they have ceased to be needed ; which are tedious to 
prepare, expensive, and require multiple sizes for vari- 
ous contingencies ; which are not to be gotten in an 
emergency ; and which, finally, so far as the opening is 
concerned, are too small-sized. Whereas, on the con- 
trary, these vegetable plates serve every purpose of 
Senn's, are more quickly softened and absorbed when 
no longer needed, may be carved in a minute, are al- 
ways at hand, may be made, if desired, with a four-inch 
opening, and are devoid of cost. 
The various catgut substitutes for plates, such as 
Abbe's and Davis's, are of comparatively little value, be- 
Fig. 247.-The Potato Plate Beady for Use. (Threads short and needles 
omitted ; plate reduced about one-half In length.) 
cause, after a short time in the wet, warm faeces, they lose 
all rigidity, becoming absolutely limp. The same is true, 
in lesser degree, of Brokaw's segmented rubber rings 
filled with catgut strands. Moreover, the catgut devices 
swell greatly when put in any watery solution, such as 
semi-liquid faeces ; and, as Senn alleges, have sometimes 
thus produced dangerous pressure at the point of liga- 
tion. The catgut rings of Abbe (described in my previous 
article) are no longer used by him. A number of patients 
have recovered under their employment, but union of 
peritoneal surfaces was largely due, I must think, to 
the row of sutures surrounding his rings wherever 
used.* The solid catgut (drum-snare) rings devised by 
Matas are not open to the same objections as the other 
members of that group, but they require to be boiled and 
otherwise specially prepared. Robinson's plates of fresh 
raw hide would seem to possess no advantages, and cer- 
tain obvious disadvantages, when compared with the 
plates cut from raw potato. 
Regarding the question of safety (aside from the factor 
of speed) in bowel -work by any method, two points are 
often neglected, and, as I believe, to the patient's peril. 
The first is the scraping of the peritoneum lightly, wher- 
ever adhesion is desired. This can be done in a few 
seconds, and should not cause bleeding if properly per- 
formed, but simply congestion ; and, because of this, a 
* As a matter of fairness. I wish to state that in a few instances these 
rings, on being recovered forty-eight hours or so after an unfortunate 
demise, have been found hard. It is pure guess-work trying to account 
for such an oddity, but it would seem most likely that in these patients, 
the bowels being thoroughly emptied, at or before the time of operation, 
of their semi-liquid contents, the catgut rings were not given a free 
opportunity to absorb water and become soft. 
410 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Hernia. 
Hernia. 
more rapid and certain plastic exudate sealing the ap- 
posed peritoneal surfaces. 
Tips matter seems to the writer hardly open to argu- 
ment. Twenty cases in which rapid adhesion of tin- 
scraped peritoneal surfaces has occurred would prove 
nothing herein, when compared with one in which smooth 
and unscraped peritoneal surfaces did not become agglu- 
tinated after a prolonged contact. And such rare cases 
have been reported, although the surfaces were in contact 
many hours after being sutured. 
A light scraping, as Senn first demonstrated, will ren- 
der certain the formation of very firm adhesions within 
even three or four hours. 
The second point which, it seems to the writer, is com- 
monly neglected, although of the utmost value, is always 
to give the patient, even before the ancesthetic, as large a dose 
of morphine by needle as is compatible with safety to his life. 
In the first place, by following this procedure, much 
less ether or chloroform will be needed than if no mor- 
phine be used, and the consequent liability to vomiting, 
with its attendant risk of tearing out or loosening sutures, 
etc., is hence largely avoided. Probably, too, morphine 
is of some little value as a prophylactic against shock 
from the severe operation about to be undergone. I 
quite agree with Dr. John B. Roberts,1 who, in discuss- 
ing operative shock, says: "The preliminary hypoder- 
mic injection of morphine and atropine, always given a 
quarter or a half-hour before commencing anaesthesia, 
probably lessens the shock, and without much doubt 
diminishes the tendency to vomiting after etherization 
has been discontinued." 
In the second place, because of that morphine the 
bowel will be absolutely quiet, absolutely devoid of 
peristalsis, for hours afterward ; and this is just what 
we need : splinting the intestine for a short time. 
(SUPPLEMENT.) 
acknowledges the wisdom of its treatment, or better, pre- 
vention, by saline laxatives ; but submits that here (as dis- 
tinguished from ovarian or uterine surgery) exists an indi- 
cation of the strongest kind for the use of morphine. And 
in the great majority of instances of this particular class 
of abdominal work, that indication outweighs, in his 
judgment, the arguments on the other side. Further- 
more, it must be distinctly understood that the writer 
would not at all approve of continuing for an indefinite 
period to exhibit morphine, following bowel and stomach 
operations. When from ten to twelve hours have elapsed, 
then we can feel assured that firm agglutination has oc- 
curred between our lightly denuded peritoneal surfaces ; 
an adhesion so firm as almost to tear elsewhere rather than 
yield at that spot. And now, the liability, or even the 
possibility, of leakage being practically past, we should, 
if there be some tendency then or later, to abdominal 
distention, from this period post operationem, give hourly, 
small doses of saline laxatives, and perhaps also a glyc- 
erine enema. Under this line of treatment the effect of 
the morphine upon intestinal peristalsis is, within a few 
hours, overcome ; and usually quite readily so. 
And what, now, becomes of the five-inch plates of 
potato or turnip within the gut ? 
After twenty-four hours, or, if high in the intestinal 
canal, after perhaps even a somewhat lesser period of ex- 
posure to the heat and digestive fluids therein, the plates 
will readily yield to the waves of peristalsis, first permit- 
ting the freest passage of faeces through the four-inch 
lumen, and presently cutting out at the plate-stitches be- 
cause of extreme softening ; and they will be swept away. 
Their four stitches, if, as seems preferable, of catgut 
rather than silk, are soon after absorbed and also disap- 
pear. 
Let me now describe in some detail a method of lateral 
Line of union. 
Fig. 248. 
Peristalsis during these critical hours, before fibrin has 
sealed the spaces between our stitches, is fraught with 
such danger that to permit it is almost like inviting a 
possible leakage, by forcing out a drop, here or there, of 
liquid poison. 
Should we refuse morphine, we cannot depend for 
safety upon the paralysis, however commonly present, 
of the loop recently subjected to operation. For, al- 
though this portion may be quiescent for some hours, 
yet tlie whole alimentary tube above will not be so ! And 
semi-fluid faeces are being hurried along in surging cur- 
rents, thrusting themselves forcibly against the newly 
placed barriers, whether of thread or plates. 
Indeed, it is only because I also insist upon the use of 
morphine as stated that I think the use of plates abso- 
lutely safe without a complete row of stitches about 
them. During the hours while the plastic exudate from 
the lightly scraped peritoneum is sealing, more firmly 
than any sutures could seal, that wound, the intestine is 
as devoid of motion as if dead. 
Let me here interpolate the remark that if the patient's 
general condition were excellent, and the abdominal 
cavity had not been very long opened (not otherwise), I 
should, as precaution upon precaution, sew once entirely 
around the plates a running Lembert, or some similar 
stitch, such as that elsewhere illustrated (see Fig. 248). 
And because of the smooth tension made possible by the 
plates, this sewing could be completed quite a little 
sooner, as well as more safely, than otherwise. In deal- 
ing with the lower half of the ileum, the danger of an 
occasional complete penetration with the needle is a very 
real one, save in expert hands-so very thin-walled is 
this part of the intestine. 
To return to the question of a morphine-splint: the 
writer is not ignorant of the views upon peritonitis held 
by Lawson Tait and many other surgeons. The writer 
anastomosis with plates, as practised by me since the 
winter of 1890-91 (in entero-enterostomy only). In such 
operations-not very rarely needed, following, for in- 
stance, dead gut from a strangulated hernia, or resulting 
from tearing into the alimentary canal during separation 
of old adhesions in major gynecology-the technique 
about to be described possesses two advantages over any 
other, with plates or without them. These are : (1) Op- 
portunity to test by the water test the perfection of the 
line of suturing. (2) Entire avoidance of possible infec- 
tion of the line of intended adhesion by repeated acci- 
dental dragging out, necessitating tucking back of the 
cut bowel-edges, which are none too thoroughly disin- 
fected at the best. 
Regarding the first point (the hydrostatic test), it is with 
surprise that I have noted how little it has received at- 
tention. If the operator means to depend solely upon 
suturing for securing union, one would suppose that from 
a half minute to a minute more spent in proving such 
stitches evenly and properly tight would be anything 
but wasted. Indeed in the bladder this is commonly 
done. 
The error lies in closing the bowel-ends first, and then 
making the lateral anastomosis, with its surrounding lines 
of suturing (or plates). Such technique of course pre- 
vents the water-test. If instead, as suggested by me, 
these steps be reversed, then by running a stream of warm 
water into one gut-end, through the new lateral opening, 
and out of the other gut-end, how easy it is, in a moment, 
to notice a point of leakage and to correct it by an addi- 
tional stitch ! The tapes or clamps, always applied a few 
inches away, of course prevent the water from taking 
another path than that desired. And then the bowel-ends 
are to be inverted and closed, instead of this being made 
the first step of the operation. 
And how much more pleasant, so to speak, for the 
411 Hernia. 
Hernia, 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
patient, to have a stream of leakage discovered at this 
time rather than subsequently upon the autopsy-table ! 
As to the second point in technique mentioned, let me 
quote from a recent article by Dr. Robert F. Weir :1 In 
speaking of anastomosis he says : 
"I had already called attention ... to the ten- 
dency of the opposed intestinal incisions to slip out beyond 
the rings. This also occurs with Senn's plates, and, in 
fact, is common to all of these contrivances, so that 
special care in their use is demanded, and often the es- 
caping portion requires to be tucked in between the plates 
more than once before the restraining outside sutures are 
finally inserted." 
Had Dr. Weir used the method about to be described, 
he would not have had this complaint-and it is a just 
one-to make, regarding the usual methods either of 
suturing or of using plates. By the writer's plan, any and 
all sewing to be done about the new opening is completed 
before that opening is made, and for just the reason given. 
Preparalion of Plates.-These are cut one-third of an 
inch in thickness, and on an average five inches, or 
nearly, in length. Their width is not great, in order 
that they may slip easily into the bowel. At first I made 
them too wide. ' A very narrow slit is all that we need. 
The powerful circular muscles cause the cut bowel-edges 
in the slit to retract so that they do not touch each other, 
and the prompt infection of these edges by faeces prevents 
the likelihood of their adhering even if they did touch. 
The slit should be nearly or quite four inches in length. 
Of course this length is an added safety (immediate as 
well as remote), because the freer the passage of faeces 
when that begins, the less the strain on the integrity of 
the line of union. 
Each plate is armed with four coarse catgut threads, 
not over nine inches long, to avoid tangling. The threads 
have a large knot, and before penetrating the plate we 
sew through a scrap of rubber cut from a drainage-tube, 
or, lacking this, a minute bit of cloth ; this to avoid cut- 
ting through. If no running line of sutures about the 
plate is contemplated, it will be best to use sir instead of 
four threads in each plate. Use a round, straight sew- 
ing-needle, the eye of which (to avoid accidental un- 
threading) should be a close tit for the catgut. The 
needles should all have their points buried in bits of 
potato, each about the size of a pea. If time permits, 
immerse the plates for a half hour in warm water, to 
make them more rigid and hard. 
Method of Using the Plates.-Assume that the tapes or 
clamps are applied, and the bowel properly cleansed out 
by irrigation. Now : 
(la) Seize a needle with the needle-holder so that it 
shall be in the long axis of the holder. Begin with the 
one marked A in the accompanying diagram (Fig. 249). 
Pass the needle several inches (about seven, in operations 
upon the small intestine) into one of the open gut-ends, 
and when the place is reached at which, in the judgment 
of the operator, it should come through, detach the bit of 
potato from its point with the fingers, seizing it from 
without, and then pass the needle through and out. The 
little piece of potato will take care of itself, dropping to 
the bottom of the bowel; it is insignificant. The spot at 
which the end sutures, A and D, should escape, is one 
directly opposite the mesenteric attachment; that is, as 
far as possible from the mesentery. Now (after A) pass 
needles B and C in the same way. After each thread is 
passed, it should be held by an assistant tense against the 
wall of the gut on the side where it belongs, and the next 
needle should carefully run along the opposite wall; 
this to avoid tangled threads. Pull lightly on threads A, 
B, and C, while pushing the plate from behind, drawing 
it thereby into place within the intestine. Push rather 
than pull, to avoid oblique tension on the threads and 
possible cutting of the plate. Next pass D, and draw it 
also taut. 
Go through the same steps with the other plate and the 
other gut-end. Always leave at least a full inch and a 
half between the plate-end and the gut end, in each in- 
stance. 
(1Z>) The following alternate method of introducing the 
plate and its threads is, so far as the suggestion of the 
shorter needles is concerned, due to Dr. H. M. Hall, of 
Seattle, Washington. The plate is to be armed with four 
(or six) short, straight, round (so-called gynecological) 
needles, only one-half to two-thirds of an inch long. 
Their threads need not exceed four inches in length. 
(In other respects they are prepared as in the other plan.) 
These needles are inserted into the plate at their proper 
places, and their points made to penetrate just to the 
thickness of the plate, but no further. (These prepara- 
tions are, of course, made before the operation begins.) 
The plate thus prepared is laid, needle-hilts downward, 
upon a thin, long strip of hard wood, as wide as the plates 
-a piece of cigar-box, for instance,-and both are in- 
serted together a sufficient distance into the intestine, 
from its open end. By placing the four short plate- 
threads each on its own side of the wooden strip, tan- 
gling during the insertion is avoided. It is now the work 
Fig. 249.-A plate in place and ready to tie to its fellow. 
of but a moment to press upon the bowel overlying the 
plate, and thereby force the needles through at exactly 
the right places. Their points are seized by the needle- 
holder, and each is drawn through until its thread is 
tense. 
By this technique, which I prefer to the other, both 
plates may be inserted and their threads tied in less than 
two minutes. The former technique would be necessary 
where only ordinary needles are procurable, i.e., in 
emergency work. 
(2) Wipe off the threads with a cloth wet in some an- 
tiseptic solution. Of course, this is not essential, but is 
a safeguard. 
(3) Scrape lightly but thoroughly with a scalpel the 
surfaces to be coaptated ; this also includes the ends to 
be inverted. 
(4) Tie the four anchor (plate) threads each to its ap- 
propriate fellow, being careful to draw snugly but not to 
make extreme pressure. Tie first the threads on the 
lower (under) side of the seat of operation. Sloughing 
is of course possible if no care is used ; though because 
of rapid softening of the plates, inside of twenty-four 
hours, it is less a danger even in careless hands than if 
bone-plates were used. 
Experience proves that it is of little moment in which 
directions the open ends are pointed, before this ligation 
of the threads ; that is, whether in opposite directions or 
not. 
(5) Take one square Lembert stitch at the plate-edges, 
opposite to and concealing each of the four (or six) plate- 
stitches. This is precautionary. In the event of a drop 
of pus forming where a plate-stitch penetrates the gut 
(infection by capillarity), that pus, like any other fluid, 
412 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Hernia, 
Hernia. 
would move in the direction of least resistance, and, the 
softened plates not opposing, would be obliged, by this 
square stitch, to re-enter the intestines at the cut edge. 
As an alternate choice-and perhaps preferably to such 
interrupted stitches-we may, as a matter of convenience, 
begin the entire operation by a straight, running line of 
suture five inches long, between the loops to be joined, 
and about one-fourth inch from their mesenteric border. 
This line may, if desired, be continued and carried 
completely around the plates, after these have been tied 
together. The stitches are rapidly inserted, being no 
more than three to the inch, and are preferably of the 
kind illustrated in Fig. 248. The surfaces are smoothly 
coaptated, and sloughing, from over-tension, is hardly 
possible ; because the pressure from any stich of this 
continuous thread is not met by that of an opponent 
across the line of union. 
Just as in suturing without plates, about the opening, 
great care should here be exercised 
lest the surgeon sew too deeply and 
penetrate into the bowel. As has been 
previously remarked, the smooth, 
though moderate, tension about the 
plate-edges permits very rapid and ac- 
curate sewing. 
If the patient were in real and im- 
mediate jeopardy, I would advise not 
stopping for sutures at all ; but, as the 
end of the bowel technique, to wrap 
(SUPPLEMENT.) 
the slit in the plate, and thus be exactly guided. We 
should make as long an anastomotic opening as the plates 
will allow. The strip of wood opposite, which has pre- 
vented cutting too deeply, should now be removed. 
Should bleeding follow, of more than trivial degree, it 
coidd easily be controlled by forceps. As stated, the 
incision is open to inspection-from either end-with a 
little care. Also, the potato is elastic enough to permit, 
without harm, a temporary widening of the slit by any 
blunt means, for greater ease in seizing a vessel. 
However, annoying bleeding is very unlikely to hap- 
pen, both because the point at which the bowel is di- 
vided is that farthest from the mesentery, and, therefore, 
where the vessels are smallest ; and, also, for the reason 
that the moderate pressure of the plates would tend to 
check it. 
(8) Irrigate, under very gentle hydrostatic pressure, 
closing the outlet end with finger and thumb for a few 
moments. The line of suture, or union, should not leak, 
if contact is properly made. 
(9) Invert and close the ends, each with one running 
line of suture, as in Fig. 248. The free end is seized with 
dressing-forceps and turned in until the plate is felt. The 
forceps holds it thus inverted while the stitches are placed. 
The long intussusceptum, far from being the danger that 
was once feared, proves a decided protection against 
leakage. • A few needles, temporarily thrust through the 
intussusceptum transversely, prove of aid in preventing 
the rolling out of a part of the end during sewing. 
(10) Take a stitch or two between the blind ends and 
the bowel, against which each should rest, first scraping 
lightly. This sewing prevents possible forcing of an- 
other loop into this angle, with resultant undue tension on 
the stitches at the plate-ends ; an accident which led to 
leakage in one of my first experiments on dogs. It is 
also a safeguard against intussusception into the new 
opening, which has been observed by one worker in this 
field (Robinson). Of course, this point in technique is 
as applicable to lateral anastomosis without plates as 
to that with them. 
Finally, of course, we remove the clamps or tapes from 
the bowel on either side of the region just subjected to 
surgical treatment. 
For the sake of clearness, ten successive steps in per- 
forming the operation have been numbered and itemized ; 
but it will be noted that half of these are not peculiar to 
this, or any other plate method, but are just as advisable 
when suturing alone, without such aids, is attempted. 
I know of no briefer, no safer plan. It is my hope 
that the points herein discussed, and which the reader 
may not heretofore have put in practice, will be accorded 
an unbiased trial. They are the fruit of a number of 
years of work in this line ; and the conclusions have not 
been drawn without time for consideration. 
In discussing anew the subject of radical cure of rupt- 
ure, the writer wishes to call attention to the appalling 
frequency of hernia, as marking the importance of the 
subject, and therefore demanding of every medical man 
his most earnest study. 
The tables of Dr. Baxter show that not less than three 
million people in these United States are so afflicted ; and 
the recent and thorough work of Dr. H. O. Marcy, in 
which these figures are quoted, does not deem them ex- 
cessive. 
Malgaigne estimated that in France one in every thir- 
teen males, and one in every fifty-two females, are rupt- 
ured ; including both sexes, one in every twenty. 
Since my former article was published there has been 
a most striking change in the mental attitude of the 
surgical world-due to published statistics - upon the 
question when to operate upon hernia which is not stran- 
gulated. 
It is not too radical a statement to say that, to-day, 
most surgeons advocate operation for radical cure sim- 
ply because a patient has a hernia. 
If this is true, it must be for the reason that surgeons 
not only think that radical cure is now regularly to be 
expected following operation for that purpose, and that 
Fig. 250.-The suturing about the platesis completed ; the anastomotic 
opening is being made ; in short lines the row of sutures is indicated 
roughly; a, block of wood, to cut against. (When properly tightened, 
the sutures cannot easily be seen, of course.) Straight scissors, with 
one sharp point, should be substituted for the knife in this illustration. 
around the plates at their line of union a long strip cut 
from the omental edge. A preliminary cobbler's ligature 
applied to the omentum will avoid loss of blood here. 
This, by actual time measurement, may be done in one 
minute. Such an omental strip is shown by Senn to be 
almost sure to live, though completely detached, for it 
becomes firmly adherent where it rests, and is a decided 
additional safeguard against possible leakage, with conse- 
quent infection. 
(6) Run into one open gut-end a thin strip of wood as 
wide as the potato-plate (a, in Fig. 250). This is to cut 
against. 
(7) Now we make our opening through the opposed 
and sealed gut-walls. I strongly advise for this purpose 
straight scissors, with, as usual, one blade sharp-pointed, 
instead of the bistoury indicated in the illustration (Fig. 
250). If desired, by a little trouble, the bowel-end may 
be so held as to render the line of incision visible through- 
out its whole length ; but this is hardly worth while, as 
with the scissors one can very easily feel, before cutting, 
413 Hernia. 
Hernia. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
failures are indeed few ; but also such advice must mean 
that, whereas once a patient herein jeopardized his life, 
now, from thorough asepsis, the operation has become 
practically free from all danger ; as much so as amputat- 
ing a finger, for instance. 
The following figures will put the reader in position 
to judge for himself upon this matter : 
Bassini has published 251 cases, with but 1 death, from 
pneumonia, when the wound had aseptically healed. 
Svennsen and Erdman, at the Sabbatsberg Hospital, 
200 operations, no deaths. Lucas-Championni^re had a 
single death among his 266 cases ; cause not stated. 
Kocher, 119 operations, 1 death from pulmonary embol- 
ism on the fifteenth day after the operation, when the 
wound was completely healed. Macewen has lost 1 pa- 
tient, from scarlet fever, out of his 98. Roswell Park, 
85 cases, no deaths. Halsted, 83, no deaths. 
It must ever be borne in mind, however, that such 
safety as this implies absolute surgical cleanliness, and 
this is no slight acquirement. This is a true coeliotomy, 
for by any and all modern methods of attempting radi- 
cal cure of hernia the peritoneal cavity is opened in order 
to ascertain accurately whether the sac is empty or not. 
Let no man dare attempt it until he has made sure by 
lesser operations, in safer regions, that he can always 
command asepsis ; that wounds of his own making shall 
regularly heal without suppuration. 
Regarding the question of success in effecting radical 
cure, Bassini reports recurrences among but 5 patients in 
251 cases of unincarcerated inguinal hernia ; although-■ 
be it remembered-the period over which many of these 
cures extend is far too short to permit of our consider- 
ing this report a final one. 
In one of his recurrences Bassini had not removed the 
sac as usual. In another he trusted entirely to catgut 
sutures. In two others there was not strictly a recur- 
rence, but simply an abnormal bulging at that part of 
the abdomen. 
Kocher records 76 cases with but 2 recurrences ; cov- 
ering a period of from four and a half years down to less 
than a year (in a few cases). 
Halsted has recently told me that from the time in 1889 
when he began his present technique, until now, in 
1893, he has had no recurrences among his 83 cases. 
It would be a waste of time to multiply figures here. 
The methods which are now generally regarded as most 
reliable are of such recent introduction that the true re- 
sults as to radical cures-those covering periods of not 
less than three, and. better, five years as a test-are not 
yet obtainable save in a very limited number of cases. 
However, it is extremely instructive to learn what not 
to do ; and a study by Dr. W. T. Bull,* of a series of 
forty cases, inspected at periods varying from a few 
months to six years, is of great value herein ; and his 
frankness in reporting undesirable methods, which he 
doubtless no longer uses, is a virtue all too rare. 
He says : " Twenty of this number had been operated 
upon by excision and ligation of the sac ; the remaining 
twenty had excision and ligation of the sac, together 
with suture of the pillars of the external abdominal ring. 
. . . By both methods, in all varieties, there were 
sixty per cent, of cures, and forty per cent, of failures." 
In a second paper he states that only about half his 
wounds healed primarily ; slow-healing drainage-open- 
ings being generally the cause of this. His drains were 
of rubber, usually. His catgut sutures were prepared 
by saturating them with Kocher's oil of juniper plan. 
In this latter paper the importance, by any method, of 
obliterating the sac is emphasized. He states that every 
case operated upon by him after the method of Heaton 
-with injection of a solution of white-oak bark into the 
inguinal canal-has now relapsed ! 
Dr. Bull insists, as do Macewen and Lucas-Champion- 
niere, on the use of a truss "from the time the patient 
leaves his bed. " 
In this respect he differs from Bassini's customary prac- 
tice, from McBurney, from Wolfler, and, in most cases, 
from Kocher. I cannot help feeling, however, that it is 
the part of wisdom to give the newly healed wall a light 
support for a few weeks by a truss (unless, indeed, the 
patient has been kept about six weeks in bed). If this 
were permanently to be worn, however, as a necessity, 
that would imply no true and radical cure, and should 
not properly be classed as such. 
In Vol. III. the reader will find discussed certain 
methods-mostly antiquated-of attempting radical cure. 
In my former article, in Vol. VIII., are yet other stud- 
ies upon this subject, giving especially the plans advo- 
cated by Drs. Czerny, Banks, Nussbaum, Sewell, Riesel, 
Barker, Ball, Macewen, and McBurney. Since the final 
volume of the Handbook appeared, various additional 
methods have attained prominence. These from their 
originality, or else their intrinsic value, deserve a per- 
manent record, and will presently be discussed here. 
It is noteworthy that two points in the technique of 
operation upon the inguinal canal have of late years re- 
ceived especial care. 
The first of these has reference to strengthening the 
weak rear-wall of that canal, which, for an inch or so to 
the inner side of the deep abdominal ring, is composed 
of nothing more resisting than transversalis fascia and 
peritoneum. Obliteration of the sac, alone or combined 
with closing the external (superficial) abdominal ring by 
sutures, will still leave this a weak spot. And if once 
the bowel begins to re-enter the canal, inevitably the 
wedge principle will at length permit of a complete re- 
turn of the hernia. Therefore it is that most surgeons 
to-day so carefully sew together the deep parts, hoping 
to prevent, by a tight, deep ring, and a strong, musculo- 
aponeurotic rear wall of the canal, the least admission of 
the thin end of the wedge. 
The second of these points just referred to is the fact 
that an element of weakness in our operations is the 
presence of the spermatic cord running through the canal. 
If we could prevent this, then the canal could be solidly 
and completely closed against the invading bowel. In 
the middle ages, as Koeber has recently reminded us, 
surgeons used to castrate their patients, and remove the 
corcl, as a simple means of solving this problem. lat- 
erally, that was cutting the Gordian knot with a ven- 
geance ! and led to a popular outcry against such sur- 
gery. Of late, certain operators have insisted upon the 
importance of this principle; and, without castrating, 
have nevertheless succeeded by various plans in perma- 
nently emptying the inguinal canal of the spermatic cord. 
Drs. Halsted, Fowler, Postempski, Wolfler, and Frank, 
are instances in point. 
Among so confusingly long an array of methods the 
reader may wish to know which are at this time regarded 
by the profession with most favor. 
I think I am safe in replying that to-day Bassini's 
method stands first in popularity among surgeons, and 
Macewen's second. Others are regarded as either more 
complicated, or as yielding a smaller percentage of true 
and permanent cures. 
Bassini's Method.-This was first described by Dr. 
Eduard Bassini, of Padua, at the Congress of Italian Sur- 
geons held in March, 1888. He reported at that time 
two hundred and sixteen cases. The following, which I 
have carefully compared with his own more recent ar- 
ticle,* is taken very largely from Dr. S. E. Milliken's 
clear description. 
Operation.-An incision is made, beginning at the 
spine of the pubis, and extending upward and outward. 
The upper extremity should be about two inches internal 
to the anterior superior spine of the ilium ; everything is 
divided down to the aponeurosis of the external oblique. 
The latter is incised over a grooved director, passed into 
the external abdominal ring, superficial to the hernial sac 
and cord structures, and then running outward even a lit- 
tle beyond the deep ring. To expose this ring properly, 
the aponeurosis should be cut for about two or two and 
one-half inches. The upper flap is now freed from the 
* Read before the New York State Medical Association, 1889. 
* Archiv. f. klinische Chir., Berlin, 181)0, vol. xl. 
414 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Hernia. 
Hernia. 
underlying structures and reflected toward the median 
line until the conjoined tendon, composed of the internal 
oblique and transversalis muscles, is brought well into 
view. The lower flap or segment of the anterior wall of 
the inguinal canal is next dissected from its underlying 
fascia, until the shelving edge of Poupart's ligament is 
exposed. These flaps being held back by retractors, the 
next point of technique is to hook up with the index-fin- 
ger the cord structures as they pass over the spine of the 
pubis, and lift them and the hernia out of their bed. 
This blunt dissection should be continued until you have 
reached the deep ring. The hernial sac, without reduc- 
ing its contents, should now be isolated ; this is best done 
by dividing the overlying structures on a grooved direc- 
tor until you have exposed the bluish-gray thickened 
membrane over a small area. This coat is raised with a 
small pair of rat-toothed forceps, that the hernial con- 
tents may not be injured when the»opening is made. 
The entrance into the peritoneal pouch should be mani- 
fested by the escape of a small amount of serum, un- 
less it be an incarcerated or strangulated hernia, when 
the fluid may be tinged with blood. The contents hav- 
ing been examined, all adhesions that may exist are tied 
off with fine catgut. Large masses of omentum should be 
ligatured, not necessarily at the most distal point, but 
when passed through Poupart's ligament, must not in- 
clude more than one-quarter of an inch of tissue from the 
edge. The relaxed posterior wall of the canal, composed 
of the transversalis fascia, should be included in the upper 
grasp of the needle, along with the conjoined tendon. 
From four to six sutures, inserted in this way, will be 
sufficient to unite firmly the musculo-tendinous struct- 
ures, forming a new posterior wall for the canal. In 
this reconstruction care must be taken not to constrict 
the tissues of the cord. The first two sutures, close to 
the pubes, include also the border of the rectus muscle. 
All of these stitches should be made to include a large 
amount, say an inch (two to three centimetres), of the 
internal oblique and transversalis muscles (Fig. 252). 
Third Step.-The formation of the anterior wall of the 
canal is accomplished by suturing the recently divided 
external oblique aponeurosis, continuously, with fine cat- 
gut (Bassini uses silk), throughout its entire length (Fig. 
253). This re-establishes the valve-like condition of the 
inguinal canal. Finally, the skin wound is closed with 
interrupted sutures after the insertion of a small glass 
drainage-tube, from two to two and one-half inches long 
(Bassini commonly does not use drainage) into the lower 
angle of the wound, and the following dressing is ap- 
plied : 
Iodoform powder (or what is preferable, fine crys- 
tals) should be spread along the line of suture and 
around the drainage-tube; on this a strip of Lister 
protective or rubber tissue, two inches wide and long 
enough to overlap one inch at the ends, a perfora- 
tion being made for the drainage-tube ; moist iodo- 
form gauze, six layers thick and sufficiently long and 
broad to overlap the wound two inches on all sides, 
also perforated for the drainage-tube ; next, a larger 
compress of moist sublimated gauze is placed over 
the upper part of the wound and held in position by 
a two-inch strip of surgeons' rubber adhesive plaster, 
extending almost entirely around the pelvis. An in- 
tervening layer of rubber tissue should be used to pre- 
vent infection of the wound from the plaster. Over 
the drainage-tube is placed sublimated gauze, very 
loosely distributed ; next, cotton, and lastly it should be 
covered by rubber tissue, one foot square, which is per- 
forated for the penis and held in position by a spica band- 
age. The advantages of having the above dressing are 
several: First, infection from without is prevented by the 
rubber tissue, which is most external, and by the small 
strip which is in immediate contact with the skin. By 
means of the adhesive plaster alone can perfect retention 
of the deeper dressing be accomplished. However, the 
most important point in this detailed dressing is the ar- 
rangement of the drainage-tube, which should be re- 
moved at the end of thirty-six or forty-eight hours by sim- 
ply taking off the external dressing and not disturbing that 
which is in immediate contact with the wound. After 
the removal of the drain the point of exit should be well 
dusted with iodoform, covered with loose sublimated 
gauze, and a new protective dressing applied. Where 
animal sutures have been employed the wound should 
heal under one dressing, even in cases of strangulation. 
Perhaps two to three weeks in bed would be the average 
duration. Some have been allowed to get up as early as 
on the tenth day. No truss is advised.* 
Method of Dr. William S. Halsted.2-This plan agrees 
in most essential respects with that of Bassini, but in ad- 
dition so deals with the spermatic cord as to remove it 
-by a plan presently to be detailed-permanently from 
the inguinal canal, at the same time reducing its size. 
Consequently there is made-1, a new posterior wall to 
the now obliterated canal ; 2, a tighter deep ring, the 
Fig. 251.-First Step. 
Bassini's Method of Operation for the Radical Cure of Hernia. 
Fig. 252.-Second 
Step. 
Fig. 253.- 
Third Step. 
where the greatest constriction exists, and it is advisable 
to use the transfixion method. Occasionally it occurs that 
the obstacle to reduction is a fibrous constriction, situated 
within the deep ring. That is, however, easily detected 
at this stage of the operation, and can be divided without 
danger by incising upward. Returning to the treatment 
of the sac, it must be completely separated from the cord 
and other adherent tissues, to a point well within the deep 
ring, and a moderate amount of traction made uniformly 
at all points, which is best accomplished by a series of 
artery forceps held by an assistant. (The blunt dissection 
of the sac from the cord and other structures is best be- 
gun at its neck.) 
Ligation of the sac with catgut is now done, also, by 
the transfixion method, having first twisted it at its neck. 
The sac is excised, leaving the pedicle about a fifth of an 
inch (one-half centimetre) in length, which immediately 
retracts into the abdominal cavity. If the hernia is very 
large, and thus the neck and opening of the sac are broad, 
Bassini applies, besides the ligature mentioned, a glover's 
suture, for security's sake. When a congenital hernia 
exists, the sac should be cut off one inch above the testis. 
The reforming of the tunica vaginalis is of no impor- 
tance, and the prevention of hydrocele will thus be at- 
tained. This completes the first step of the operation 
(Fig. 251). 
Second Step.-The upper and lower flaps, composed of 
the segments of the aponeurosis of the external oblique, 
being well retracted by sharp hooks, the cord structure 
held out of the operative field by a blunt hook or the fin- 
ger of an assistant (if necessary we may lift the testicle 
out of the scrotum in doing this), the conjoined tendon of 
internal oblique and transversalis muscles, on the upper 
side, is now united to the shelving edge of Poupart's 
ligament by a series of interrupted chromicized catgut or 
kangaroo-tendon sutures. Bassini prefers silk sutures. 
The Macewen blunt-pointed needle accomplishes this ad- 
mirably, but any curved needle will do. The needle, 
* The writer, while preferring Bassini's technique in most respects, 
would suggest as a plan worth trying, the complete and permanent 
emptying of the inguinal canal by a method which he has not seen here- 
tofore described. This consists in drawing the testicle, by its cord, out 
of the scrotum and then placing both cord and testis in the loose cellular 
tissue behind the inguinal canal, where they are to remain. Over them 
the conjoined tendon is sewn to Poupart's ligament as just described, 
etc. The advantages of having no canal and no inguinal rings is obvi- 
ous, and true castration is avoided. 
415 Hernia. 
Hernia. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
latter in a new situation ; and 3, a much smaller sper- 
matic cord. 
Dr. Halsted published his method in the autumn of 
1889, eight or nine months before that of Bassini ap- 
peared in print; although the latter surgeon, as heretofore 
stated, read a paper upon his method, in Italy, in 1888. 
Both began work upon a clear and definite new principle 
in hernia operations-Halsted upon two new principles 
-at about the same time. The priority is commonly, 
under such circumstances, given to the paper first appear- 
ing in print ; and should therefore rest with Halsted. 
The following is his description of this plan : 
1. The incision begins at the superficial abdominal 
ring, and ends one inch or less (less than one inch in 
children) to the inner side of the anterior superior spine 
of the ilium, on an imaginary line connecting the anterior 
superior spines of the ilia. Throughout the entire length 
of the incision everything superficial to the peritoneum 
is cut through. 
2. The vas deferens, with its vessels, is carefully isolated 
up to the outer termination of the incision, and held 
aside. 
3. The sac is opened and dissected from the tissues 
which envelop it. 
4. The abdominal cavity is closed by quilted sutures 
passed through the peritoneum at a level higher by one 
and a half to two inches, than that of the so-called neck 
of the sac. 
5. The vas deferens and its vessels are transplanted to 
the upper, outer, angle of the wound. Before doing 
this, all the superfluous veins of the cord (all of them 
save one or two) are excised ; thereby reducing the size 
of the cord, perhaps three-fourths. Consequently the 
new deep ring will be much smaller than otherwise-an 
evident advantage. 
6. Interrupted, strong silk sutures, passed so as to in- 
clude everything between the skin and the peritoneum, 
are used to close the deeper portion of the wound, which 
is sewed from the crest of the pubes to the upper, outer, 
angle of the incision. The cord now lies superficial to 
these sutures, and emerges through the abdominal mus- 
cles about one inch to the inner side of the anterior su- 
perior spine of the ilium. 
7. The skin is united over the cord by interrupted 
stitches of very fine silk. These stitches do not perforate 
the skin, and when tied they become buried. They are 
taken from the under side of the skin, and made to in- 
clude only its deep layers-the layers which are not oc- 
cupied by sebaceous follicles ; this to avoid possibility of 
suppuration by stitch-infection. 
Dr. Halsted has for more than two years sewed most 
of his wounds in this way. The method was suggested 
to him by his experiments on dogs. He thinks that it 
is very difficult, and perhaps impossible, to disinfect the 
skin of a dog, and believes that pyogenic organisms may 
occasionally be present in the sebaceous follicles of the 
skin. At any rate, he had repeatedly observed pus in the 
suture-holes of the perforating skin-stitches, and could 
not with any certainty secure primary union of the skin- 
wounds of dogs until he had resorted to this subcutaneous 
method of sewing the skin. 
Dr. Halsted states, in this connection, that whether or 
not it is possible or easy to disinfect absolutely the hu- 
man skin, he had been much impressed with the fact 
that skin-sutures not infrequently suppurate, even in 
wounds sewed by the most careful surgeons in this 
country and abroad. He has thought it advisable, there- 
fore, to test for a time the subcutaneous, buried skin 
suture. 
8. One or two small, short, gauze plugs are used as 
wound drains. 
The After-treatment.-The gauze plugs are removed at 
the first subsequent dressing - usually at about the 
seventh day. The patients are allowed to walk about on 
the twenty-first day. 
A few cases have suppurated. These were laid wide 
open at once, and the stitches divided. Should the 
hernia return in these cases, it could not, of course, be 
counted against this method. In one instance of this 
nature, after the wound had been freely opened again, 
urine at length discharged for a time by this route ; 
showing that one or more of the innermost stitches had 
pierced the bladder-wall-a most instructive case. 
It will be observed that whereas Bassini uses three 
rows of sutures,-sewing the external oblique aponeurosis 
as a layer by itself,-Halsted has but two rows, including 
every structure between the peritoneum and skin in his 
first, or deep line of stitches. 
The object of making the new deep ring further out- 
ward than before is in order that the vas deferens may 
pass through broad, raw surfaces, where the muscles are 
thick, and be thereby snugly embraced in its new situa- 
tion. 
Method of Dr. J. Lncas-ChampionniereA-1. It is nec- 
essary to remove absolutely the sac by a ligature at the 
highest possible point, leaving not even the slightest in- 
fundibulum in the, peritoneum opposite the deep ring. 
To accomplish this we must dissect up the peritoneum 
wall above the neck of the sac. 
2. In the second place we should oppose to the return 
of the hernia a heavy, firm cicatrix, the result of the very 
free dissection to expose the peritoneum beyond the utter- 
most part of the neck of the sac. The whole length of 
the inguinal canal is, of course, split open in order to do 
this. The larger the operation-the more extensive the 
dissection,-the firmer this scar will be. These deep parts 
are sewn together by deep sutures. (No more exact state- 
ment than this is given as to where the stitches are 
placed.) 
3. It is important, where omentum is present in the sac, 
to treat it boldly. In this respect the author claims that 
he has done what no surgeons have ever done before him. 
He pulls out of the abdomen, using "energetic effort," 
the omentum, when this has been a part of the hernial 
protrusion, and ties off and cuts away all he can. The 
consequence of this is to increase the empty space within 
the abdomen, and to remove from the inguinal region 
any remaining part of the omentum. In both respects 
this is desirable, and the omentum no longer plays its 
customary role in provoking a relapse. 
" If I consider my method of radical cure superior to 
all others which I have studied, it is because I believe 
that other surgeons have not taken the care to obey all of 
these three fundamental rules. . . 
" The most interesting characteristic of the operations 
which have given the best results is the presence, subse- 
quently to the operation, of a cord of cicatrix, volumi- 
nous and hard, extending from the scrotum up into the 
abdomen, along the region formerly occupied by the 
hernia. . . . The cicatrices really powerful, truly 
solid, are those made not by a suppurative process but 
by primary intention." 
In the sewing he uses buried sutures : not to make a 
reunion of the pillars, in the proper sense of that word, 
but to fuse together and solidify all the deep soft parts 
resulting from the free dissection. To do this, he uses 
stout catgut. Sometimes the same thread, after having 
been tied, is repassed and its ends are finally tied together 
after having been made to surround a fresh portion of 
the soft parts. 
These sutures may be placed either in single or double 
tier, from one end of the wound to the other. The bar- 
rier is completed by suturing, over these deep parts, those 
more superficial, i.e., the cellular tissues situated super- 
ficially to the muscular wall. This suture is always 
made with strong catgut, tying invariably three times, 
against slipping. 
An interesting point in the technique is that in those 
cases in which the anterior aponeurotic wall of the canal 
seems quite lax, after removing the sac, the author over- 
laps the lips of the cut external oblique aponeurosis, 
sewing them with the deeper parts, together in this posi- 
tion, and thereby making the canal a tighter one. 
Fig. 254 shows his method of tying off the sac. He 
insists, repeatedly, upon this chain-method. (To the 
writer of this review this device seems to possess no ad- 
vantages over the more simple and easily applied " purse- 
string" or " tobacco-pouch " suture described by Gerster, 
416 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Hernia, 
Hernia. 
and mentioned by me in the article on hernia in Vol. 
VIII. Furthermore, by the latter plan, the stump of the 
sac is not entirely cut off from its blood-supply, which is 
certainly a point worth considering.) 
" Among all known ways of operating for radical cure 
two only seem to me more interesting than the rest, viz., 
those of MacEven* and of Bassini. I do not much be- 
lieve in the efficacy of the folding up of the sac, thereby 
constituting a kind of stopper of defence to the hernial 
region, as MacEven teaches. But, to accomplish his 
procedure, it is absolutely necessary to carry the dissec- 
tion of the sac very high, even into the belly; and in 
this his procedure resembles mine. One is assured there- 
by that, at least, because of such high dissection, the sac 
will be completely abolished, and the cicatrix due to the 
fusion of the freshened surfaces will be both large and 
long. 
"As for the procedure of Bassini, I do not attach 
much importance to the reconstruction of the inguinal 
canal which he thinks to make around the cord. But to 
than otherwise ; and thus less dead tissue would be left 
to decompose. 
Method of Drs. Weir and Trendelenburg.-These sur- 
geons, at nearly the same time, attempted radical cure 
by the device of opposing the return of the hernia (after 
tying off and cutting away the sac) by placing in the in- 
guinal canal a plate of fresh bone. It would probably 
be a mistake to suppose that either surgeon regards the 
plan favorably to-day. Indeed, Dr. Weir quite recently 
spoke to me of it as having been merely .tentative. He 
used it in two cases ; in one the operation was a failure, 
the bone having shortly to be removed ; in the other the 
result was unknown. Dr. Weir* used a piece cut from 
the scapula of a recently killed dog. A semicircular disk 
was cut out of this plate at its upper edge, to avoid pres- 
sure here upon the cord running over it. Several small 
holes were also punched in the plate, whicli was then 
disinfected, placed in the wound, and covered up. 
I mention this method simply as standing for a prin- 
ciple-that of opposing to the return of the bowel some 
resisting solid mass tilling, and yet foreign to, the in- 
guinal canal. A very old method of attempting this is to 
plug the canal with the patient's testicle of that side, 
which has been forced up in place and held there by sut- 
ures outside, or by prolonged pressure, inducing adhesive 
exudation. Another of these devices was the introduc- 
tion of a gelatine cylinder covered with isinglass (Eel- 
mas). The open treatment of the canal during the seven- 
teenth and eighteenth centuries, permitting it to become 
filled by organic material-granulation tissue-of course 
comes under the same head, as does also the implantation 
therein of a skin-flap (Dzondi), or of the invaginated 
scrotum (Gerdy). This principle is not now approved 
by those best qualified by experience to decide, and cer- 
tainly the percentage of recurrences observed after this 
mode of operating is not encouraging. 
Method of Dr. Theodor Kocher f-In describing this I 
have used, in the main, his own language. The skin 
and superficial fascia are divided over the inguinal canal, 
and laterally outward, in the direction of Poupart's liga- 
ment (Fig. 255). At the superficial ring the cord and sac 
are exposed. By lifting these toward the light the bor- 
der of even a very thin hernial sac can be recognized. 
This is then carefully dissected and isolated from the 
structures of the cord until it can be strongly drawn 
down and its pedicle exposed. (Kocher does not mention 
it, but of course the sac is opened, for obvious reasons.) 
The index-finger of the left hand is now introduced 
into the inguinal canal, and laterally from the deep in- 
guinal ring a small opening is made through the aponeu- 
rosis of the external oblique muscle (again see Fig. 255). 
A slender pair of artery forceps is passed through this 
opening and through the lower muscular fibres of the 
internal oblique and transversalis muscles, following the 
left index-finger as it is withdrawn through the in- 
guinal canal, and finally out of the superficial opening 
(Fig. 256). With the same instrument the isolated sac is 
grasped and drawn through the canal and through the 
narrow opening in its anterior wall, that is, in a lateral 
direction from its upper end. 
The hernial sac now hangs through a narrow opening 
above Poupart's ligament (Fig. 257). It is drawn out as 
much as possible, and then, as Heliodorus did, and as 
Ball has recently advised, it is energetically twisted. 
The sac is, however, not removed nor ligated, but is 
strongly drawn down and laid over the outer surface of 
the aponeurosis of the external oblique muscle and 
against the superficial ring ; in other words, running 
superficially to, and in the direction of, the inguinal canal. 
By this tension on the sac, as is shown in Fig. 258, the 
anterior wall of the unopened inguinal canal, and espe- 
cially the tense aponeurosis of the external oblique muscle, 
are pressed inward and backward into a gutter. 
As the twisted sac lies tensely stretched in this manner, 
deep silken sutures should be applied, beginning at its 
upper and outer extremity. These are passed above the 
twisted sac, through the fibres of the aponeurosis of the 
external oblique muscle and the underlying muscle-fibres 
of the internal oblique and transversalis, through the 
Flo. 254.-Method of Lucas-Championniere in Tying off the Hernial Sac. 
A represents the incision made for the purpose of ascertaining whether 
the sac is empty or not. 
accomplish that end he opens freely that canal, in front 
and behind, and carries high his dissection of the serous 
sac. Necessarily, then, he will obtain a result analogous 
to that which I recommend-a free and thorough sac- 
removal and a very big cicatrix. That' is the reason of 
his success." 
Dr. Lucas-Championniere claims 266 operations upon 
hernia, of which 221 were in men. He states that he has 
had only one opportunity to operate a second time upon 
one of his own cases. 
A propos of his radical teaching with reference to 
thorough excision of omentum forming a part of the 
hernia (quoted above), it is well to appreciate and guard 
against dangers due to defective technique in carrying 
out this procedure. Dr. W. T. Bull4 has classified these 
under three heads, as follows : 
1. Bleeding from inefficient ligature. 
2. Damage to neighboring intestine, which may be in- 
cluded in a carelessly applied ligature. Such a nipping 
lasting only fifteen minutes before its discovery and cor- 
rection, has in one published instance led to a slough, 
perforative ulceration, and death. 
3. Inflammation and abscess of the omental stump : of 
course to be avoided by the strictest asepsis, and sterility 
of the ligature-material, of whatsoever kind selected. 
As to the first of these three points, Lucas-Champion- 
ni^re advises, just as in dealing with the sac, his chain- 
ligature (see Fig. 254). Bull ligates in sections, no one 
of which is of as great volume as the finger. It is as 
wTell, as an additional safeguard, to tie any large vessels 
seen on the face of the omental stump. The latter, with 
but small masses embraced in the loops of ligature, may 
safely be cut much nearer to the point of constriction 
* There is no letter w in the French alphabet. This is Dr. Macewen's 
misfortune. 
417 Hernia. 
Hernia. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
twisted hernial sac itself, and then including the liga- 
ment of Poupart beneath it. We must be careful not to 
sew into the external iliac vessels, and the finger-tip in- 
troduced deeply into the canal, and crowding back the 
spermatic cord, is our guide as to the deep structures em- 
braced. 
These sutures-five to seven or more-bring together 
also the pillars of the superficial ring, to which the lower 
end of the hernial sac is fastened. In case of a long sac, 
all that extends below the superficial ring is cut away. 
The operation is more certain when the upper suture 
can be deeply applied laterally from the place of entrance 
of the spermatic cord into the abdominal wall. 
In tying the sutures, begin with the highest first. The 
finger-tip, once more introduced within the canal, is our 
guide as to when the deep parts are brought properly to- 
gether thereby. Finally the skin-wound is sutured. 
No drainage is used as a rule, and, save in exceptional 
cases, no truss is advised afterwards. The patient-in 
those cases healing per primam-averaged only seven and 
a half days in bed. This was not Kocher's wish, how- 
ever, but due to the limited hospital space. He says, 
" we agree with Macewen that it is right and desirable 
that after a radical operation the patient remain six 
weeks in bed, and not return to work until after eight 
weeks." 
Method of Dr. Joseph D. Bryant.'1-This consists in 
isolation of the sac-after exposing by incision the whole 
length of the canal and the deep ring-and then weaving 
the empty sac in and out, across and across the long axis 
of the canal, through four slitscut in the external oblique 
aponeurosis. Thereby the sac is made at once to oppose 
a return of the hernia, and also to aid in bringing more 
closely together the hernial parts. 
The exact mode of weaving the sac is clearly shown in 
the accompanying illustrations, Figs. 255, 256, and 257. 
(SUPPLEMENT ) 
Dr. Bryant remarks : " It is my opinion that this 
method cannot be applied indiscriminately, as can the 
open method, since it frequently happens tliat the sac is 
Fig. 256.-Sac going through Slits of Inner and Outer Pillars. 
illy developed, or so much damaged by isolation that it 
will be unwise to hope for particular benefit from the 
weaving process, even if it be possible to employ it; and, 
Fig. 257.-Sac passing through Outer Pillar and beneath Inner Pillars. 
too, not infrequently, the external pillar of the ring may 
be found to be so narrow and attenuated as to render its 
slitting impracticable." Recently Dr. Bryant has not 
Fig. 255.-Sac going through Upper Slit of Inner Pillar. 
A ease of sloughing of the sac following its ligation 
has led Dr. Bryant to cease tying it in this technique. 
To this extent, therefore, Fig. 255 is now incorrect. 
Finally the original slit in the external oblique apon- 
eurosis is closed, and the superficial ring narrowed, with 
quilted catgut sutures, which are also to be carried 
through the sac beneath for added solidity ; over all the 
skin is to be sutured. 
Fig. 258.-Quilted Tissues. 
performed this operation so frequently as heretofore, and 
so informs me. 
Method of Dr. George II. Fowler.-This surgeon makes 
418 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Hernia. 
Hernia, 
(SUPPLEMENT.) 
his incision, and treats the sac in the same manner as 
does Bassini. He then follows a plan of his own, to be 
described, which is a modification of the method of Pos- 
tempski. In this latter plan the technique throughout is 
like Bassini's, save that Postempski permanently removes 
the spermatic cord from the inguinal canal, thereby being 
enabled to close the latter more completely. Postempski 
lifts out the cord as far as the deep ring, displacing it in 
a direction upward and toward the median line, and at- 
taches it in its new position (just beneath the skin, and 
superficially to the external oblique aponeurosis) by loose 
loops of buried catgut suture. 
Dr. Fowler's method (used for two years, now) differs 
from this, the Bassini-Postempski, in two respects, 
viz., as regards the character of his incision, and in re- 
spect to a peculiar method of suturing. He first slits 
the abdominal wall, " an inch or more," straight upward 
from the deep ring, and going as deeply as the peritone- 
um. Into this slit he lifts the cord, and holds it there, 
at the highest point possible, by "a loose loop of catgut 
suture placed at a proper distance above the internal 
ring." The integument and fascia are dissected up from 
the aponeurosis of the external oblique for a distance to- 
ward the median line sufficient to permit the placing of 
the spermatic cord in this, its new position, so far as its 
length will allow. 
" Both ring and cord, as well as the inguinal canal be- 
ing now cleared, the next step to be taken consists in a 
close approximation of the margins of the gap left. In 
order to accomplish this in the most perfect manner all 
drainage of the wound must be dispensed with, and it 
goes without saying, in these days, that the most rigid 
aseptic precautions have been adopted, in order to make 
this entirely safe. If antiseptic fluids have been used 
these should be washed away with sterilized salt-solu- 
tion, or a solution of the blood-salts in normal propor- 
tions. In this way any fluid remaining approaches in 
character normal connective-tissue fluid, and no irrita- 
tion is produced by its presence. 
"The wound is now ready for suturing. In order to 
secure proper layer-to-layer approximation of the divided 
and separated structures it was formerly the custom to 
secure these by means of buried catgut sutures. I have 
abandoned this method ever since employing the Bassini- 
Postempski procedure, and have substituted for it a 
method devised by myself, and which I have heretofore 
described as the "crossed suture." The material em- 
ployed is crin de Florence, or silkworm-gut. Firm and 
evenly rounded strands of this are selected. In using it 
the strand is threaded at both ends upon large and full- 
curved Hagedorn needles. In order to avoid trouble- 
some and annoying unthreading of the needles during the 
manipulation, I secure these to the thread by passing the 
end of the latter through the eye of the needle a second 
time from the same direction as that from which it was 
first passed. By this means a firm loop or "bight" 
holds the strand securely to the needle, Fig. 259 (Annals 
of Surgery, May, 1892). 
The needles, after emerging (the loop being drawn taut) 
each from its respective side, are reversed as regards 
position ; that which passed through Poupart's ligament 
being now carried to the inner side and passed through 
the skin, again from behind forward, -while that which 
included the inner margin of the lowermost layer, or 
muscular structures and conjoined tendon, is passed 
through the skin at the outer margin in the same manner. 
The thread is therefore crossed on a level with the plane 
which represents the space between the two layers. 
Upon drawing upon the ends of the 
threads the loop which includes the )) 
muscular structures and conjoined W Jf 
tendon upon the inner, a fold of 
transversalis fascia in the floor, and 
Poupart's ligament upon the outer ff 
side, of the wound, is tight- 
ened, and perfect approxima- 
tion of these structures results. By tying the suture over 
the skin the incision is completely closed. Fig. 260 (An- 
nals of Surgery, May, 1892) shows the "crossed suture," 
in this case crossed a second time. 
" The sutures are placed about three-eighths of an inch 
apart and a sufficient number are employed to close com- 
pletely the wound, no drainage being employed. All the 
sutures are placed in position before any are tied. In 
accomplishing the latter it is well to begin from above 
and as each is drawn taut a finger is carried to the bot- 
tom of the wound in order to assure one's self that each is 
fulfilling its purpose. A strip of protective and the usual 
dressing complete the procedure. 
" The sutures are left in place for at least three weeks ; 
I have left them in for five weeks with no ill effects. 
They are removed as an ordinary suture by simply cut- 
ting the thread upon one side of the knot and making 
traction upon the other. No difficulty is found in with- 
drawing the silkworm-gut, the latter readily following 
the figure-of-eight track which it forms. 
" I never permit a patient thus operated upon even to 
sit up in bed for the first six weeks following the opera- 
tion. This, at the present time, I consider an important 
adjunct to the operation, although further experience 
may shorten this time somewhat in selected cases. In 
persons in whom, from long truss wearing or other 
causes, there is a loss of resiliency of the wall of the ab- 
domen, it is well to prolong the stay in bed for a fort- 
night longer, and to employ, in addition, massage and 
electricity, following the healing of the wound. 
" The advantages claimed for this method of operation 
relate, first, to the plan of placing the cord in such a 
position as to render it next to impossible for a knuckle 
of intestine to follow it in its course. Under all circum- 
stances in which a recurrence is favored or produced, the 
duration of the force is from within forward and down- 
ward. When the cord is made to assume a course up- 
ward and then inward before making its descent in the 
direction of the scrotum, nothing short of the patient 
standing on his head will favor the entrance of a portion 
of intestine alongside of the cord, and permit it to follow 
its course. It may be said that the weight of the testicle 
will tend to straighten the cord finally ; this is true to a 
certain extent, but the manner of placing the sutures here 
described will prevent this, for the reason that the cord 
Fig. 260. 
Fig. 259. 
"The strand being thus secured to the needles the latter 
are passed from behind forward, one through each edge 
of the divided lowermost layer. The latter consists es- 
sentially, in the case of an ordinary indirect inguinal 
hernia, of the muscular structures and conjoined tendon 
upon the inner margin, and Poupart's ligament upon the 
outer. At the points where the transversalis fascia pre- 
sents itself as the floor of the canal, a fold of the latter is 
included in the loop. Care should be taken in this part of 
the manipulation not to wound the external iliac vessels. 
419 Hernia. 
Hernia. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
is held away from the line of incision by being retained 
entirely outside of these, independently of the chromi- 
cized catgut loops which fasten the cord in its new position. 
Second, the crossed suture secures, in the approximation 
of the edges of the divided layers separately, all the advan- 
tages of the buried catgut suture ; being removable at will 
it presents none of the disadvantages arising from the un- 
certainty as to the length of time which the latter may 
be depended upon to hold securely. In addition to this, 
the crossed suture firmly grasps and securely holds the 
several layers, not only edge to edge, but surface to sur- 
face. The result of this is a firm and solid wall, extend- 
ing from the parietal peritoneum to and including the 
skin-surface. Third, prolonged maintenance of the dor- 
sal decubitus insures stability and firmness of this wall, 
and at the same time, aided by massage and faradization, 
it restores the relaxed and thinned abdominal wall to some 
approximation to the normal condition." 
Dr. Fowler has used this method up to date in thirty- 
three cases ; and has had but one recurrence-a patient 
with femoral hernia, in whom suppuration and extensive 
sloughing occurred. The author advises against the use 
of a truss after the operation. 
Method of Dr. George A. Baxter.3-This consists in an 
incision exposing the whole length of the inguinal canal 
to the deep ring, followed by a second cut going directly 
upward from tins ring through the entire abdominal wall 
and exposing the bowels for a distance-varying as to 
number of inches in different cases-"sufficiently far to 
enable the sac to be engaged in it without being too 
much folded upon itself." 
The sac, after a very thorough dissection to the highest 
possible point, is tied at a level which would be " within 
the canal " if the sac were still lying there. Then the 
sac is turned vertically upward from the deep ring and 
pressed deeply into the upper wound. Any excess at the 
free end of the sac is cut away. 
Two lines of sutures are next inserted. The deepest 
pass first through the skin and directly into the peritoneal 
cavity, then out through the sac in its new position, then 
into the belly again, and so out of the skin on the opposite 
side of the wound. About four or five of these stitches 
are inserted transversely, going from the highest point 
down to the deep ring. Next, a more superficial row, 
about as numerous, and covering the same extent of 
wound ; but these only pass from the skin to the perito- 
neum, and run over the sac, and embrace the musculo- 
aponeurotic coverings of the abdomen and the skin. 
The author points out the danger of ventral relapse 
from allowing, while suturing, the muscles to retract, as 
they will to different degrees, and of passing the needles 
without first remedying this. One should seize the 
muscle-edges and draw them flush and even with the 
skin, and, while holding the wall thus, pass the needles. 
Next one or two " curved or crucial sutures are passed 
at the internal opening of the canal from below upward, 
dipping over the cord (which is placed to the outer side of 
the incision, and still in the canal) but entering and pass- 
ing through the tissues after the manner adopted in the 
majority of operations for ruptured perineum-traversing 
them, in other words," Now tie all the sutures passed. 
Finally, " the hernial canal and scrotal opening are 
closed with deep suturing." (As to this, no more definite 
statement is made, nor is the kind of suture-material 
named.) No drainage is to be used unless we find the 
sac or its contents diseased. 
The author calls attention to the " necessity for care- 
ful removal of all fat from the neighborhood of the in- 
ternal opening, and the freshening of the edges of the 
tissue at this point for better union." 
Dr. Baxter claims among its advantages that this plan 
" deflects all expulsive efforts from the ring and canal 
to the abdominal parietes, thereby lessening greatly the 
liability to a recurrence in the old channel ; and, by do- 
ing so, leaves the ring and canal in a perfectly quiescent 
state during the whole progress of healing." 
This operative procedure is so recent as to have no list 
of cases to show as yet. Dr. Baxter gives illustrations 
of methods and results in one difficult case. 
(SUPPLEMENT.) 
Method of Dr. A. Wolfer A-This, the most complicated 
of possible methods for radical cure, has, I think, for this 
Fig. 261. 
reason been but little tried by others than 
Wbltler himself. It is, however, so ingenious 
in several respects as certainly to be deserv- 
ing of accurate description. Most of the steps 
he has used for four years past. These are : 
Fig. 2t»2. 
420 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Hernia. 
Hernia. 
1. Denudation of the superficial ring, and of the an- 
terior-wall of the canal-the aponeuroses of the external 
oblique muscle (Fig. 261). 
2. Splitting the external oblique aponeurosis, 
thereby exposing the cord, sac, and the deep ring 
(Fig. 262). 
Fig. 263. 
3. Isolation of the blind (distal) end of the sac (Fig. 
263) ; and opening this freely by aid of several pairs of 
forceps (Fig. 264). 
Fig. 264. 
Fig. 266. 
421 Hernia. 
Hernia. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
4. Closure of the neck of the sac by suturing (silk), 
by either of two methods (Fig. 264). 
5. Then scorching of its interior by actual J 
cautery (Fig. 265). 
6. Final closure, by suture, of distal portion of 
of step 5, be cut away near its first-named line of sutures 
after the cauterization. 
7. The cord must now be displaced from the deep 
ring and brought as far inward as is possible. 
8. Temporary castration, by pulling the testicle, at- 
tached to its cord, out of the scrotum, then tucking it 
through an opening behind the sheath of the rectus 
muscle of its own side, then out through a slit between 
the two recti, and so back again home (Fig. 267). This 
device has only as yet been used four times, and but re- 
cently. The inguinal canal is now, of course, empty, 
save for the scorched and doubly sutured sac. 
9. Narrowing of the canal and deep ring by sewdng 
snugly over the sac in them first the transversalis mus- 
Fig. 267. 
sac, Fig. 266, leaving it still in inguinal canal. 
In case the sac is easily peeled up, it may, instead 
Fig. 269. 
cle, and next the internal oblique, each to the deeper, 
shelving portion of Poupart's ligament (Fig. 268). 
10. Opening sheath of rectus muscle (Fig. 269). 
11. Displacement outward of this muscle until it is 
sewn, like the previous muscles, to Poupart's ligament 
(Fig. 270); or else to the under surface of the aponeurosis 
of the external oblique, on the outer side of the cleft in 
the latter. In addition, the cut sheath of the rectus, or 
its anterior portion at least, is so sutured. 
12. Closure of the split external oblique aponeurosis, 
and obliteration of the superficial ring, by suturing, 
even down to the pubic bone (Fig. 271). 
13. Suture of the integument, over a small drainage- 
tube.* 
In making the superficial incision this should run, 
not parallel with Poupart's ligament, as the cut (Fig. 261) 
would indicate, but rather more nearly in a vertical di- 
rection. The same is true of the direction in which the 
external oblique aponeurosis is slit. Consequently there 
is a much broader aponeurotic surface than merely Pou- 
* In Figs. 268, 269, 270, and 271 it is evident that the cord is wrongly 
drawn, and should have been made to appear running in its new position, 
from between the two recti muscles, downward and outward to the 
scrotum. 
Fig. 268. 
422 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Hernia* 
Her ilia. 
part's ligament to which to sew the two deeper muscles. 
Also, the rectus does not have to be dragged so far out- 
crowds it as much as possible against the deep ring, and 
then sews the muscles over it as stated. " When (excep- 
tionally) this cannot be done, the sac is drawn, before this 
suturing, toward the scrotum ; and any excess in length 
is divided opposite the superficial ring by either cautery 
or knife." 
Regarding the temporary castration, Wolfler advises 
inserting a thread through the scrotum at the location of 
the divided gubernaculum, for the purpose of readily 
finding it again, so as to replace, by a stitch, the testis in 
its exact former relation to the gubernaculum. 
It will be observed that Wolfler indulges, as a rule, in 
eight distinct lines of suturing : 1, The neck of the sac ; 
2, after cautery, the more distal portion thereof; 3, the 
trans versalis muscle ; 4, the internal oblique ; 5, the rec- 
tus ; 6, its cut sheath, or the anterior part of it ; 7, the 
external oblique aponeurosis ; 8, the skin. 
In his introductory remarks it is pleasing to notice 
that he disapproves of Macewen's method, among others, 
because it is so complicated, so lacking in simplicity ! 
Method of Dr. FramkM-This surgeon has recently re- 
ported two cases in which, after removing the sac as usual, 
he has carried out a new idea, in endeavoring permanently 
to empty the canal of the spermatic cord, so that the canal 
may be obliterated by suturing. This is done by drag- 
ging the cord inward until it escapes opposite the super- 
ficial ring, when it is tucked down into a neatly fitting 
gutter of sufficient depth, chiselled from the horizontal 
ramus of the pubes. The superficial ring, like the rest 
of the hernial region, is now entirely to be closed by su- 
tures. 
Turning now from inguinal to femoral hernia, the 
writer presents, in closing this study, three recent methods 
devised for attempting radical cure of hernia escaping 
below Poupart's ligament, through the femoral ring. It 
is commonly agreed that, by whatever plan attempted, 
femoral hernia is somewhat less frequently the subject 
of relapse than is inguinal. Dr. Marcy has stated in his 
new work upon hernia, Apropos of this, that Drs. Macewen 
and McBurney have recently written him saying that 
they do not know of a single recurrence in their own 
operated cases. The widely differing plans, nevertheless, 
preferred by these two gentlemen may be ascertained by 
reading the description, in Vol. VIII., of their respective 
inguinal operations. 
Dr. George 11. Foicler's method in femoral hernia con- 
sists (after the isolation, high ligation, and cutting away of 
the sac) in the application of his " crossed suture," before 
mentioned in this article (see Fig. 260). Poupart's liga- 
ment is forcibly retracted upward, when the internal 
opening of the crural canal is brought into view. The 
first loop of each suture will include, according to its 
location, either Poupart's ligament or the lower border of 
the aponeurosis of the external oblique muscle, the vagina 
vasorum, the pectineus muscle and fascia covering it, 
and, perhaps, Gimbernat's ligament. The usual care 
must be exercised, while sewing, not to wound the vessels. 
The needles are now reversed, the suture crossed, and the 
margins of the iliac and pubic portions of the fascia lata 
included in the second loop. The needles are again re- 
versed, the suture again crossed, and the superficial fascia 
and integument grasped in the last or outer loop, this last 
being completed by tying the suture upon the outer sur- 
face of the skin. 
Dr. Salzer11 first removes the sac and then closes the 
external orifice by a flap formed from the fascia covering 
the pectineus muscle turned upward and sutured to the 
middle third of Poupart's ligament. In this manner the 
septum crurale is replaced by a tough, resistant layer of 
fibrous tissue. The thickness of the pectineal fascia 
varies, but it is most likely to be strong enough in old 
persons and in those who have worn a truss for femoral 
hernia for a long time. 
I think it preferable to oppose to the advance of the 
bowel a thicker, firmer mass than that made by Salzer's 
layer of pectineal fascia alone, and have preferred, as a 
slight but not unimportant modification of his method, 
to dissect up quite a deep and free flap of pectineus 
muscle and not alone of its fascial covering, suturing this 
Fig. 270. 
ward for suture (as shown in Fig. 270) as other- 
wise would be the case. 
As to the further treatment of the cauterized and 
stitched sac, the author states that lie commonly 
Fig. 271. 
423 Hernia. 
Histological. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
to the freshened and well-exposed broad under surface 
of Poupart's ligament, and thereby solidly filling the space 
between the femoral vein and the free edge of Gimbernat's 
ligament. Outside this musculo-fascial flap I also unite 
the freshened iliac and pubic portions of fascia lata, if 
need be making a long vertical incision through this 
membrane, an inch or more to one or other side, to per- 
mit easy apposition of the edges, without tension on the 
sutures ; and finally I close the skin-wound ; all stitches 
being preferably of freshly boiled silk. 
Dr. Kocher describes as follows the method preferred 
by him : " In femoral hernia, also, it is necessary com- 
pletely to isolate the hernial sac serosa, to draw it strongly 
down, and to tie it as high as possible. With the short 
and broad pedicle this ligation is not always so easy as it 
is in the inguinal hernia. Then cut away the excess. 
Still more difficult is the suturing of the canal. Nothing 
is to be gained by sewing the remains of the processus 
falciformis which forms the anterior crural ring, to Pou- 
part's ligament; but here also the deep parts of the 
femoral canal must be brought together. This is best 
attained (as we can say after watching the courses which 
our cases have followed), by passing the sutures through 
the transverse portion of the pectineal fascia (which, under 
the name of " ligament of Cooper," covers the pectineus 
muscle at its insertion into the pubes, and which can 
plainly be seen on the lower side of the neck of the hernial 
sac), and drawing it up and firmly suturing it to Pou- 
part's ligament. This causes broadening of the ligament 
of Gimbernat which covers the inner angle of the femoral 
ring, and usually gives a sufficiently good closure of the 
hernial opening." 
Dr. Kocher has sometimes also employed the following 
method in the treatment of the sac : This, having been 
completely isolated and twisted as strongly as possible, is 
drawn through a small opening made above Poupart's 
ligament, and in the manner above described is included 
in the sutures which are passed through the pectineal 
fascia and Poupart's ligament for the purpose of closing 
the femoral ring. Robert H. M. Dawbarn. 
rules must be borne in mind in the fixation of tissues : 
Use those reagents which do not form tissue-like precipi- 
tates with protoplasm. This requirement is met by 
chromic salts, sulphate of copper, sublimate and some other 
salts. Preparations from chromic salts when transferred 
to alcohol should be kept in absolute darkness (Virchow) 
until the fixing agent is removed so far as possible. 
Chromic acid transforms protoplasm into tissue-like 
forms and should be avoided unless its application can 
be controlled. Fixing fluids should contain an organic 
acid (e.g., acetic) which changes nuclein into an insoluble 
state. The acid should be used in a diluted form, as 
nuclein is said to be soluble in strong acids, or even in 
weak acids if their action is too long continued. A 
small quantity of alcohol is also desirable. Strong alco- 
hol dehydrates too rapidly and induces changes in the pro- 
toplasm. With the foregoing as a basis, he recommends 
the following solution : Alix excess of finely powdered 
bichromate of potash and sulphate of copper in fifty per 
cent, alcohol and allow the solution to stand in complete 
darkness for twenty-four hours. A greenish - yellow 
fluid is the result and this before using should be acidu- 
lated with acetic acid (five or six drops to one hundred 
cubic centimetres). The object to be fixed is placed in 
this fluid from twelve to twenty-four hours, according to 
its size and the degree of hardness required, the whole 
transaction being carried on in the dark to avoid the 
precipitation of the salts. The specimen is then placed 
in strong alcohol from twelve to twenty-four hours, af- 
ter which it may be sectioned in any of the usual ways. 
The usual reagents for preservation after fixation, alcohol, 
chromic acid and its salts, are rejected on account of the 
tissue-changes induced by them ; ether, xylol, toluol, 
or any substance which does not act upon albuminous 
matter, is recommended. 
Osmic acid in the form of vapor or in solution, corro- 
sive sublimate, Flemming's, Kleinenberg's, Perenyi's, 
Merkel's, and other mixtures have stood the test of time 
and are too well known to need more than the briefest 
mention. Tissues fixed in osmic and chromic acids do 
not readily take the carmine stains. Osmic acid is easily 
reduced in the presence of organic matter. This is a 
more important factor than light. 
To retard this reduction Lee2 recommends that the 
osmium should be kept in the form of a two per cent, 
solution of osmic acid in a one per cent, aqueous chromic 
acid solution. This solution serves for fixation with 
osmium vapors and for the making up of Flemming's 
solution. AU dust should be carefully excluded. 
Rabi's Fluid:3 
One-third per cent, chromic acid.. 200 c.c. 
Concentrated formic acid 4 or 5 drops. 
The mixture must be prepared fresh whenever needed. 
After twelve to twenty-four hours' fixation the tissue is 
washed with water and the hardening completed in alco- 
hol. It is one of the very best reagents for karyokinesis. 
Permanganate of Potash *-This reagent, in a saturated 
solution, is said to kill even more rapidly than two per 
cent, osmic acid. It preserves the forms of cells very 
well and has been found useful in the study of isolated 
and contractile cells, e.g., spermatozoa. 
Car noy's Fixing Fluid or Acetic Alcohol.*-First for- 
mula : 
Glacial acetic acid 1 part. 
Absolute alcohol 3 parts. 
The second is : 
Glacial acetic acid 1 part. 
Absolute alcohol 6 parts. 
Chloroform 3 parts. 
The chloroform is said to render the action of the fluid 
more rapid. Acetic alcohol is one of the most rapid and 
penetrating " fixers " known. It preserves nuclei well, 
but must not act too long, and admits of most any way of 
staining. It is applicable to tissues in general and should 
be washed out with alcohol. 
Davidoff's Solution :5 
Saturated solution of corrosive sublimate, 3 parts. 
Glacial acetic acid 1 part. 
This has been found very useful for ova, which may 
1 Amer. Journ. Med. Sciences, 1892, p. 258. 
2 New York Medical Record, April 9. 1892. 
s Johns Hopkins Hospital Bulletin, vol. i., No. 1. 
4 Cure Radicale des Hernies. Paris, 1892. 
s Annals of Surgery, March, 1893. 
8 Medical News, Philadelphia, February 15. 1890. 
' Annals of Surgery, December, 1892. 
8 New York Medical Record, November 9, 1889. 
8 Annals of Surgery, March, 1893. 
Billroth : Jubilee Volume. Stuttgart. 1892. 
11 Wiener klin. Wochenschrift. 21 Juli, 1892. 
12 Centralbl. f. Chir., August 20, 1892. 
HISTOLOGICAL FORMUL/E, ETC., RECENT. 
That histology is a progressive science is evidenced by 
the many new and modificatory formulae constantly ap- 
pearing ; that it is becoming more and more an exact 
science is shown by the quality and accuracy of the re- 
sults. Methods are the sine qua non and their impor- 
tance cannot be too greatly emphasized. 
Fixation of Tissues.--Fixing, as ordinarily under- 
stood, implies the killing as well as a slight degree of 
hardening of the tissue. Its more precise aim is to cause 
as nearly as possible, by means of certain reagents, the 
same relative position, size, and structure of the elements 
after death as before. This may be more or less success- 
fully accomplished either by the use of an agent that acts 
instantaneously or one that acts gradually. Rapid fixa- 
tion perhaps gives the most satisfactory results. It is of 
course essential that the structures should be alive at 
the time of fixation, so that pathological or post-mortem 
changes may be avoided. Plenty of the " fixer" should 
be used. Fifty to one hundred times the volume of 
the specimen is a good proportion. It should be changed 
whenever it becomes turbid. After once being used it 
is to be thrown away. No universal fixer has as yet 
been found. With so many varying conditions and pe- 
culiarities of structure, experiment alone can decide just 
which formula is best for any particular case. 
According to Kultschitzky 1 the following important 
424 REFERENCE HANDBOOK OF TIIE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Hernia. 
Histological. 
remain in it from half an hour to an hour, then w'ashed 
for a few minutes in water and carried up through the 
successive alcohols. This mixture also works very satis- 
factorily with other tissues and for the rapid killing of 
many animals. 
Another solution, almost as good, consists of : 
Saturated solution of picric acid 3 parts 
Glacial acetic acid 1 part 
The structures are to remain in it for three or four 
hours and then brought into seventy per cent, alcohol. 
Kolossow's Solution."-A 0.5 per cent, solution of os- 
mium in two or three per cent, of nitrate or acetate of 
uranium is recommended as having very great penetrat- 
ing power. 
Gage's Picric Alcohol: 
Distilled water 500 c.c. 
Ninety-five per cent, alcohol 500 c.c. 
Dry picric acid 2 gms. 
It amounts to a one-fifth per cent, solution of picric 
acid in fifty per cent, alcohol. The tissues are fixed in this 
solution from one to three days, then washed in sixty- 
seven per cent, alcohol for two to three days and kept for 
at least one day in eighty-two per cent, alcohol. They 
may remain in the latter indefinitely. If small pieces of 
tissue are used the time for each step may be abridged ; 
if large, the time should be lengthened. This "fixer" 
is of quite general application and admits of any of the 
usual methods of staining. 
Picric acid should always be washed out with alcohol 
(Lee). 
This reagent is said to transform albuminates into an 
insoluble state. After the removal of the acid the tissue 
can be colored with any stain. It is recommended for 
chitinous structures on account of its penetrability. It 
has also some decalcifying power. 
Zinc Chloride.-Broca,6 in 1879, recommended a ten 
per cent, alcoholic solution of this salt for the preserva- 
tion of gross preparations of the brain. Grandmaison 
(Oomptes rend, hebdom Sw. de Biol., I., 1889) has con- 
sidered " De 1'emploi des solutions de chlorure de zinc 
pour la fixation des elements anatomiques." This re- 
agent has given excellent results on brain-tissue for histo- 
logical purposes in the following solution : 
Ninety-five per cent, alcohol 100 c.c. 
Zinc chloride. 5 gms. 
Its action is rapid and even. After two to three days' 
immersion the tissue is placed in ninety-five per cent, al- 
cohol until thoroughly hardened and dehydrated, when 
it may be imbedded and cut in any of the usual ways. It 
stains very readily in hematoxylin or carmine. 
Lemon-juice,"1 fresh and filtered, has been warmly rec- 
ommended by Van Gehuchten as a fixative for nuclei.. 
Fix for five minutes, wash well with water, and stain 
with methyl green. 
Alcohol.-Two grades are sometimes employed. Di- 
lute alcohol is often useful, in that it is strong enough 
to exert some coagulating power, but has sufficient 
water to render its dehydrating action feeble and innoc- 
uous. Absolute alcohol kills quickly and the tissues 
are not allowed to become deformed. Alcohol, however, 
is chiefly useful as a "fixer" in connection with some 
salt dissolved in it, as corrosive sublimate, picric acid, 
etc. 
Pyridin*-A coal-tar product, possessing the peculiar 
property of being miscible with either oils or water, and 
coagulating albuminates with a neutral reaction. Hard- 
ening is effected in an incubator in about eight days ; 
with small specimens less time is required. The tissues 
are at once hardened, dehydrated, and cleared, and can 
be easily sectioned and stained. The anilin dyes dis- 
solve very readily in pyridin. The sections may be 
mounted in balsam, or after four days' hardening trans- 
ferred to water, in which case they take up hematoxylin 
and picrocarmine very well. The reagent gives the best 
results with nervous tissue. It has also been found use- 
ful in the study of bacteria. The odor is very penetrat- 
ing and rather disagreeable. 
Heat.-Heat is very efficacious in killing suddenly and 
coagulating albuminous substances. "It has the great 
advantage of allowing of good staining subsequently 
and of hindering less than any other method the applica- 
tion of chemical tefets to the tissues." * Heat is not ap- 
plicable to all organs or organisms, nor is it always easy 
to determine the exact degree of temperature suitable for 
each structure; 80° to 90° C. will generally be amply 
sufficient, and very frequently it will suffice not to go 
beyond 60° C. A few seconds' exposure is generally 
enough. When the protoplasm is supposed to be coagu- 
lated throughout the structures are brought into thirty 
to seventy per cent, alcohol, if water is employed as the 
heating agent. The efficacy of the ordinary fixing mixt- 
ures is largely increased by heating them. 
Small objects (Protozoa, etc.) may be brought into a 
little water in a watch-glass or on a slide, and heated 
over the flame of an alcohol lamp. For larger objects 
the water or other liquid may be heated beforehand and 
the animals thrown into it. For the fixing of eggs 
(amphibian and others) heat has given most excellent 
results. 
Decalcification.-Bones or calcified tissue contain a 
considerable amount of inorganic substance, represented 
chiefly by the phosphate and carbonate of lime. These 
salts are soluble in various acids, and when once re- 
moved the organic constituents are left behind, leaving 
the bone flexible, elastic, and more or less translucent, 
and, with proper imbedding, admitting of easy sectioning. 
"To obtain the most satisfactory results the bone must 
be thoroughly fixed and hardened like any other tissue, 
before being put into the decalcifier. Reagents which 
are said to harden and decalcify at the same time are of 
doubtful utility for fresh specimens. 
A general but important rule to bear in mind is to em- 
ploy the acid in a very weak solution, in order to make 
as little change as possible in the soft tissue it leaves be- 
hind. When the lime is chiefly in the form of a car- 
bonate, as in the skeleton of Echinoderms, the acid must 
be added very gradually. The specimen should be im- 
mersed in water in a glass vessel, and the acid added 
drop by drop until the appearance of air-bubbles shows 
that it is taking effect, the remainder of the acid being 
added as required. When the lime is mostly in the form 
of a phosphate, as in the bones and teeth, the acid may 
be used in a stronger solution. 
The most widely used reagent for this purpose is 
nitric acid. It exerts a great gelatinizing power even in 
weak solutions, thus tending to deteriorate the soft 
structure if acting alone or in aqueous solution. It has 
been found that the gelatinizing or softening action 
might be greatly hindered by the use of an alum solu- 
tion (Gage). Care must be taken not to allow the ob- 
jects to remain too long in the decalcifying fluid, or de- 
composition will ensue. 
Gage's Methods.™-The fresh bone, tooth, or calcified 
cartilage, is fixed and hardened by any of the approved 
methods, as for soft tissues. Picric alcohol has been 
found very satisfactory. The tissue is then ready for 
the following decalcifying mixture : 
Sixty-seven per cent, alcohol (95 per cent, alco- 
hol, 2 parts ; water, 1 part) 100 c.c. 
Strong nitric acid 3 c.c. 
Other things being equal, the smaller the volume of 
the bone the more rapidly will it decalcify. The fluid 
should be changed after twenty-four to forty-eight 
hours. If the specimen is large it may be necessary to 
change the fluid two or three times. A stay of from ten 
to fifteen days does not seem to injure the soft structures. 
If there is no gritty feeling upon the introduction of a 
needle, the decalcification is complete. Upon removal 
from the decalcifier, the tissue is rinsed a minute or so 
in water, then placed in sixty-seven per cent alcohol one 
to two days, then in eighty-two per cent, until ready to 
section. 
Small animals, e.g., salamanders, treated by this 
method give most excellent results for skull, brain, etc. 
Second Method.-After fixing, the tissue is put into the 
following mixture : A saturated aqueous solution of 
alum is diluted with an equal volume of water, and to 
each 100 c.c. of this half-saturated alum solution add 
425 Histological 
Form u lie. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
5 c.c. of strong nitric acid. The mixture is changed 
every two or three days until the decalcification is com- 
plete. It is somewhat more rapid than the first decal- 
cifier. After decalcification the tissue is thoroughly 
washed in water and carried through the alcohols as be- 
fore. 
For teeth this is perhaps the better decalcifier. Both 
mixtures preserve the soft structures, marrow-cells, cili- 
ated epithelium, etc. 
In the first tlie alcohol, and in the second the alum, 
serves as a restrainer, preventing the gelatinizing and 
destructive action of the nitric acid. 
Thoma's Method.-Bones or other calcified tissue, either 
fresh or hardened, are placed in alcohol 95° Tralles until 
completely saturated, and then transferred to a solution 
consisting of : 
Alcohol (95° Tralles) 5 parts. 
C. P. nitric acid 1 part. 
in which they are left several days, being frequently 
shaken. The fluid should be renewed and shaken until 
the tissue is completely decalcified.. The fluid acts 
quickly, the calcic nitrate formed being quite soluble 
in weak alcohol. This may be proven by adding to the 
above solution a surplus of precipitated carbonate of 
lime ; upon evaporating 100 c.c. of the filtrate there will 
be found 8.67 grms. of calcic nitrate. Large pieces 
of tissue may be decalcified in two to three weeks. 
They are then washed in alcohol and put into a vessel 
containing a surplus of precipitated carbonate of lime in 
alcohol 95° Tralles. This mixture is also shaken up and 
renewed, until every trace of the acid is removed from 
the tissue, which takes usually from eight to fourteen 
days. The specimens should be left in the solution even 
a short time after litmus-paper shows no acid reaction. 
Most of the deposit of the carbonate of lime can be re- 
moved from the specimen with a spray of alcohol; the 
small particles left do not interfere. The deposit may 
be avoided by wrapping the specimen in filter-paper, 
but it takes longer to remove the acid. Or a dialyzer 
with a diaphragm of filter-paper may be used. Large 
pieces of dense tissue are rapidly decalcified and the acid 
completely removed, no swelling of any account occurs, 
and the soft structures undergo little or no change. 
Hydrochloric Acid.-This acid also has an extensive 
use, but it has the disadvantage of causing considerable 
swelling. To obviate this to a greater or less extent it 
may be used in combination with chromic acid or alco- 
hol. Or a three per cent, solution may have added to 
it ten to fifteen per cent, of common salt. Or (Waldeyer) 
to one thousand parts of a one-tenth per cent, solution of 
palladium chloride may be added ten parts of hydro- 
chloric acid. 
Lactic Acid.9-This is said to work well in ten per 
cent, or stronger solution, being more rapid than picric 
acid, and as applicable for embryonic and small bones as 
for older calcified tissue. 
Phosphoric Acid9-This has also been recommended in 
ten to fifteen per cent, solutions. The tissue must be im- 
mersed for a long time. Unless absolutely pure acid is 
used the tissue does not stain well. Considerable pre- 
caution must also be taken in the handling of it. 
Chromic Acid.-This reagent is used for decalcifying, 
generally beginning with a weak (one-tenth per cent, 
solution) and passing to the strong (one percent.). Bone 
should remain in it from two to three weeks. 
Haug's Phloroglucin Method9-One of the most rapid 
of the decalcifying agents. It preserves the structures 
perfectly, except blood, which it modifies considerably. 
The method was introduced by Andeer, who used the 
phloroglucin in combination with hydrochloric acid, but 
with variable results. The substitution of nitric acid 
removed this difficulty. The solution is prepared by 
warming 1 gm. of phloroglucin in 10 c.c. of C. P. nitric 
acid. This must be done slowly and carefully. Soon a 
dark ruby-colored solution is obtained; to this is added 50 
c.c. of distilled water. If a larger quantity of the fluid is 
desired, 10 c.c. of the acid are added to every 50 c.c. of 
water, until the volume has reached 300 c.c., which is 
the limit of the protective influence of the phloroglucin. 
In this solution the pieces of well-fixed and well- 
washed material are placed. Foetal or young bones, as 
well as those of the lower vertebrates, are decalcified in 
half an hour. Older and harder bones require but a few 
hours. 
A twenty per cent, solution generally suffices, although 
thirty-five per cent, may be found useful for teeth. If 
rapidity is not so essential, the following may be used : 
Phloroglucin 1 part. 
Nitric acid 5 parts. 
Alcohol, ninety-five per cent 70 parts. 
Distilled water 30 parts. 
After decalcification the bones are washed in running 
water for about two days. The sections stain well and 
do not fade. 
Desilicification.-Objects should be first hardened 
in alcohol, then placed in alcohol in a vessel made of 
lead, gutta percha, or glass coated with paraffine. Hydro- 
11 uoric acid is then added drop by drop, care being taken 
to avoid its poisonous fumes. Contact of the acid with 
the skin causes wounds difficult to heal. Small sponges 
and other similar siliceous objects, by remaining a few 
hours or a day in the above solution, are wholly deprived 
of their silica, while the tissues do not suffer. 
Staining.-The chief function of a stain is to differ- 
entiate certain tissue-elements, or, as in a successful gold 
chloride impregnation of nerve-endings, a whole tissue 
or group of tissue-elements. The former Lee5 desig- 
nates as cytological selection, the latter as histological 
selection. The precise action or combination of stains is 
as yet very obscure. Living tissue has no affinity for 
ordinary stains. Certain special reagents which do color 
living tissues, temporarily at least, will be noted later. A 
living cell is neverat rest, and only after it has become 
considerably weakened will it permit the stain to act. 
The coloring of the nucleus is a sign of death. If the 
cell recovers, the cytoplasm will ultimately throw off the 
stain. 
Furthermore, according to M. Flesch,10 a favorable 
stain, e.g., cyanin, produces a much different result in a 
"fixed" preparation than in a living one. The parts 
affected in the dead preparation can never be similarly 
affected when alive. 
Some stains are successful only after previous treat- 
ment of the tissue with easily reducible combinations. 
By control experiments it is seen that the staining ex- 
tends only as far as the metallic precipitate. The orig- 
inal constituents of the tissue are not stained, but the 
chemical products, probably the metal albuminates re- 
sulting from the treatment with hardening agents. There 
is reason for believing that the parts which, when living, 
are more highly endowed physiologically, take on a 
deeper color. The methods of fixing and hardening 
count very much, therefore, toward the successful action 
of a stain, and must be taken into careful consideration 
when making a selection. Tissues fixed in chromic acid 
or its compounds do not take the carmines well, while 
hematoxylin acts very readily on such tissues. 
Lee2 considers two methods of bringing about selec- 
tive staining, the direct and indirect. With the former 
the operation must be watched and stopped at just the 
right stage, when the desired elements are sufficiently 
colored, otherwise the stain acts on the other parts and a 
diffuse color is the result. With the indirect (by far the 
more common) the tissues are over-stained and the super- 
fluous color afterward removed by some reagent (usually 
acidulated alcohol). 
Stains may be used in aqueous or alcoholic solutions. 
Each is useful in its own way. With the former there 
is danger of maceration if the tissue is delicate and left 
too long in the fluid. With some tissues the swelling 
induced by the water may be an advantage, and results 
not attainable by any other method are produced. Al- 
coholic stains possess the property of preserving the 
structures while the coloring is going on. Considerable 
time is saved by not being compelled to carry the speci- 
men through as many grades of alcohol, and the danger 
of tearing delicate parts by osmosis is likewise prevented. 
Structures may be stained after having been imbedded 
426 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Histological 
Formulae, 
and cut, i.e., in the form of sections, either before or after 
fastening to the slide, or they may be stained in bulk be- 
fore being imbedded. Here again there are certain ad- 
vantages peculiar to each method. A more even distri- 
bution of color is perhaps insured with aqueous or weak 
alcoholic stains. 
According to Whitman,11 the more important qualifi- 
cations of a dye for staining in toto are the following: 
(1) It should penetrate readily, so that its action on the 
deeper and more superficial parts may be as equable as 
possible. (2) Its action at full strength should be intense, 
capable of imparting any desired depth of color. (3) It 
should give a differential rather than a diffuse staining; 
i.e., it should act with unequal degrees of intensity on 
the different elements of the cell, thus contributing to 
sharpness of definition. (4) Its preservative qualities 
should be sufficiently pronounced to enable it to act any 
required length of time without causing maceration. (5) 
The color imparted should be permanent. The differ- 
ential character of the stain may be strengthened by 
washing a few minutes in slightly acidulated alcohol. 
A rather broad generalization, then, would be that aqueous 
solutions are more adaptable for sections or for very small 
and easily penetrable organisms, while for staining in 
bulk alcoholic solutions are to be preferred. Too strong 
an alcoholic solution of stain will cause diffuseness of 
color. The percentage employed may be as high as 
seventy per cent. 
Any system of classification of stains must be extreme- 
ly artificial and inadequate. Stains themselves may be 
derived from organic or inorganic sources. As to their 
use, they might be grouped according to their action on 
fresh or hardened tissue. A more common and per- 
haps better division would be their affinity, either chemi- 
cal or cohesive, for only certain parts of the tissue, i.e., 
selectivity ; or for the general and indiscriminate color- 
ation of the whole tissue : diffuseness. 
The following table may serve as a convenient index : 
1 gm. of hematoxylin with the aid of heat in 20 c.c. of 
distilled water, filter, add 1 c.c. of caustic ammonia 
(specific gravity 0.875), and put the purple fluid into a 
dish large enough to allow the liquid to cover the bottom 
to the depth of | c.c. Protect from dust and allow to 
evaporate. The amount of dry ammonia-hematein is 
about equivalent to the hematoxylin first used. 
Mayer's Hemalum: 
(a) Hematein or ammonia-hematein 1 gm. 
Ninety per cent, alcohol 50 c.c. 
Dissolve by the aid of heat. 
(b) Alum 50 gms. 
Distilled water 1 litre. 
Mix the two solutions, cool, and filter. A crystal of 
thymol may be added to prevent moulds. Quite large 
pieces become intensely stained in twenty-four hours, 
and the stain apparently gives as good results as Bohm- 
er's solution. For most purposed it is better to dilute 
with water or a weak alum solution. For a good nu- 
clear stain wash out with a one per cent, alum solution. 
An acid hemalum may be obtained by adding to the 
above solution (a and b) a two per cent, solution of gla- 
cial acetic acid. This is said to give a more precise 
color than the ordinary hemalum. Remove the acid by 
simply washing with water. 
On account of certain defects found in Kleinenberg's 
mixture (alcoholic), Mayer recommends the following 
solution : 
Hemaealcium: 
Hematein or ammonia-hematein 1 gm. 
Aluminium chloride 1 gm. 
These should be rubbed together in a mortar very 
thoroughly. 
Glacial acetic acid 10 c.c. 
Seventy per cent, alcohol 600 c.c. 
Calcium chloride 50 gms. 
Mix the alcohol and acetic acid and add the hematein 
aluminium chloride. When dissolved add the calcium 
chloride. The fluid is red-violet in color. If the ob- 
jects are stained too red, treat with two per cent, alu- 
minium chloride dissolved in alcohol, or in a one-half per 
cent, to one per cent, solution of acetate of sodium or 
potassium in absolute alcohol. 
For some purposes it is well to mix the hemaealcium 
with one-third of its volume of glycerine (e.g., entoderm 
or tentacles of hydroids). It is said that the perma- 
nency of the fluid is good, but clearing with bergamot or 
clove oil causes an early fading. Certain oxidation or 
reduction changes are likely to occur in time and injure 
the preparations. 
Delafield's Hematoxylin.-A well-known and exceed- 
ingly useful stain. It will keep for years. See Vol. III., 
p. 676. 
Ehrlich's Acid Hematoxylin: 
Water 100 c.c. 
Absolute alcohol 100 c.c. 
Glycerin 100 c.c. 
Glacial acetic acid 10 c.c. 
Hematoxylin 2 gms. 
Alum in excess. 
This mixture should ripen until it assumes a dark-red 
color. It will keep for years in a well-stoppered bottle. 
Sections stain in a few minutes. The stain is suitable 
for coloring in toto, as over-staining does not occur. To 
get a blue stain, wash out with common drinking-water 
which is slightly alkaline. It is said that the addition 
of acetic acid prevents the alum from splitting up into 
free sulphuric acid, and a basic, lake-forming compound 
of alumina, as generally occurs in the ordinary (alum) 
hematoxylin solutions. 
Haug's Hematoxylin: " 
Dissolve hematoxylin 1 gm. 
In absolute alcohol 10 c.c. 
This is added to an aqueous solution of alum acetate 
(Liquor aluminis acetici) 200 c.c. 
A good nuclear stain and useful in most methods for 
the nerves; It is quite durable but, like the other hema- 
toxylins, it must be well ripened before use. It is more 
useful for section than bulk staining. The fluid has at 
Diffuse or 
general 
stains. 
- Eosin, picric acid, and other aniline colors. 
D i ff e ren- 
tial or selec- 
tive stains. 
Nuclear. 
Metallic. 
Intra vi- 
tam. 
Fresh tissues, 
color temporary. 
Methyl green, 
aceto-carmine. 
Some ani 
Hardened tis- 
sues, color more or 
less permanent. 
H e m atoxylin, 
carmines. 
lin colors. 
Silver ni- 
trate, palla- 
dium chlo- 
ride. 
Methyl 
blue, cya- 
nin. 
Hematoxylin.-This, except for permanency, is perhaps 
the best all-around stain for animal and vegetable tissues. 
It stains alcoholic, osmic, and chromic acid preparations 
very readily, but with the latter care should be taken 
that all of the acid is extracted, or fading will soon ensue. 
Hematoxylin is the active principle in the extract of log- 
wood. As it is not very readily or easily extracted, it 
had better be obtained from the market already prepared. 
None of the solutions of hematoxylin are perfectly stable, 
only one or two are fairly so (Lee). 
Over-staining may be corrected by the use of weak 
acids. The tissue should be re-neutralized with ammonia 
to prevent fading. This is quite likely to occur even 
with the greatest care. 
Hematoxylin solutions are not ready for use imme- 
diately after being made up. They must first "ripen," 
according to the mixture, for a few hours, or days, or 
months. The ripening process, according to P. Mayer,1'2 
is due, not necessarily to light, but to the air, which causes 
the oxidation of the hematoxylin. From the products 
of oxidation, or from treatment with alkalies, there may 
be obtained the active coloring principle, hematein, or 
ammonia-hematein, which in trade is known as hema- 
teinum crystallisatum. It is a brown-red powder and 
soluble in either distilled water or alcohol. The solution 
should remain clear upon the addition of acetic acid. 
The hematein may be prepared as follows : Dissolve 
427 Histological 
Formulae. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
first a deep violet-black appearance, but after some 
weeks' ripening it assumes a brown-black color, much 
like Ehrlich's acid hematoxylin. After treatment for 
over-staining with acid alcohol, the sections are washed 
out in water till they become blue. 
Gage's Hematoxylin: '8 
Distilled water 200.0 c.c. 
Potash or ammonia alum 7.5 gms. 
Chloral hydrate 4.0 " 
Hematoxylin crystals 0.1 gm. 
Place the water and alum in an agate or porcelain ves- 
sel and boil for five minutes or more. This is to destroy 
any germs in the water or alum. Let the solution cool 
and add sufficient freshly-boiled distilled water to replace 
what has evaporated from the original 200 c.c. Add the 
chloral hydrate and dissolve the hematoxylin crystals in 
10 c.c. of ninety-five per cent, alcohol, and add to the 
mixture. Let it " ripen " for a week. If the stain is too 
concentrated, it may be diluted with freshly - distilled 
water, or with the mixture of water, alum, and chloral. 
If the stain is not sufficiently concentrated, add more 
hematoxylin. With the above sections are usually suf- 
ficiently stained in from one to five minutes. It has not 
been tested for bulk staining. "The boiling is to de- 
stroy any living ferments present in the water or alum, 
and the chloral hydrate is to prevent the development of 
germs which accidentally reach the solution after it is 
made." 
Benda's Hematoxylin^ for karyokinetic figures.- 
Treat the sections with a concentrated solution of cupric 
acetate for twenty-four hours, in a brood oven. Wash 
out thoroughly. Stain in a one per cent, aqueous solu- 
tion of hematoxylin till the sections are black. Extract 
the superfluous color in hydrochloric acid, 1 to 500, until 
the sections are yellow. Neutralize the acid in a satu- 
rated solution of cupric acetate. Wash. Dehydrate and 
mount. 
Cuccati's Alcoholic Hematoxylin :14 
Iodide of potassium (C.P.) 25 gms. 
Distilled water 25 c.c. 
Dissolve and pour into absolute alcohol. 75 c.c. 
Keep in a tightly-stoppered bottle and shake repeat- 
edly. 
Bub together in a mortar, 
Crystallized hematoxylin 75 etgms. 
Alum (C.P.) (Neutral Potash) 6 gms. 
Add of the above iodine solution 3 c.c., keeping the 
mixture well stirred, and gradually add the rest of the 
iodine solution. Keep in a well-stpppered bottle and 
leave from ten to fifteen days. Then shake well and after 
an hour or two filter, and preserve the filtrate very care- 
fully to prevent evaporation and deposit of alum or 
iodide crystals. This fluid is said to stain only the chro- 
matic part of the nuclei, the color being most deeply 
fixed in the karyokinetic figures. As over-staining does 
not occur, the sections may be left in the mixture almost 
indefinitely, and it is therefore also suitable for bulk 
staining. It is stated that with proper care the solution 
never goes bad. 
Another Alcoholic HematoxylinM-Make the three fol- 
lowing saturated solutions: First, calcic chloride in 
seventy per cent, alcohol ; second, powdered alum in 
the same percentage of alcohol ; and third, hematoxylin 
in absolute alcohol. Mix one part of the calcic chloride 
solution with eight parts of the alum solution, and add 
the hematoxylin drop by drop until a deep purple color 
is obtained. The color becomes richer by time. If tis- 
sues have been hardened in any chromic or acid medium, 
they should be put into a five per cent, solution of sodi- 
um bicarbonate before staining; all trace of acid must be 
removed. 
Iodized Hematoxylin 16 (Sanfelice) : 
(1) Hematoxylin 0.7 gm. 
Absolute alcohol.. 20.0 gms. 
(2) Alum 0.20 gm. 
Distilled water 60.00 gms. 
After dissolving, solution (1) is poured drop by drop into 
solution (2). The fluid is then exposed to the light from 
three to four days. Ten to fifteen drops of the tincture 
of iodine are added and the fluid, well shaken up, is al- 
lowed to stand for some days. Tissues stain in this 
mixture in from twelve to twenty-four hours. They are 
then transferred to ninety per cent, alcohol acidulated 
with acetic acid, in which they remain for the same length 
of time. Sanfelice believes that this gives the same stain 
as Bohmer's hematoxylin with tissues previously treated 
with tincture of iodine ; it thoroughly penetrates pieces 
to be stained in Mo. Owing to its antiseptic qualities, it 
keeps longer than most hematoxylins. 
• Cochineal. - Cochineal for some purposes is un- 
rivalled. In aqueous solution it gives a greater richness 
of differentiation perhaps than alum carmine. In an 
alcoholic solution it gives a direct nuclear stain (Lee). 
Bartsch's Alum Cochineal11-An old formula ; its great 
utility for histological purposes is a sufficient justification 
for calling attention to it. Powdered cochineal is boiled 
for some time in a five per cent, solution of alum, the 
decoction is filtered, and a little salicylic acid added to 
prevent mould. Paul Mayer thinks that in some ways 
it is better than the well-known but later formula of 
Czokor. 
Mayer's New Cochineal Formula:18 
Cochineal 5.0 gms. 
Calcium chloride 5.0 gms. 
Aluminium chloride 0.5 gm. 
Nitric acid (sp. gr. 1.20) 8.0 drops. 
Fifty per cent, alcohol 100.0 c.c. 
Pulverize the cochineal, and mix with the calcium and 
aluminium chlorides in a mortar. Add the acid and 
alcohol, and heat to boiling. Let the mixture stand a 
number of days, shaking frequently, and finally filter. 
The objects must be treated with fifty per cent, alcohol 
before and after entering the stain. 
Carmine.-Carmine is a most excellent nuclear stain, 
and pre-eminently adapted for staining in toto. The 
stain should have a slight alkaline reaction ; the presence 
of too much alkali is injurious, rendering the solution 
unstable ; the want of it, on the other hand, deprives the 
stain of very much of its differentiating effect. Fix the 
stain by treating with acetic or formic acid before de- 
hydrating and mounting the sections. In botanical 
preparations, carmine stains most vegetable albuminoids, 
while starch and cellulose take it up slightly, or not at all. 
To obtain the best results with carmine, especially am- 
monia carmine, on preparations hardened in bichromate, 
the tissue must be stained before going into alcohol1 
Carmine is not readily soluble, even in water, without 
the aid of some other agent, e.g., ammonia or borax. 
Carminic acid, the basis of the coloring matter of cochi- 
neal and carmine, is readily soluble in either water or 
alcohol.* 
Paul Mayer 18 found, after some experiments, that if 
carminic acid, or, better yet, ammonia carminate, be 
treated with acetate of alum, all the acid is precipitated 
as alum carminate. This substance has the peculiar 
property of being soluble in either acids or solutions of 
acid salts (e.g., alum) or in alkalies, or in solutions of alka- 
line salts (e.g., borax). Water or very weak alcohol must 
be used for the solvent. An alum solution stains nuclei 
in the same way as does alum carmine. The borax solu- 
tion, though weaker, but with other things being equal, 
gives a redder color. The differentiation is very clear 
even when washed with water only. 
Mayer's Carmalum : 
* Carminic acid..:.................. 1 gm. 
Alum 10 gms. 
Distilled water 200 c.c. 
Heat the mixture and filter. The filtrate will remain 
clear if an antiseptic is added. The solution is of a light 
red color, shading toward violet. It is said to have good 
penetrating powers even in osmium preparations, and 
it is claimed that it is better than alum carmine for stain- 
ing in toto. 
Simply washing out with water is likely to leave the 
* For the various methods of preparins? carminic acid, see the paper 
bv George Dimmock, published in the American Naturalist, vol. xviii., 
p'. 324, 1884. 
428 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Histological 
Formulae. 
plasma slightly colored ; if this is not desirable use a 
weak alum solution, or in more stubborn cases weak 
alcohol. If a less amount of alum is used in the solu- 
tion, a deposit will form after a time. 
As an equivalent for Grenadier's alum carmine, Mayer 
suggests a one-tenth percent, solution of carminic acid in 
a three to five per cent, solution of alum ; this may readily 
be made in the following proportions : 
Water 1,000 c.c. 
Alum 30 to 50 gms. 
Carminic acid 1 gm. 
Dissolve without heat. This is a weaker and cheaper 
solution than Grenadier's, and gives a redder tone to the 
tissue. The absence of heat is an advantage. Like the 
alum carmine it requires an antiseptic-a crystal of thy- 
mol. 
Mayer's Paracarmine: 
Carminic acid 1 gm. 
Aluminium chloride i gm. 
Calcium chloride 4 gms. 
Seventy per cent, alcohol 100 c.c. 
May be dissolved cold or warm. Let it precipitate, and 
filter. The solution is of a clear red color. Washing 
out with acid is said to be unnecessary either for sections 
or masses. If found desirable to wash out for surface 
views, use a weak solution of aluminium chloride in 
alcohol, or alcohol with about five per cent, acetic acid. 
The objects do not become so fiery red after treatment 
with acid alcohol as with borax carmine. The time limit 
of staining depends upon the objects. This is claimed 
to be preferable to borax carmine, because it is in a 
stronger alcoholic solution, therefore a better preserva- 
tive and not alkaline. 
The carmine formula? of Mayer have not yet been suf- 
ficiently tested to warrant a statement as to whether they 
are superior, or perhaps inferior, to some of the older 
formulae for carmine stains, or if, indeed, they are as 
valuable to the carmines in general as his hematein 
method is to the hematoxylins. 
An Alcoholic Acid Carmine: 
Carmine 4 gms. 
Hydrochloric acid 2 c.c. 
Seventy per cent, alcohol 100 c.c. 
Boil over a water-bath until dissolved, cool and filter. 
A good stain for general purposes. It is rapid in its ac- 
tion and differentiates well, and should be washed out 
with seventy per cent, alcohol. 
Strasburger's Borax Carmine :15 
Borax « 4 gms. 
Distilled water 56 c.c. 
Dissolve and add carmine 1 gm. 
One volume of this solution is diluted with two volumes 
of absolute alcohol, and filtered. The nuclei stain with 
great clearness. 
Haug's Alum-Borax-Carmine :9 
Carmine 1 gm. 
Borax 1 gm. 
Ammonia-alum 2 gms. 
Pulverize and add 
Liquor aluminis acetatis 100 c.c. 
Boil the solution for half an hour or more. Decant and 
filter after twenty-four hours. It is good for use in a 
few weeks. Said to stain sharper and clearer than alum 
carmine and to be more permanent, also useful for bulk- 
staining. Wash out in water. 
Haug's Ammonia-Lithium-Carmine: 
Carmine 1 gm. 
Ammonium chloride 2 gms. 
Pulverize and boil in water 100 c.c. 
After cooling add drop by drop, 
Liquor ammonii caustici 15to20c.c. 
Pure lithium carbonate 0.3 to0.5 (gm.?) 
The stain should be filtered. It colors intensely imme- 
diately after its preparation. The solution is very per- 
manent, and is especially recommended for preparations 
hard to stain. It gives a gorgeous strawberry-red color, 
and stains sections in from one to three minutes. Differ- 
entiate the over-stained sections in hydrochloric acid alco- 
hol, then put immediately into absolute (picric) alcohol. 
(SUPPLEMENT.) 
Delage's Osmic Carmine}9-Take a strong solution of 
carmine in ammoniacal water and evaporate it on a water- 
bath, until the appearance of red clouds on the surface 
indicates that the excess of ammonia has disappeared. 
After cooling, add an equal volume of osmic acid (one per 
cent.) and tiller under a bell-jar. A very dark fluid is 
thus obtained which has the staining properties of car- 
mine, and the fixative properties of osmic acid. At 
the end of some days this reagent loses its odor and 
becomes darker. The fixative qualities have disap- 
peared. It is best, therefore, to mix the acid and car- 
mine solution at the time of using. This mixture is said 
to bring out more minute anatomical features than gold 
chloride. 
Anilins.-Anilin 20 (C8H6NH2) is a colorless oil boil- 
ing at 183° C., partly soluble in water (1 to 31), and acts as 
a strong base, forming well-crystallized salts with acids. 
The anilin oils of commerce are a mixture of anilin 
with ortho- and para-toluidin (Benedict). When mixt- 
ures of anilin and toluidin are heated together with cer- 
tain oxidizing agents-such as arsenic, chloride of tin, 
mercuric chloride, etc.-among the various substances 
formed are two compounds named rosanilin and para- 
rosanilin. The dyestuffs under the anilin colors are 
derivatives of these. Benedict divides them into three 
groups : basic, acid, and neutral coloring matters. In dye- 
ing the basic are always used in the form of their salts 
i.e., of their compounds with mineral or organic acids. 
They all contain nitrogen atoms, and it is to the presence 
of these that they owe their basic properties. The acid 
contain hydrogen atoms, which can easily be replaced 
by metals. They possess the property of combining 
with bases to form salts with the simultaneous evolution 
of water. The neutral are not numerous, the only ex- 
ample given by Benedict is artificial indigo obtained from 
propiolic acid. 
The anilins are derived from coal-tar, and must be of 
the proper quality to be of any use in histology. Many 
are inconstant, and not to be depended upon for perma- 
nent results. Some are soluble in water, others in alco- 
hol only, and one must be largely guided in his selection 
of a dye by the method in which the tissue has been 
treated. It is believed that the dyes are best fixed with 
benzole, and that by the use of this fluid there is a greater 
probability of the colors remaining permanent in Canada 
balsam. These dyes, as a rule, are not adapted to bulk 
staining. Very few of them give a precise nuclear stain 
by the direct method. Two of them, methyl green and 
Bismarck brown, are pre-eminently nuclear stains. 
Some of the others may be made so with fresh tissues by 
combining them with acetic acid. 
The majority give a diffuse color, which in some few 
cases may result in a most precise and useful stain, by 
the indirect method-decolorizing. 
Lee classifies these dyes according to their use for di- 
rect or indirect staining-the latter is also known as the 
" Flemming " method. With the indirect method it is 
necessary to get as strong a solution as possible, and the 
sections must be very thoroughly stained. Up to a cer- 
tain point, the more the tissues are stained, the better do 
they resist the washing-out process, which is an advan- 
tage. Washing out is generally done with (ninety-five 
per cent.) alcohol, but it is well tojws< rinse the sections 
in water before bringing them into the alcohol. Clove 
oil will extract more color from the tissues, and it is there- 
fore better to use some clearing medium, such as cedar 
oil, bergamot oil, xylol, etc., which does not attack the 
stain. 
Victoria Blue.-The specimens fixed in "Flemming's 
mixture" for some hours are stained in a saturated aque- 
ous solution of the dye. Wash in pure alcohol, clear in 
cedar or bergamot oil. It is a brilliant and useful nuclear 
stain. Chromatin and nuclei are colored blue. The cy- 
toplasm is colorless if well washed out ; if not, green or 
greenish blue. The " spongioplasm " is very finely 
brought out by this method. The reagent has a special 
affinity for elastic fibres. For this Lustgarten recom- 
mends an alcoholic solution diluted with from two to 
four parts of water. It is believed that fixation in some 
429 Histological 
Formulae. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
chromic mixture is a necessary condition. Stain for a 
long time. 
Safranin.-This is one of the most important of the 
anilin dyes, on account of its various degrees of electiv- 
ity for nuclei and other constituent elements of different 
tissues, and for its superior permanence in balsam. It 
is exceedingly necessary to have a good safranin. With 
no other stains are there, perhaps, so many grades. It is, 
therefore, quite essential to procure the dye from some 
reliable source. Griibler (Leipzig, Germany) supplies 
only such as have been found by experiment with tissues 
to furnish the desired stain. Miinder (Gottingen) also 
furnishes reliable dyes. 
Babes's Solution : 
Water 100 parts. 
Anilin oil 2 parts. 
Safranin to excess. 
The mixture should be warmed to from 60° to 80° C. 
and filtered through a wet filter. This solution will 
keep for a month or two. 
Zwaar demaker's Solution.-This is obtained by mak- 
ing a mixture of about equal parts of alcoholic safranin 
solution and anilin water (anilin water is simply a satu- 
rated solution of anilin oil-pure anilin-in water); shake 
up the two and filter. 
Cyanin (Quinolein Blue, Chinolinblau).-Cyanin should 
be dissolved in ninety per cent, alcohol and the solution 
diluted with an equal volume of water. (The dye must 
be dissolved in the alcohol, it will not dissolve in the di- 
lute solution.) This stain colors fatty matters an intense 
blue. As it has powerful staining qualities, it should be 
used in very weak solutions. It is said that if tissues be 
stained slowly in very dilute aqueous solution of cyanin 
they may be mounted in balsam and a fairly precise and 
nuclear stain may be obtained. This dye is also useful 
for staining Infusoria, which under certain conditions it 
stains during life. 
Congo Red^ {Gongoroth\-A.n "acid" dye, the aque- 
ous solution, however, having a neutral or alkaline reac- 
tion. It becomes blue in the presence of the least trace 
of a free acid. (A test for the acidity of tissues.) It is a 
diffuse stain, but seems to be used chiefly in staining 
axis-cylinders. 
Benzopurpurin.-Weak aqueous solutions should be 
used for staining, which is effected in a few minutes, 
then wash out with alcohol. Zschokke22 says that Ben- 
zopurpurin B., is the very best contrast stain to hema- 
toxylin known to him, because it is not apparently 
affected by alcohol, or the usual clearing agents. 
Deltapurpurin.-This is of a more purple red, having 
properties similar to those of Benzopurpurin, and may be 
used in the same way. 
Benzoazunn.^-This dye is used in dilute aqueous so- 
lutions. The sections are over-stained and decolorized 
with one-half to one percent, hydrochloric acid alcohol. 
If a nuclear stain is desired, the sections should be with- 
drawn when the celloidin has become bleached. If the 
tissue-elements are also to be stained, they should be taken 
from the acid alcohol a little earlier. A beautiful blue 
nuclear stain is obtained, which is quite as distinct and 
sharp as that given by hematoxylin or carmine. Two 
points are made for this dye : (1) that it stains very read- 
ily old alcoholic preparations ; (2) that preparations con- 
taining picric acid are little or not at all affected. 
Eosin {Erythrosin, Primrose soluble, Pyrosin B., Rose 
B. d I'eau).-Eosin is obtained by the action of bromine 
upon fluorescine, and is chiefly used as a contrast stain to 
hematoxylin. Lee suggests that a solution of eosin in 
anilin water might give results very different from those 
obtained from the ordinary solutions. Most prepara- 
tions of eosin are soluble in both alcohol and water ; 
some, however, are soluble only in alcohol. 
Picric Acid.-This is very useful for secondary or 
ground staining in connection with hematoxylin and 
various carmine solutions. It has considerable power of 
washing out anilins, and great care must be used in this 
connection. 
For Fresh Tissues.- Methyl Green (Methylanilin 
Green, Vert Lumiere, Lichtgrun, Grunpulter, Vert en 
(SUPPLEMENT.) 
Cristaux).-A most excellent nuclear dye. It should be 
used in the form of a strong aqueous solution containing 
a little acetic acid (about one per cent.). The solutions 
must always be acid. Wash with water (may be slightly 
acidulated) and mount in some acid aqueous medium 
containing a little of the methyl green in solution. In 
the nucleus it stains nothing but the chromosomes or 
nuclein element, leaving the nucleoli, caryoplasm, and 
achromatic filaments untouched. Outside of the nucleus 
it stains some kinds of cytoplasm and some kinds of 
formed material, especially glandular secretions. Extra- 
nuclear structures are in general stained in some tone 
of blue-violet. Staining is instantaneous, over-staining 
never occurs. The solution is very penetrating, killing 
cells instantly without swelling or other change of form, 
and preserving their forms for at least some hours, so 
that it may be considered a delicate fixative. It is a 
most useful reagent in amyloid degeneration. " Un- 
doubtedly methyl green is one of the most valuable 
stains yet known." 
Schneider's Aceto-carmine.™-An old formula, but most 
admirably adapted for fresh tissues. To boiling forty-five 
per cent, acetic acid, add as much carmine as will dis- 
solve. (Forty-five per cent, holds the greatest amount of 
carmine.) It may be used in a weak solution-diluted to 
one per cent.-or strong. The latter fixes and stains at 
the same time, and is very penetrating, a quality which 
renders it of much use where common reagents would 
often fail. The stain is a pure nuclear one. 
Bismarck Brown {Manchester Brown, Phenylin Brown, 
Vesuvin, La Phenicienne).-The dye is not easily soluble 
in water. It may be boiled, and filtered after a day or 
two, or acetic acid added (the acid destroys the perma- 
nency of the stain), or alcoholic solutions may be used. 
A convenient form is the following :25 
Bismarck brown 2 parts. 
Alcohol 15 parts. 
Distilled water ; 85 parts. 
The solution gives a light oak tint and forms a pleasing 
contrast to safranin or hematoxylin. The mixture must 
be filtered often. The dye never over-stains and is rapid 
in its action. It is a fairly pure nuclear stain, and will 
work well either with fresh tissues or with such as have 
been hardened in chromic acid. It also possesses the 
property of staining cellular elements during life, but 
must be pure and neutral. For general purposes the ad- 
dition of carbolic acid has been recommended. 
Trinkler's Vegetable Stain.26-The staid is obtained by 
extracting the chlorophyll from the leaves of Syringa 
vulgaris by means of alcohol. After twenty-four hours 
the filtered extract is evaporated to dryness and the resi- 
due dissolved in water. The solution is of a dark-green 
color tinged with brown. 
Double Staining.-Genevan Reagent.™-Under this 
name is recommended a double-staining reagent found 
usefid in the differentiation of vegetable tissues. It con- 
sists of a slightly alcoholic and ammoniacal solution of 
Congo red (two per cent.) and chrysoidin (one-fifth per 
cent). The section is first decolorized by eau de jarelle 
and then immersed in this reagent for a few seconds, 
when a beautiful double or triple staining is obtained. 
New Method of Double Staining 28 (Pianese).-There is 
first prepared a saturated solution of nigrosin in a satu- 
rated solution of picric acid in alcohol (Martinotti's solu- 
tion). Two parts of this solution and one part of anilin 
water are next mixed and allowed to evaporate in the 
open air. The crystals deposited from this are dissolved 
in absolute alcohol. From the latter solution are ob- 
tained cubical crystals of an olive-green color, soluble in 
waler, alcohol, or ether. With these crystals is made a 
two per cent, solution in alcohol for tissues, in water for 
micro-organisms. 
The sections are first stained with Beale's carmine or 
Orth's lithium carmine, and having been treated with 
acidulated alcohol are washed and dehydrated. They 
are now immersed from two to ten minutes in the alco- 
holic solution of picro-nigrosin, until they assume a 
brown hue. They are«next decolorized in an alcoholic 
solution of oxalic acid, dehydrated, cleared, and mounted. 
430 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
HiHtoIogical 
Formulae. 
The nuclei are stained red ; the plasma, a dark yellow ; 
connective tissue, a pale green ; elastic fibres, violet, and 
cartilage yellow. If it is desirable to stain micro-organ- 
isms at the same time as the tissues, the sections are, after 
having been stained with carmine, decolorized by Gram's 
method, or by the Koch-Ehrlich method for tubercle 
bacilli, and then are immersed for five minutes in the 
aqueous solution of picro-nigrosin, and the process con- 
tinued as above. 
Kossinskiis Safranin and Indigo Carmine.'29-Stain the 
sections from ten to twenty minutes in a saturated aque- 
ous solution of indigo-carmine, wash with water and 
with alcohol and stain with safranin (0.5 per cent, in 
dilute alcohol), dehydrate, and mount. 
"Metallic " Stains.-The discussion of this group of 
stains will be limited to those applicable par excellence to 
the nervous system, and will be treated of under the head 
of staining nervous tissue, in conjunction with certain 
other stains. 
" Intra Vitam" Stains.-A very few dyes possess 
the peculiar property of staining the cells of living tissue 
without any very evident impairment of their powers. 
They are cyanin, methyl blue, Bismarck brown, Congo 
red, and under certain conditions dahlia and gentian vio- 
let, and some others whose action is as yet insufficiently 
known.* 
The dyes must be used in an extremely weak neutral 
or alkaline solution, Congo being an apparent exception 
in that it is among the " acid " anilins and may be used in 
quite strong solution. Of all these methyl blue has re- 
ceived the greatest amount of attention on account of its 
special affinity for the peripheral nerve-endings. This dye 
will also be treated of under stains for nervous tissue. 
Staining Nervous Tissufi.-Impregnation.-Ramon 
y Cajal's30 modification of Golgi's short silver nitrate 
method. Small pieces of the brain or myel are fixed in 
the following solution : 
Potassium bichromate 3 parts. 
Osmic acid, one per cent 25 parts. 
Distilled water 100 parts. 
Use plenty of the solution and change at least twice 
during the first day, keeping in the dark. Embryonic 
or adult tissue may be used, the former giving perhaps 
the best results ; since the fibres are as yet deprived of 
their myeline, the silver is more readily deposited in them. 
It should be left in the solution from twenty-four to forty- 
eight hours. Older tissue should remain two or three 
days. The hardening process is of very great impor- 
tance : if it is insufficient the silver later will form a 
granulous precipitate ; if the hardening be too great, the 
precipitate will not occur at all. 
After hardening, the tissue is washed in 0.25 per cent, 
solution of silver nitrate for fifteen minutes. It is then 
brought into a 0.75 per cent, solution of silver nitrate, to 
which has been added a little formic acid in order to 
favor the reduction of the silver. For the best results 
some care must be used as to the amount of the acid used. 
Van Gehuchten recommends one drop to each 100 c.c. of 
the fluid. 
The tissue may be left in this silver solution from 
thirty-six to forty-eight hours. A longer stay does not 
ruin it. 
If the hardening is of the proper degree, the silver 
nitrate will be deposited with extraordinary fineness in 
the nerve protoplasm as silver bichromate. The process 
thus far should have been carried on in the dark. 
Kolliker recommends placing in forty per cent, alcohol 
before cutting free-hand, or better dehydrate in one hun- 
dred per cent, alcohol for one hour, then in celloidin one 
hour, and after an hour or two of hardening cut in the 
microtome. Put sections in creasote for a quarter of an 
hour, then in turpentine, and mount in xylol balsam 
without cover-glass. It is desirable that the imbedding 
process should be as short as possible. Van Gehuchten31 
transfers the specimens from the silver bath directly to 
strong alcohol, where they are left from fifteen to twenty 
minutes, then about a quarter of an hour in absolute al- 
cohol. They are left about the same length of time in a 
solution of celloidin, then fastened to a holder and put 
into seventy per cent, alcohol to harden. 
According to this process, sections can be cut in about 
an hour from the time the specimen has left the silver 
solution. 
On account of the difficulty of obtaining successful 
silver precipitates in the sympathetic nervous system by 
the ordinary method, Ramon has suggested that double 
or even triple impregnations be made by re-immersing 
the tissue in the osmium-bichromate mixture, after it has 
passed through the silver baths. The reaction is said to 
be much more constant. 
If a cover-glass be placed upon the balsam while it is 
yet soft, the sections soon become blurred or decolor- 
ized, the supposed reason being the irregular drying of 
the balsam causing a diffusion stream that carries off the 
silver precipitate. Greppin32 uses hydrobromic acid to 
prevent this. As recommended by Ramon y Cajal, it is 
well to put the slides after mounting in an oven heated 
to about 40c C., so that the balsam may dry as rapidly 
as possible. Huber33 employs a cover-glass after the fol- 
lowing manipulation : The sections are mounted in tur- 
pentine balsam. The slide is held over a flame and 
gradually heated to avoid the formation of air-bubbles 
and to drive off the turpentine vapor, until the balsam is 
so thick that when cooled it becomes hard immediately. 
On the hot balsam a heated cover-glass is now lightly 
dropped and the preparation is said to remain durable. 
Martinotti34 has recommended the addition of five per 
cent, glycerine to the silver solution as favoring the re- 
action with the ganglionic cells and their nervous pro- 
longations, and for obtaining preparations of extreme 
delicatesse. To prevent surface precipitates, he uses a 
pap of blotting-paper prepared in distilled water. 
The silver method35 colors deep black the nerve-cells 
with their protoplasmic processes and all non-medullated 
nerve-fibres, the neuroglia cells and their extensions a 
reddish-brown, while the vessels assume more of a red- 
dish cast. At times certain lymph-spaces and a few me- 
dullated nerve-fibres are also colored. It is not yet settled 
whether the coloration depends upon an impregnation of 
the cell-bodies with the silver salt, or if it is simply an 
incrustation. Golgi, Ramon y Cajal, and Kolliker hold 
to the first idea ; it is only certain that with the non- 
medullated fibres it is an impregnation. The order in 
which the parts color most readily is as follow's : the 
nerve-fibres, the protoplasmic processes, the nerve-cell 
bodies, the neuroglia cells, and the blood-vessels. 
Golgi's Sublimate Method.™-An old but useful method. 
Very briefly, it consists of hardening the nervous tissue 
for fifteen or twenty days in potassium bichromate, and 
then passing it directly over to 0.25 or 0.50 per cent, solu- 
tion of mercuric chloride. This is renewed as often as 
it becomes yellow, and the tissue should remain in the 
mercuric solution at least ten days. A longer stay will 
probably improve the results. The sections should be 
cut on a freezing microtome, and afterward thoroughly 
washed in water to avoid the formation of a black pre- 
cipitate. They are best preserved by mounting in gly- 
cerin. The method is useful in demonstrating the nerve- 
cells with their processes, also the nuclei, and sometimes 
the blood-vessels. 
The sublimate seems to be more limited than the 
silver nitrate method, as the more favorable results are 
obtained only from the cerebral cortex. 
Signor Tai31 modifies the above method by after- 
treatment with sodium sulphide. The mercury is 
changed into sulphide and the preparations become 
blackened ; the tissue that has not undergone the influ- 
ence of this reaction is stained with a solution of Mag- 
dala red. The silver method is also said to be improved 
by this after-treatment with the sulphide. 
Magini38 recommends the substitution of zinc chloride 
in 0.5 to 1 per cent, solution for the sublimate. Sec- 
tions are washed quickly in alcohol, imperfectly cleared 
with creasote, and mounted in damar. 
The process is said to demonstrate better than Golgi's 
♦ For a fuller discussion of this question, see Martinotti's paper. Zeit. 
f. Wiss. Mik., v., 305 (1888). 
431 Histological 
Formulae. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
the finer structure of ganglion cells and their pro- 
cesses. 
Cox's Sublimate Impregnation.™-The hardening and 
impregnating fluids are combined and allowed to act to- 
gether for two or three months. 
The mixture is as follows : 
Five per cent, potassium bichromate.. 20 parts. 
Five per cent, mercuric chloride 20 parts. 
Five per cent, potassium chromate.... 16 parts. 
Distilled water 30 to 40 parts. 
The reaction of the fluid should be as slightly acid as 
possible. The preparations are not permanent under a 
cover-glass in Canada balsam or damar, on account of 
the acidity of the medium or some other unknown cause. 
The sections must be cut in a freezing microtome. They 
are placed for an hour or two in a five per cent, solution 
of sodium carbonate, washed in water, placed for a 
short time in absolute alcohol, then in some oil, and final- 
ly covered with some rapidly drying resin [sandarac ?]. 
If they must be covered with a glass, the resinous 
layer should be allowed to dry and then covered with 
castor-oil. Then the cover-glass is put on and squeezed 
down so as to squeeze out the superfluous oil, or by us- 
ing styrax, or a mixture of gum arabic and water, etc., 
the preparations may be kept intact under a cover-glass. 
Obregia's Gold Modification of Golgi's Methods.40-The 
sections are transferred from absolute alcohol to the fol- 
lowing solution : 
Gold chloride, one percent 8 to 10 drops. 
Absolute alcohol 10 c.c. 
This should be made half an hour previous to use and 
exposed to diffuse light. When the sections are put 
into it, the containing vessel should be placed in the 
dark. In from fifteen to thirty seconds or longer the 
silver is gradually replaced by the gold, or the mercury 
changed into gold amalgam. The sections are quickly 
washed, first in fifty per cent, alcohol, then in distilled 
water, and finally in a ten per cent, solution of hyposul- 
phite of soda for ten or fifteen minutes, and then washed 
in distilled water thoroughly. Too long an immersion 
bleaches so that the finer fibres disappear. The sections, 
after the proper degree of toning, may be stained as de- 
sired (Weigert's, alum carmine, etc.), and mounted in 
Canada balsam with cover. 
Paladino's Palladium Chloride Method.4'-Small pieces, 
5 mm. thick, of the neuraxis, previously hardened in bi- 
chromate or sublimate, are left for two or three days in 
a one-tenth per cent, solution of palladium chloride, a 
trace of hydrochloric acid being added to insure the 
complete solution of the salt. The pieces are then trans- 
ferred to a four per cent, solution of potassium iodide 
and left for an hour or two, then dehydrated and im- 
bedded in paraffine. The paraffine is removed by xylol 
and the sections mounted in balsam. The reaction is 
favored by keeping in a dark place. The method is also 
applicable to the peripheral nervous system, and demon- 
strates the axis-cylinders particularly well. 
Monti's Copper Method.™-Small pieces of nervous tis- 
sue are hardened in two to three per cent, bichromate or 
Miiller's fluid, until they become quite firm. They are 
then immersed in a mixture of equal parts of a solution 
of copper sulphate and Miiller's fluid. The reaction 
takes place after twenty-four hours. The stained ele- 
ments appear of a blackish-yellow color in transmitted 
light, and of a reddish color in direct light. The reaction 
has been obtained in the small nerve-cells of the cortex 
and of the cerebral ganglia, in the small nerve-cells of 
the molecular layer of the cerebellum, and in the cells 
of the olfactory bulb, and in the fibres and neuroglia 
cells. 
Berkley's Osmium ■ Copper • Hematoxylin Stain.43 - A 
rapid Weigert method. Small pieces of the cerebrum, 
cerebellum, or myel, not more then 2.5 mm. thick, are 
fixed in Flemming's solution from twenty-four to thirty 
hours, in a temperature of 25° C., and then without wash- 
ing transferred directly to absolute alcohol, which is 
changed twice during the following twenty-four hours, 
then placed from twelve to twenty-four hours in cel- 
loidin. 
The knife must be well moistened with alcohol, and 
the sections must be very thin. They are washed in 
water and then brought into a saturated solution of cop- 
per acetate, and allowed to stand overnight in a small 
covered vessel; or, if it is desirable to expedite matters, 
the vessel containing the sections may be put on a water- 
bath and heated to a temperature of 35° to 40° C. for 
twenty-five to thirty minutes, and the copper solution al- 
lowed to cool. 
The sections are washed again in water for a very 
short time, and finally carried into a hematoxylin solu- 
tion which is prepared as follows : 50 c.c. of distilled 
water are boiled thoroughly for a few minutes in a flask 
and 2 c.c. of a saturated solution of lithium carbonate 
added ; allow the boiling to continue a minute longer, and 
then add 1.5 to 2 c.c. of a ten per cent, solution of hema- 
toxylin in absolute alcohol. The flask is then shaken 
and corked, and placed aside to cool. It is better to pre- 
pare small quantities of the solution as needed, since it 
deteriorates somewhat. The solution can be used at once, 
but it is better to allow it to stand for a day. After 
staining, the sections are thoroughly washed and put into 
Weigerl's differentiating fluid of borax and potassium 
ferrocyanide, which may be diluted one-third with water. 
This decolorizing is an important part of the process. It 
is necessary that the fluid should penetrate the tissue 
quickly and that its action be not too long continued, 
otherwise a number of the finest medullated fibres will 
become decolorized. Usually one to three minutes are 
sufficient for the purpose. After decolorizing, wash the 
sections two or three times in water, then in alcohol, 
bergamot oil, and mount in xylol balsam. Sections pre- 
pared according to the above method should be of a 
blackish-brown color ; the differentiation between white 
and gray substance is as clearly seen as with Weigert's 
method. Under the microscope the medullated fibres 
should appear blue-black-brown, the glia-substance yel- 
low, and the nerve-cells colorless ; or in case the chrome 
salts have not been completely reduced, some or all cells 
with their processes appear of a brownish-biack color. 
Ziehen's Method.44-The pieces of nervous tissue are to 
be placed for five weeks in a mixture of equal parts of 
one per cent, chloride of gold and one per cent, corro- 
sive sublimate. The pieces are then sectioned in dilute 
lugol (one-quarter per cent.) solution. The medullated 
or non-medullated fibres, the nerve-cells, and the neuro- 
glia cells are colored blue. In the ganglion cells the 
nucleus and nucleolus are clearly differentiated. 
Benda's Picric Acid Method.19-Small pieces of nervous 
tissue are placed for two or three days or longer in a 
saturated aqueous solution of picric acid, washed in 
water, and the hardening continued in alcohol. Paraf- 
fine is preferred for imbedding, celloidin not giving good 
results. The sections are made as thin as possible and 
placed for some hours in a concentrated solution of iron 
sulphate (mordant) ; after careful and repeated washings 
they are transferred to a one per cent, aqueous solution 
of hematoxylin until they become of a deep-black color 
(about ten minutes). They are then bleached for about 
five minutes in chromic acid (1 to 2,000), washed well 
in water, dehydrated, and mounted in balsam. It is stated 
that not only are the fibres but the intimate structure of 
the ganglion cells made evident. 
Upson's Gold Method for Axis-Cylinders and Nerre- 
Cells.^-Pieces of the neuraxis are hardened in the dark 
for four to six months in potassium bichromate, begin- 
ning with one per cent, and increasing to two and one- 
half per cent. Wash in water and complete the harden- 
ing by putting into fifty per cent, alcohol for the first 
two or three days, ending with ninety-five per cent, until 
the pieces are of a greenish color. Sections may be made 
with or without imbedding, but must be thoroughly de- 
hydrated before proceeding. First method : Place the 
section for one or two hours in a one per cent, gold chlo- 
ride solution to which two per cent, hydrochloric acid 
has been added. Wash in distilled water, transfer on 
platinum or paper lifter to the following solution : 
Ten per cent, solution potash 5 c.c. 
Ferricyanide of potassium a trace. 
432 DEFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Histological 
Formula:, 
(SUPPLEMENT 
It is said that Weigert's ordinary method can also be 
usefully applied to lymphatic glands and skin. 
Hill's Modification of Weigert's Method.™-The object 
of the method is to render the nerve-cells and non-medul- 
lated fibres susceptible to the stain by previous treat- 
ment with carmine alum, or simply an alum solution. 
For good results the following process must be rigidly 
carried out: (1) Pieces of brain or myel are placed in a 
two per cent, to a two and one-half per cent, solution of 
potassium bichromate for six weeks. (2) The bichro- 
mate is washed out with an abundance of thirty per 
cent, alcohol, changed daily until no further color comes 
from the tissue. (3) The hardening of the tissue is com- 
pleted in strong alcohol. (4) Pieces of convenient size 
are placed in water to remove the alcohol, and then for 
two days in a solution of carmine alum, prepared as fol- 
lows : Place in a shallow dish carmine, potash alum, and 
distilled water. Boil for three hours, restoring the water 
to its original level from time to time as it evaporates. 
Both carmine and alum should be in excess. When cold 
the solution is decanted and filtered. (5) The tissue is 
then cut and the sections placed for twenty-four hours 
in a half-saturated solution of copper acetate. (6) The 
sections are then placed in the hematoxylin for eight 
hours at a temperature of about 40° C. (7) Decolorize to 
exactly the right degree in Weigert's bleaching solution 
diluted with an equal volume of water. It is safe to as- 
sume that the matrix of the tissue and the celloidin are 
decolorized at the same time. 
Vasale's Modification of Weigert's Method.9-Three solu- 
tions are required : (1) Hematoxylin, one gm., dis- 
solved in one hundred gms. of water by the aid of 
heat. (2) A saturated filtered solution of neutral acetate 
of copper. 
(3) Borax 2 gms. 
Ferricyanide of potassium .... 2.5 gms. 
Water 300 gms. 
The sections are removed from alcohol to solution (1) 
for three to five minutes, then for same length of time 
in solution (2), whereon they become black. They are 
washed quickly in water, and transferred to solution 
(3), wherein the ganglion cells, the neuroglia and degen- 
erated parts are quickly decolorized, the medullated 
fibres remaining of a dark-violet color. Finally, the sec- 
tions are washed thoroughly in water, dehydrated in ab- 
solute alcohol, cleared in carbol-xylol (three parts xylol 
to one part carbolic acid) and mounted in balsam. Alum 
or picro-carmine or Pal's method are recommended if a 
contrast stain is desired. 
Mallory's Phospho molybdic Acid Hematoxylin ;48 
Ten per cent, solution of phospbo-molyb- 
dic acid . 1 part. 
Hematoxylin crystals 1 part. 
Water 100 parts. 
Chloral hydrate 6 to 10 parts. 
Let the solution ripen for a week exposed to the sun- 
light. Filter before using ; it can be used repeatedly. The 
sections stain in from ten minutes to an hour. Wash 
out in forty per cent, to fifty per cent, alcohol, changing 
two or three times. The celloidin becomes perfectly 
colorless. Then dehydrate and mount as usual. The 
best results are perhaps obtained by staining rather 
deeply for about thirty minutes and washing out 
thoroughly for thirty minutes or an hour. The gan- 
glion cells and their processes, axis-cylinders, and neuro- 
glia (seen especially well around the central canal of the 
myel) are all sharply stained of a deep blue color. If 
the specimens are left too long in the alcohol they lose 
their sharpness and clearness of detail. The staining 
fluid must be kept free from alcohol. The chloral hy- 
drate retards deterioration. If the solution does not stain 
deeply enough, add a little more hematoxylin (Fig. 272). 
Kultschitzky'8 Hematoxylin.'1-Simpler than Weigert's. 
Pieces of brain or cord are hardened in Muller's or Er- 
licki's fluid and imbedded in celloidin. The sections 
are then placed in the following solution : 
Hematoxylin (dissolved in a little alcohol).. 1 gm. 
Sat. aqueous sol. of boracic acid 20 c.c. 
Distilled water 20 c.c. 
Wash in this for half a minute, then thoroughly in dis- 
tilled water, and transfer to the following : 
Acid, sulfurosum 5 c.c. 
Tinct. iodi (three per cent.) 10 to 15 drops. 
Mix and add liq. ferri chloridi 1 drop. 
Let the section remain in this until it assumes a rose 
color. It is then washed thoroughly in distilled water, 
dehydrated in absolute alcohol, oil of cloves, and balsam. 
Second Method : The section is immersed for two 
hours in the following solution : 
One per cent, chloride of gold 5 c.c. 
Ammonium vanadicum (sat. sol.) 10 drops. 
Acid, hydrochlor 3 drops. 
After washing in distilled water it is immersed from 
thirty to sixty seconds in the following: 
Ten per cent, caustic potash 5 c.c. 
Ammonium vanadicum a trace. 
Ten percent, permanganate of potash.... 10 drops. 
The section is again washed and put in the following fluid: 
Tin solution 15 drops. 
Distilled water 3 c.c. 
Iron solution 3 to 5 drops. 
Acid, sulfurosuin 3 c.c. 
The tin solution is obtained by adding chloride of tin 
to three per cent, tincture of iodine, until the color be- 
comes white or yellowish. The iron solution is a satu- 
rated solution of ferrum phosphoricum in distilled water. 
When the section has become red it is treated as in the 
first method. It is said that the results are splendid. 
Marchi's Solution:46 
Muller's fluid 2 parts. 
One per cent, osmic acid 1 part. 
Of great value in pathology in staining nerve-fibres in 
the earlier stages of degeneration, before sclerosis sets in 
(especially a few days after the establishment of a lesion). 
The degenerated medullated fibres are stained black 
while the rest remains almost uncolored. It is better to 
put thin pieces of the brain or myel into a large quantity 
of the solution (after previous hardening for ten days in 
Muller's fluid), and to leave them in it for a week or 
more ; sections can also be stained by immersing in the 
above solution for a few hours. The further process is, 
as usual, mounting in Canada balsam. 
Weigert's Method without Decolorizing.-The tissue is 
hardened in Muller's fluid and treated in the usual way 
with eighty-five per cent, alcohol, and then an equal 
length of time in absolute alcohol; then it is transferred 
to celloidin and finally imbedded. An important part of 
the process is the coppering. The imbedded pieces are 
allowed to remain for twenty-four hours in a mixture of 
equal parts of a seven per cent, to ten per cent, solution 
of sodium tartrate and a cold saturated solution of cop- 
per acetate, which is kept at an equable temperature of 
38° to 40° C. They are then transferred to a mixture of 
equal parts distilled water and saturated solution of cop- 
per acetate for twenty-four hours, also in the incubator. 
The pieces may then remain in eighty per cent, alcohol 
until cut. The sections must be very thin to produce a 
sharp differentiation. 
The staining fluid is composed of one part of the or- 
dinary alcoholic hematoxylin solution (one to ten), as 
used for the old method, and nine parts of an aqueous 
solution of lithium carbonate. This mixture should be 
prepared as needed. The sections remain in the stain 
from four to twelve hours. They are then thoroughly 
washed in distilled water, dehydrated in ninety per cent, 
alcohol and cleared, first in anilin-xylol (two to one), and 
afterward in clear xylol, and mounted in xylol balsam. 
Care must be taken to employ the best balsam, otherwise 
the color will gradually fade from the specimens. If it 
is desirable to have the ground-work particularly light, 
the preparations can be washed in a very weak solution 
of acetic acid (i per cent, to i per cent.), but a longer stay 
in distilled water usually suffices. The advantages 
claimed for this method are, that it dispenses with the 
tedious process of differentiation, and brings out more dis- 
tinctly than the old method the finest medullated fibres, 
and the distinction between these fibres and the cells and 
other components of the tissue is more plainly marked. 
433 Histological 
Form ulre. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
took the stain. Arnstein 52 found in 1887 that the motor 
nerves and other elements stain as well, but later. The 
stain has already cleared up many doubtful points, and 
promises a solution to the nerve-ending problem. Useful 
as is Golgi's method in this connection, the methyl blue is 
in some ways superior to it. The stain seems to be more 
favorably adapted to the lower forms (cold-blooded). 
Mammals and birds soon die after the injection, and a 
true intra vitam reaction is not easily obtained. 
The living tissue soon throws off the color unless some 
restraining agent is used. Iodine, picro-carmine, corro- 
sive sublimate or picrate of ammonia may be used for this 
purpose. Various methods are employed with greater or 
less success. That of Professor S. Mayer29 is among the 
recent ones, and probably as successful as any. The pro- 
cess consists essentially of two parts: first, the staining 
of the tissue, and second, the fixation of the stain. The 
staining solution is made by dissolving one gm. of the 
methyl blue in 300 to 400 c.c. of a one-half per cent, salt 
solution. The "fixing" solution is composed of a cold 
saturated solution of picrate of ammonia diluted with an 
equal volume of pure glycerin. The staining fluid is in- 
jected into a blood-vessel of the animal, or pieces of the 
fresh tissue are soaked in the fluid, or the animal itself im- 
mersed in the solution without immediate danger to life. 
The amount injected varies with the size of the animal. 
Six to eight cubic centimetres41 are generally sufficient 
for a frog, the coloring usually taking .place in from 
one to three hours. Small pieces of the object are im- 
mersed in the picro-glycerin, and are at once ready for 
examination. If suitable for a permanent preparation, 
the cover can be fastened down with a mass composed 
of equal parts of wax and resin. The picro-glycerin 
changes the color, all shades of red, brown, and black 
being seen in the axis-cylinders and the non-medullated 
terminal nerve-expansions. This is compensated for by 
the clearing up of the preparation and the permanency 
of the stain. The method is simple and rapid. Small 
pieces, as fresh as possible, are placed for about ten min- 
utes in the methyl blue solution; they are then well washed 
in a one-half per cent, solution of salt and examined at 
once in the picro-glycerin ; the operation being complete 
in about thirty minutes. 
Professor A. S. Dogiel0 has found that the addition of 
osmic acid to the picrate of ammonia solution is attended 
with several advantages, in that it hardens the tissue just 
a little and stains the medullary sheath of nerves black. 
The solution is made by adding 1 or 2 c.c. of a one per 
cent, osmic acid solution to 100 c.c. of a saturated aque- 
ous solution of ammonium picrate. The stain is fixed by 
immersing the preparation in this mixture from eighteen 
to twenty-four hours. It is then transferred to glycerin 
diluted with an equal volume of water, in which the 
color of the nerves will keep for a long time. If it is 
desirable to render the object firmer for sectioning, a 
stronger solution may be used as follows : 
Picrate of ammonia (sat. sol.) 25 to 30 c.c. 
One per cent, osmic acid 1 to 2 c.c. 
The specimen remains in this for twenty-four hours, 
after which it may be imbedded in elder pith, liver, etc., 
and sectioned. 
Parker's Method of Imbedding Methyl Blue Preparations 
in Par affinep-A concentrated aqueous solution of corro- 
sive sublimate was found to be the best fixative for the 
stain. The object was left in this for about ten minutes. 
It was then dehydrated for fifteen minutes in solution (A) 
made as follows : 
Methylal 5 c.c. 
Corrosive sublimate 1 gm. 
The next step is to remove the sublimate and replace 
gradually the methylal by xylol. To accomplish this the 
object is put for ten minutes into the following solution 
(B): 
Methylal 1 vol. 
Solution A 1 vol. 
Xylol 2 vols. 
It is then transferred to an abundance of xylol for 
four or five days, and then it may be mounted as a trans- 
parent specimen in xylol balsam, or imbedded in paraffine 
A little acetic acid is added before using (two or three 
drops to a watchglassful). The sections should stain 
some few hours. The medullated nerve-fibres are stained 
blue, the rest of the tissue yellow or yellowish-red. If 
the sections are then placed for twenty-four hours in 
a saturated aqueous solution of carbonate of sodium or 
lithium, the nerve-fibres become dark blue, while all 
the rest becomes almost uncolored. Then pass through 
alcohol and mount in balsam. 
A still more simple hematoxylin solution which is said 
to give the same result is : 
Two per cent, acetic acid 100 c.c. 
Hematoxylin (dissolved in a little al- 
cohol 1 gm. 
Schmaus's Stains for the Axis-Cylinder in Sections of the 
Spinal Cord.49-Gierke's method is modified as follows : 
After previous hardening of the tissue in Muller's fluid, 
the sections are stained in the following solution : 
Carminate of soda 1.0 gm. 
Nitrate of uranium 0.5 gm. 
Water 100.0 c.c. 
The solution is heated for half an hour and filtered 
when cold. The sections are left in the fluid for fifteen 
to twenty minutes, and then washed in water. The axis- 
cylinders take the stain well, leaving the celloidin unaf- 
fected. 
Fig. 272.-Purkinje's Cell. 
Another method is to stain the axis-cylinders with 
English blue-black. The solution consists of one-quarter 
per cent, blue-black in fifty per cent, alcohol, with a little 
picric acid added. After an immersion of one hour the 
sections are washed and mounted. 
Sig. C. Negro 60 has recommended a stain for the de- 
monstration of the motor nerve-endings in striated mus- 
cle. It is practically Delafield's hematoxylin with some 
of the proportions slightly changed. The preparations are 
teased out on a slide, stained, washed, and mounted in a 
mixture of equal parts of glycerin and water. 
Apathy's method29 for differentiating nervous and 
connective tissues consists of staining with Heidenhain's 
hematoxylin, and after-staining with very weak alum 
hematoxylin. 
Methyl Blue.-Since the introduction of methyl blue as a 
staining agent for living tissue by Ehrlich41 in 1885, with 
its special affinity for the peripheral nervous system, and 
the sensory fibres in particular, many new and important 
contributions have been given to science. It was at first 
believed that only the axis-cylinders of the sensory fibres 
434 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Histological 
Formula!. 
(SUPPLEMENT.) 
and cut in the usual manner. Ilie sections should be 
fixed to the slide with Schallibaum's collodion. Mayer's 
albumen discharges the color. It is said that after an 
interval of a month the finer details of the specimen are 
likely to fade. 
Blood. Biondi's Method.-The aim has been to find a 
method which would preserve the morphological ele- 
ments intact by means of good fixation, preservation, im- 
bedding, and mounting, or to treat blood as a solid tissue. 
The process is equally useful in the study of other fluid 
tissues, and has been successfully applied to the study of 
the maturation of the spermatozoa, and, as suggested by 
the originator, may doubtless be used to advantage in the 
study of the Infusoria. The material used for imbedding 
is agar, the columnar form {Saulen Agar) is considered 
the best. Long and explicit directions are given for the 
preparation of it, which may be consulted in Biondi's 
paper in the Archiv fur Mikroskopische Anatomic, vol. 
xxxi., p. 103 (1887), or in an abstract of the paper pub- 
lished in the American Naturalist, vol. xxii., p. 379 
(1888). The essential points are to get a very clear prep- 
aration and to keep it sterile until used. 
By the aid of a pipette blood is taken from the heart 
of a frog, and two drops of it allowed to fall into 5 c.c. 
of two per cent, osmic acid. Shake immediately in 
order to scatter the corpuscles; after standing a few 
minutes the corpuscles will sink to the bottom of the 
vial, the deeper layer being formed 
mainly of the red ones, since their spe- 
cific gravity is greater. They are left 
in the acid from one to twenty-four 
hours. When fixed, four to five drops 
of the mixture are dropped into the 
melted agar. By rotating the tube the 
corpuscles are distributed through the 
agar, the whole mass is poured into a 
paper box (as in paraffin) and allowed 
to stiffen. It is put into eighty-five per 
cent, alcohol for hardening, where it 
remains from three to six days, until it 
becomes hard enough to section, when 
it may be enclosed in elder pith and cut; 
or if finer sections are desired, the block 
of agar is transferred from the eighty- 
five per cent, alcohol to oil of bergamot 
for twenty-four hours, then direct to soft 
paraffine kept at a temperature of 45° 
C. After one or two hours the process 
may be completed in the usual way. The paraffin satur- 
ates the block, and the sections may be freed from the 
paraffin by the usual solvents and then stained. Almost 
any stain is suitable. Methyl green, methyl blue, fuchsin, 
and safranin, are mentioned as giving very reliable re- 
sults. The agar itself does not stain, except with the 
most intense anilins (e.g., gentian violet), but may be 
most easily decolorized with alcohol or any other bleach- 
ing fluid. The sections may be cleared in the ordinary 
clearing reagents except xylol, which causes the sections 
to curl. Mount in balsam or damar. 
Auerbach's Method for Amphibian Bed Blood Corpus- 
cles. 64-It is claimed that the corpuscles are invested 
with a colorless membrane. By allowing a drop of 
blood, carefully protected from loss of fluid, to stand for 
some hours, the substance of the corpuscle after a time 
recedes from the membrane, and the addition of a little 
physiological salt solution causes the membrane to swell 
up like a bladder. Hardening in a saturated picric acid 
solution and subsequent washing with water is said to 
demonstrate this still better. If such a preparation be 
stained with eosin and anilin blue, the membrane takes 
on the blue stain, and the adjacent layer the red. The 
membrane can be made to swell up and burst, allowing 
the contents to escape, leaving the empty sac behind, by 
treating with 0.1 per cent, to 0.25 per cent, solution of 
sublimate, one per cent, solution of boracic acid, one per 
cent, sodium chloride, or two per cent, to ten per cent, 
chromate of ammonia. Two parts are noted in the cell- 
body, a cortical and a medullary substance. The cortical 
portion in unstained sublimate preparations appears of a 
structureless homogeneous substance, colored reddish- 
yellow by the haemoglobin. It is said to contain all the 
haemoglobin of the corpuscle. This cortical or haemo- 
globin layer also has a peculiar contractility, which 
causes a wrinkling of the surface. 
In picric acid preparations, the cortex shows a very 
beautiful network, an unnatural condition due to the 
formation of vacuoles. 
The medullary substance is colorless. In sublimate 
preparations dark granules appear scattered about. In 
picric preparations it appears clear like a large hole. 
In the nucleus are imbedded several nucleoli. In liana 
from eight to sixteen are found, in the Urodeles still 
more,.and in Triton tceniatus as many as forty. In the 
Urodeles their diameter is from 1.2 to 2 g. As a rule, 
they are not connected with each other, so they do not 
form the junction-points of a network. In the adult 
animal these nucleoli usually stain blue ; hence they are 
termed cyanophilous. In the larval condition a few of 
them will stain red (erythrophilous); while at a still earlier 
stage, there is but a single large nucleolus composed of 
both substances. 
Gages Method of Demonstrating Fibrin Filaments.™- 
A drop of fresh blood is placed on a cover-glass or slide, 
arranged as in B or C, Fig. 273. The preparations are 
then put into the moist chamber A to prevent drying. 
After ten to thirty minutes a drop of water is drawn 
Fig. 273.-Fibrin Apparatus. A, Simple Moist Chamber ; B, bowl serving as bell-jar ; P, plate 
containing water; S, slides holding the preparations. They rest upon a bench made by cement- 
ing short pieces of large glass tubing to a strip of glass of the desired length and width. 
B, Cover-glasses, made Eccentric (C) for more Convenient Manipulation. 
C, Slide (S) with Projecting Cover-glass (C), so arranged in order to prevent the folding of the 
fibrin when the cover-glass is raised. 
around the edge of the cover, which is then raised, the 
fibrin generally- adhering to it. The specimen is thor- 
oughly washed in normal salt solution or water, and 
stained for three or four minutes in an aqueous solution 
of hematoxylin, followed by eosin for one minute. 
Wash and set the preparation on edge to dry spontan- 
eously. When dry it is put over a shallow cell of some 
good cement. Thorough dryness is very necessary. 
The network is much coarser in mammalian blood or 
lymph than in that of a cold-blooded animal, e.g., frog or 
necturus. With the latter it is necessary to work with 
the greatest rapidity, as coagulation occurs much more 
quickly than in mammals. 
Watase's Method for Differentiating Sexual Cells.-The 
following modification is adopted by Watase from Auer- 
bach. The sexual cells, either in the testes, ovary, or in 
the hermaphroditic gland, where both male and female 
cells often exist side by side, are killed in Auerbach's fluid, 
or simply in a saturated aqueous solution of corrosive 
sublimate, and cut in paraffin in the ordinary way. Use 
Mayer's albumen, or better still, dilute alcohol or distilled 
water for fixing the sections to the slide, as the latter bias 
the tissue least for staining. Make a standard solution 
(A) of anilin water by dissolving anilin oil in water. Add 
enough alcohol to make a twenty per cent, solution. 
For a blue stain (B) take : 
Cyanin B. B 1 gm. 
Standard solution (A) 100 c.c. 
For a red stain (C): 
Chromotrop R. R 1 gm. 
Standard solution (A) 100 c.c. 
435 Histological 
Formulae. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
A more powerful red stain (D) is as follows : 
Erythrosin 1 gm. 
Standard solution (A) ... 100 c.c. 
For contrast staining it is immaterial which solution, 
(B) or (C), is used first. 
If solution (D) is employed it should be used before 
the blue. The sections stain very quickly. Wash in 
fifty per cent, alcohol and proceed as usual. The anilin 
colors above mentioned may be used either in alcoholic 
or in aqueous solution without the anilin oil. 
The nucleus of the ovum takes on a red color, while 
that of the spermatozoon becomes blue, indicating that 
the nuclear substance of the female cell is erythrophilous 
(Auerbach) ; that of the male, cyanophilous (Auerbach). 
Different stages in the development of the spermato- 
zoon, as in mammals, are indicated by different tones of 
color. At the beginning (spermatogonium stage) the 
color is violet, probably due to a mixture of the blue and 
red ; at the next stage (spermatocyte) the color is decid- 
edly green, with one or two erythrophilous nucleoli ; 
another stage (spermatide) is greenish-blue, and the final 
(spermatozoon) is a deep blue. Sexual differentiation has 
been successfully demonstrated by Auerbach, Balbiani, 
and Ryder, but with different methods. Dr. Watase has 
succeeded in differentiating the sexual cells in the fol- 
lowing animals : asterias, unio, limax, loligo, necturus, 
diemyctylus, rana, bufo, tortoise, fowl, mouse, rabbit, 
cat, dog, and man. He lias also very recently obtained 
successful results in the sexual cells of Tunicates, by the 
use of the Biondi-Erlich triple mixture (aqueous solu- 
tion). 
The Permanent Preservation of Caustic Potash and 
Nitric Acid Preparations.-It was found that thirty per 
cent, to fifty per cent, aqueous solutions of caustic 
potash act with great rapidity upon intercellular sub- 
stance, but quite slowly on cellular elements. Weak solu- 
tions dissolve all the elements quite rapidly. The action 
of the strong solutions can be checked at any time by 
means of a sixty per cent, solution of potassium acetate, 
or by the addition of enough glacial acetic acid to neu- 
tralize the caustic potash and form acetate of potash. 
Perfectly fresh tissue should be used, but should not 
exceed half a cubic centimetre in size, and fifteen to 
twenty times as much potash should be taken. When 
the elements separate readily, the caustic potash is poured 
off and replaced by an abundant supply of a sixty per 
cent, solution of acetate of potash, to which one per cent, 
glacial acetic acid may be added. The isolated elements 
can be mounted in acetate of potash, glycerin, or glycer- 
in-jelly. If staining is desirable the tissue, after re- 
moval from the acetate of potash, is washed thoroughly 
in water. It can then be colored with hematoxylin or 
alum carmine. 
Nitric acid is used in a twenty per cent, aqueous solu- 
tion ; the length of treatment varies with the tempera- 
ture ; ordinarily one to three days are required. If heat 
be judiciously applied it may be completed in a few min- 
utes. The acid is thoroughly washed out with water. 
Put the tissue into the following solution : 
Saturated aqueous solution of alum ... 100 c.c. 
Chloral hydrate 2 gms. 
The nuclei are then stainable in aqueous hematoxylin. 
After the usual processes the preparations are mounted 
in glycerin jelly or balsam. 
Imbedding Methods.-The raison Fetre of imbedding 
is to fill up the interstices as well as the tissues them- 
selves, with a more or less firm material, in order that 
the specimen may be cut without being torn or distorted. 
This is the end aimed at by all infiltration methods. 
Practically, there are two methods now in vogue : pa- 
raffin and collodion (celloidin). Each has many ardent 
adherents, and each in some way possesses advantages 
over the other. Paraffin requires heat ; sections of very 
large objects are likely to split, and are necessarily rather 
thick. With small objects much thinner sections can be 
cut than with collodion ; the adhering of the sections to 
each other in the form of ribbons is very convenient for 
serial work. With collodion heat is unnecessary. It is 
a cleaner and perhaps shorter method than with paraffin, 
but except for large objects, the sections under the most 
favorable conditions are thicker than by the paraffin 
method. 
A safe rule to follow is to use paraffin for small ob- 
jects, collodion for large, or where very thin sections are 
not so essential. These methods are so extensively em- 
ployed that any detailed description is obviously out of 
place here, and what follows w ill be strictly limited to- 
some of the various modifications that have been sug- 
gested within the last few years. 
Lee withdraws his preference, except for small and 
easily penetrable objects, from chloroform as a clearing 
and infiltrating medium for specimens before going into 
paraffin. He finds it deficient in penetrating power for 
large objects, and somewhat tedious to remove before- 
putting the specimen into pure paraffin. Cedar-wood oil 
is found preferable, as it penetrates rapidly; preserves 
delicate structures ; mixes readily with paraffin, and does 
not make tissues brittle though they may be kept weeks 
or months in it. 
Przewoski's Method.™-As a safer, more economical, 
and more easily applied method than absolute alcohol, 
this writer recommends that the object be transferred 
from ordinary alcohol to anilin oil, and left there for 
at least twTenty-four hours. It is then wiped, and the 
anilin oil removed by soaking in chloroform for twenty- 
four hours. It is then immersed in chloroform paraffin 
(forty per cent.), and the next day in melted paraffin, 
which must be cooled down as soon as possible to pre- 
vent its becoming brittle. The anilin oil may be pre- 
viously dehydrated by distillation, or by dropping therein 
a piece of caustic potash. 
It is doubtful if this method possesses any real ad- 
vantage over that proposed by Lee. If the cedar-oil has 
the merit claimed for it, the above process might be 
abridged by transferring the object from the anilin-oil to- 
the cedar-oil. and then direct to paraffin. 
Paraffin Infiltration by Exhaustion.-Mr. A. Pringle 
states that this method is of great value in ordinary work. 
The preparation in melted paraffin is placed in an air- 
pump and the pumping continued as long as the air- 
bubbles arise. The paraffin is to be kept melted the 
whole time. The advantages claimed are : " great celer- 
ity, certain and complete infiltration, certain removal of 
the solvent, absence of distortion of the tissue-elements, 
obviation of necessity for prolonged heating of the ob- 
jects, possibility of using the same paraffin over again, 
pecuniary economy." Preference is given to chloroform 
infiltration. 
The rolling up of paraffin sections is often a source of 
great annoyance to the biologist. It is said that after the 
removal of the paraffin by turpentine or benzine, the sec- 
tions, if brought into concentrated carbolic acid, will un- 
roll themselves safely and float on the surface of the 
liquid. 
Fixation of Sections to the Slide. Method for 
Fixing and Flattening Paraffin Sections.™-The sections 
are placed on a dry slide or are moistened with seventy 
per cent, alcohol. The slide is placed on a horizontal 
metal plate kept sufficiently warm to soften paraffin. 
Enough alcohol is poured on to just float the sections. 
As the paraffin warms the wrinkles disappear. When all 
the alcohol has evaporated the paraffin may be just melted 
and then dissolved with benzol or xylol, and finally 
mounted in balsam. Care must be taken that the metal 
plate does not get too hot, for if the paraffin melts com- 
pletely the sections are unsupported. This is a modifica- 
tion of Canini's method, devised by Mr. H. E. Durham. 
Gulland's Method.60-For serial sectioning, care must 
be taken that the side of the paraffin block meeting the 
razor, as well as the opposite edge of the block, is coated 
with a layer of soft paraffin, and that these edges arc 
parallel with each other. 
The ribbons are cut to the proper lengths, floated on 
warm water (not warm enough to melt the soft paraffin). 
The ribbons in their proper position are floated upon the 
slide, which when full is set up on end until the water is 
thoroughly drained off. The slide is then exposed to a 
temperature a little below 50° C., where the paraffin of 
436 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Histological 
Form ii lie. 
the sections is not melted, but the water rapidly evapo- 
rates. When the evaporation is complete the sections 
adhere to the slide. The time varies according to the 
thickness of the section. One hour usually suffices for 
thin sections. The important point is that the paraffin 
must never be melted until the last trace of water has dis- 
appeared from the slide. After complete fixation the 
paraffin is melted and then washed off with turpentine 
or xylol. 
Gaule's Fixative.6'-The slide is brushed over with 
weak alcohol (forty to seventy per cent.); stronger alco- 
hols evaporate too quickly. The sections flatten out on 
this film, and, if thin, adhere with great pertinacity when 
the alcohol has evaporated and the slide is perfectly dry. 
" This is no fixative in itself, but simply a means by 
which the albumin molecules of the section are brought 
into the same adhesive contact with the glass as those of 
ordinary fixatives." 
Born and Wieger's Fixative.62-It is claimed to surpass 
Giesbrecht's shellac, Mayer's albumin, and Schalli- 
baum's clove-oil and collodion fixatives. It is prepared 
by adding to every two volumes of quince mucilage 
(mucilago cydonii) one volume of pure glycerin and a 
little carbolic acid to prevent fungi. A thin layer of the 
fixative is spread upon the slide and the paraffin sections 
placed thereon. No heat is employed ; the glycerin pre- 
vents the adhesive layer from drying too quickly. Put 
in a warm place (30° to 40° C.) for twenty minutes or 
longer. When the water has all evaporated the paraffin 
is washed out with turpentine, and the slide transferred 
to absolute alcohol for half an hour at least. Stain 
with any kind of dye, wash, and proceed as usual. 
Adhesion remains perfect throughout, and the fixative 
takes no trace of color ; even under the microscope can it 
scarcely ever be perceived. Two important points in 
this process are to be remembered : The first is that the 
slide must be perfectly clean, otherwise the fixative may 
fail to adhere properly. It is recommended to lay the 
slides for half an hour in cold soap and water, and dry 
them carefully with a clean cloth. The second point is, 
don't transfer the slide from the alcoholic bath directly 
to water ; it should pass at least through one intermediate 
grade (fifty per cent.), otherwise the diffusion currents 
are quite likely to separate the section from the slide. 
Collodion Imbedding.-Various opinions exist as to 
the relative merits of collodion and celloidin. The latter 
is said to be " merely a patent collodion." Lee inclines 
toward Duval's view, that celloidin has no real advan- 
tage over collodion, while the former has the advantage 
of being more transparent. Apathy's recommendation, 
that the celloidin be allowed to dry until it becomes 
yellow, transparent, and of a horny consistency before, 
dissolving in ether and alcohol, is a great advantage. 
After the imbedding of the object in collodion, the col- 
lodion may be further hardened, after a short exposure to 
the air, by immersion in chloroform or alcohol. For gen- 
eral use, except for large objects, chloroform is to be 
preferred, because it is more certain, rapid, and gives a 
better consistency to the mass. Alcohols from thirty to 
ninety per cent, have been recommended for this pur- 
pose. The stronger the alcohol, the more likely it is to 
soften the mass and prevent good results in cutting. 
From seventy to eighty per cent, alcohols are commonly 
used, and are to be recommended. 
Bumpus's New Method, of Using Celloidin for Serial Sec- 
tion Cutting.66-" It allows a perfect orientation ; the 
entire object is visible during the process of cutting. 
Yolk-bearing eggs offer no serious difficulty ; sections of 
large area and of unusual thinness are easily secured ; 
crimping and curling during the process of clearing are 
avoided, and the sections may be readily arranged in 
series. After imbedding in a paper tray and hardening 
in chloroform, and after the paper is removed, the 
hardened block of collodion containing the object is put 
into a vial of white oil of thyme, or some other similar 
oil. The block will become as clear as glass. The spec- 
imen is then oriented, and the side of the block to be 
fixed to the object-holder is wiped dry of the oil and im- 
mersed for a moment in ether, and then smeared with 
(SUPPLEMENT.) 
thick collodion. The object-holder, a block of wood 
rather than cork, is smeared in the same way, and the 
two collodionized surfaces are brought together. The 
holder and collodion block are now immersed for a few 
minutes in chloroform, or long enough for them to be- 
come firmly united. The preparation is now screwed 
between the jaws of the object-carrier of the microtome, 
and covered by means of a camel's-hair brush with oil of 
thyme. The microtome knife is flooded with the same 
oil. The oil which thus takes the place of the alcohol 
commonly used has the advantage, because of its lubricat- 
ing property, of not only permitting thin sections to be 
cut, but its slow evaporation allows one to leave his work 
at any time for minutes, or even hours, without injury 
to the object. The object satisfactorily oriented, is now 
cut, and the sections at once transferred to the slides, 
covered with balsam, and mounted, or, if they are not 
immediately needed, they may be kept indefinitely in a 
vial of the oil. 
" If the sections are to be arranged ' in series ' they are 
simply placed upon the slide one after the other, care 
being taken not to flood the slide with oil but to keep it 
quite dry. After the sections are arranged the slide is 
tilted up to allow the excess of oil to drain away, fifteen 
minutes generally being sufficient. Balsam is now placed 
on the sections, and a warm cover is allowed to fall gently 
over the series, no section of which ought to leave its 
place. The above method is especially useful in the prep- 
aration of larger yolk-bearing eggs. . . . " 
The following method of Eycleshymer's64 is of great 
practical utility and abridges considerably the ordinary 
manipulation of collodion technique. The knife is kept 
wet with seventy per cent, alcohol. "As fast as cut the 
sections are drawn back upon the blade of the knife by 
means of a needle, and arranged in a single row until the 
blade is filled. To remove them a heavy paper spatula 
is placed directly upon the section to which it adheres, 
and may be drawn off the edge of the knife and trans- 
ferred to the slide. By slight pressure, together with a 
rolling movement, the section is left in the desired posi- 
tion, sufficient alcohol is kept upon the slide to prevent 
drying, but not enough to allow the sections to float. 
When the requisite number have been arranged they are 
covered with a strip of toilet-paper, which is held on the 
slide by winding it with a fine thread. [The thread 
should pass between the sections ; if across, the stain is not 
likely to act there, and a clear disfiguring line will be the 
result.] The sections being thus firmly held in position 
may be stained, etc. They should not be placed in ab- 
solute alcohol but cleared from ninety-five per cent, in a 
mixture of equal parts of bergamot-oil, cedar-oil, and 
carbolic acid. When cleared the excess of fluid is re- 
moved by a piece of blotting-paper ; with gentle pressure 
sections which are by chance loose are firmly fixed in 
position, the thread is now cut, the strip of paper rolled 
back, balsam and cover applied. 
" If the object can be stained in toto, which is often the 
case, much time may be saved by the following method : 
The stained object is imbedded in the usual manner, but 
after hardening in chloroform and removing the paper, 
the celloidin block is transferred to ninety-five per cent, 
alcohol for twenty-four hours, then to carbolic acid 
(Bumpus advises white oil of thyme) or glycerine, in 
which it becomes as transparent as glass (Eycleshymer 
has since found that the clearing mixture given above 
answers the same purpose as the carbolic acid but re- 
quires a little longer time). The block is fixed in the 
usual manner. 
" Orientation is now accomplished with the greatest 
ease. In cutting, the knife is wet with the clearing medi- 
um given above. The sections may be arranged in serial 
order on the knife-blade until a slideful is obtained, 
when they are transferred and balsam and cover applied. 
By this method long series may be readily handled. 
Glycerin is used only yrhen the mounting medium is 
glycerin ; in this case the knife is wet with glycerin." 
Kultschizky's Celloidin-paraffin Method.'-The purpose 
is to combine the advantages common to each method. 
After the object is removed from the ether and alcohol 
437 Histological 
Formulae. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
bath it is put into a solution of celloidin of any strength, 
■where it remains for twenty-four hours ; it is then trans- 
ferred to origanum-oil, and then to a mixture of paraffin 
and origanum-oil, which has been heated to 40° C., and 
finally to melted paraffin. Its stay in these various solu- 
tions varies according to the characteristics of the speci- 
men to be imbedded. The advantages claimed are that 
very fragile objects can be imbedded ; that very thin 
sections, owing to the celloidin, do not break up, even 
though the paraffin has given way ; that it is not neces- 
sary to use an alcoholic drip while cutting; that sections 
of the same tenuity as those from paraffin imbedding can 
be obtained. 
Ryder63 modifies the above method by substituting 
chloroform for the oil of origanum. The sections may 
be mounted direct from the chloroform (clearing-bath), 
but the chloroform must not be allowed to evaporate be- 
fore the section is covered with balsam. 
Soap Masses.-These possess many good qualities, 
they are transparent and very penetrating, and a good 
mass is said to cut much better than even paraffin. Cut- 
ting may be done dry or with alcohol. The mass is alka- 
line, which is against it for the preservation of tissues, but, 
according to some, an advantage in clearing up the speci- 
mens. It has also been claimed that less shrinkage is 
produced than with paraffin. 
Poli's Glycerin Soap.'6-A mixture of equal volumes 
of glycerin and ninety per cent, alcohol are heated in a 
water-bath to 60° or 70° C. Into this are dropped as 
many small pieces of glycerin soap as will dissolve. A 
flask with its neck plugged with cotton, to prevent evap- 
oration, is best adapted to this process. The liquid thus 
obtained is yellow and transparent, but with a slight 
opalescence. It is then poured into a capsule or paper box. 
While it is still warm the object to be cut, and which 
has been removed from strong alcohol, is fixed in the 
desired position by means of needles until the soap has 
solidified. Large pieces must be soaked for some time 
in a cold saturated solution of soap before they are re- 
moved to the warm fluid. The imbedding mixture, 
which should be kept in a stoppered bottle, melts easily 
at about 40° C. Very small objects may be imbedded 
by placing them in a drop of the warm solution on an 
object-holder and covering them with another drop ; with 
such small quantities the soap gets quite hard in about a 
quarter of an hour. 
The sections are freed from the soap by washing in 
lukewarm water, while the alkalinity of the soap aids in 
clearing up the object. 
In practice it is found advisable to use two solutions, 
one for firm and the other for delicate objects. The 
strong solution is : 
Ninety per cent, alcohol 32 c.c. 
Pure glycerine 32 c.c. 
Soap 64 gms. 
The weak solution contains only one-half (32 grammes) as 
much soap, and is consequently much softer. The mass 
is said to work very well indeed with delicate botanical 
objects, and is also recommended for its great transpar- 
ency and easy solubility in water. 
Clearing Agents.-The functions of a " clearer " are 
to displace alcohol, to render dehydrated preparations 
transparent and to facilitate the penetration of balsam or 
any other resinous material in which the specimen is to 
be mounted. For rendering thick sections transparent a 
mixture of cedar and clove oil has been recommended.41 
The proportion varies with the quality of the oils. A 
convenient rule is to begin with two-thirds oil of cedar 
and one-third oil of cloves, stirring with a flint glass rod. 
When the rod is no longer visible in the mixture, the 
correct index of refraction is obtained. A small propor- 
tion of Venice turpentine is sometimes added. 
Mounting Media.-Under this head will be con- 
sidered a few forms, chiefly resinous, intended for the 
permanent preservation of microscopic objects. Canada 
balsam and damar are in such common use that a mere 
mention of them is sufficient. Kleinenberg has recom- 
mended a solution of Cotophonium in turpentine. The 
medium sets slowly but gives good definition. 
(SUPPLEMENT.) 
Lavdowsky's Medium.66-Two formuhe are given, the 
first for a thick, and the second for a thin, solution. 
Gum sandarac 30 gms. 
Absolute alcohol 50 c.c. 
For the thin solution dilute this with an equal volume 
of absolute alcohol. This medium also clears the sec- 
tions. 
Venice Turpentine.99-All the advantages and some su- 
periority over the ordinary resinous media are claimed 
for this preparation. Commercial Venice turpentine is 
mixed in a tall cylinder glass with ninety-five per cent, 
alcohol and allowed to stand for three to four weeks and 
then decanted. A clear yellowish, or sometimes greenish 
mixture is obtained. And this is at once ready for use. 
The ordinary solution of Canada balsam is the most suit- 
able consistence for the Venice turpentine. It is stated 
that most objects can be mounted in this without previ- 
ous clearing. It sets as closely as damar. Its index of 
refraction is lower than the above-named balsams, and 
delicate details are well brought out. Stains are well 
preserved. * 
Cassia-Oil 6"'-This has been recommended as being 
Figs. 274 and 275.-Dehydrating Apparatus. 
very successful in showing the markings of diatoms. Its 
refractive index is 1.640. 
Levulose {Fruit-sugar).66-This substance is found ac- 
companying grape-sugar in fruits and honey. It is un- 
crystallizable and preserves carmine and aniline stains 
well (hematoxylin fades somewhat). Objects may be 
brought into it from glycerin. Its refractive index is 
somewhat higher than that of glycerin. 
Miscellaneous.-Thomas's Modification of Schulze's 
Dehydrating Apparatus.69-A disk of plaster of Paris 
(Fig. 275, A) is supported at a suitable level by glass legs 
(C) in a museum jar. In the disk are perforations 
through which the dehydrating tubes are passed (Fig. 
275, B). The disk is easily made by pouring a mixture 
of plaster of Paris and water in a mould of convenient 
size and depth. The holes for the tubes and the inser- 
tion of the legs are attended to while the mass is yet soft. 
A dehydrating tube (Fig. 274) may be prepared by cut- 
* See also a paper by Dr. H. Suchanneck, Zeit. f. Wiss. Mik., vii., 
463, 1891. 
438 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Histological 
Formulae. 
(SUPPLEMENT.) 
ting off the bottom of the test-tube, and placing a dia- 
phragm of chamois skin (D) near the bottom. The 
diaphragm is fastened in its place by means of a 
spring made of steel wire (E), and forced inside of the 
chamois skin in the tube, thus pressing the former firmly 
against the latter. A rubber band around the tubes pre- 
vents their falling through the holes, and can be made 
to regulate the depth to which they shall be lowered into 
the alcohol. The tissue is placed in the tube containing 
some weak alcohol, the tube is then lowered until the 
two liquids are at a level. After twelve or forty-eight 
hours the two liquids will be of the same strength. The 
tissue is then taken out and put at once into the infiltrat- 
ing tube. 
With very delicate plant tissue it is well to immerse in 
as low as five per cent, alcohol in the tube (fifty per 
cent, suffices for ordinary tissue), or in the case of some 
algae even as low as one per cent. The strength of the 
alcohol in the jar is kept up by adding calcium chloride 
from time to time. This is said not to injure the alcohol 
in the least. It is stated that picric, chromic, acetic, or 
osmic acid can be used with equal success. [It is a 
question if the presence of the wire supporting the dia- 
phragm of the tube is of any advantage, especially when 
" acids" are used, and if the same purpose may not be 
subserved by simply fastening the diaphragm around the 
end of the tube with a thread.] The advantages claimed 
are : That not more than twenty-four hours is necessary 
for dehydrating and hardening nearly all kinds of plant 
tissue, as no sudden transition from solutions of different 
strengths occurs the tissue is less liable to shrink. The 
simplicity of the apparatus places it within the reach of 
all. Various materials can be used for a diaphragm, and 
almost any desired speed of dehydrating obtained. Ac- 
cording to its size the apparatus may be either for private 
or general laboratory work. Experiments were not tried 
with animal tissues, but there is no apparent reason why 
they should not be successfully dehydrated bv this 
method. 
Gage's Drawing-board for the Abbe Camera Lucida.™- 
In order to obtain accurate and undistorted drawings the 
axial ray from the camera must be at right angles to the 
drawing surface. To accomplish this the mirror should 
be tilted to an angle of forty-five degrees. With most 
microscopes, however, the lateral extension of the stage 
is so great that a portion of the image falls upon it and 
renders drawing impossible at this angle. If a lesser 
angle than forty-five degrees be employed, the axial ray 
will no longer be at right angles to the drawing surface, 
although the image may appear clear of the microscope, 
and an obviously distorted picture will be the result. 
The board was designed to prevent this difficulty. Upon 
a board of convenient dimensions is hinged a shorter 
board (A B), near the attached end of which the micro- 
scope is placed (Fig. 276). The drawing surface (A B) 
may be raised or lowered to any desired angle by simply 
shifting the wedge (W). The figure with the mirror at 
thirty-five degrees illustrates clearly the direction of the 
rays of light, and shows obviously enough the distortion 
that would result if the board were not used. 
" The general rule is to raise the drawing sur- 
face twice as many degrees toward the micro- 
scope as the mirror is depressed below forty-five 
degrees." A camera with a longer arm attach- 
ment would enable the image to fall clear of 
the stage or base of the microscope with the 
mirror at forty-five degrees, and a drawing, 
without distortion, could be made upon the 
ordinary surface of the table. A quadrant 
may be easily made and attached by any 
skilled mechanic. 
To Rectify Turpentine for Microscopical 
Use.11-Mr. Charles C. Faris suggests the 
following method : " Take one-half liter of the common 
turpentine and mix in a liter bottle with one hundred 
and twenty cubic centimetres of ninety-eight per cent, 
alcohol. Agitate well, and let stand until the twro fluids 
separate. Decant the turpentine (which will form the 
lower layer) from the alcohol and mix it with one-half 
liter of clear water. Agitate thoroughly, and let stand 
until these two fluids separate ; then from the water 
decant the turpentine (which this time will form the up- 
Fig. 276.-Drawing-board for Microscope. 
per layer), and finally mix with the turpentine about 
thirty grams of powdered starch and filter through paper. 
" By pursuing the foregoing plan any one may securea 
pure, limpid, and brilliant turpentine. The alcohol used 
in rectifying it need not be wasted, as it will do to burn, 
to clean slides, or for other purposes. I usually make a 
large quantity and recover the alcohol by distillation." 
Fig. 277.-Minot's Improved Microtome. Front view. 
Microtomes.-The following brief description is con- 
fined entirely to instruments of American design, al- 
though Figs. 277 and 278-the front and rear views of 
Minot's microtome12-show some modifications very re- 
cently introduced by a foreigner (Zimmerman). The 
principle of the microtome is to secure sections by 
439 Histological 
Formulae. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
moving the object to be cut in a vertical plane past the 
knife, which is held in a fixed position. The slide A 
(Fig. 277) moves up and down. In this figure it is rep- 
resented at its highest level above the knife. To this 
(the vertical) slide is attached another, the horizontal 
slide, which is moved by a micrometer screw, the head 
of which is a cogged wheel, B. In the knife end of 
this slide is clamped the object-holder. This may be 
turned until the object is in the desired position and then 
fastened by screws. From a movable bar attached to 
the vertical slide is a hooked lever, which catches in the 
teeth of the large wheel B. 
The free end of the bar projects far enough beyond the 
hooked lever to strike against one of the six arms of a 
windlass arrangement at the side ; this causes the lever 
hooked in the wheel to be pulled down, thereby turning 
the wheel and moving the horizontal slide with its 
object-carrier toward the knife. The arms of the wind- 
lass are of different lengths, and the distance through 
which the horizontal slide moves is proportionately 
greater or less, thus regulating the thickness of the sec- 
tions. These can be made to vary from three to twenty 
microns. 
For thinner sections the small wheel C (Fig. 278) is 
adjusted so that its cogs will fit into those of the large 
wheel B, the windlass of which is not now used, but in 
place of it one regulating the turning of the small wdieel 
C. With this arrangement sections can be made from 
one to six microns in thickness. 
Fig. 277 shows a belt attachment fastened to the knife 
supports, for the purpose of enabling the worker to more 
easily manipulate his " ribbons " of sections. By simply 
turning the wheel, section after section can be cut with 
the greatest rapidity. 
Compressed Carbonic Acid Gas for the Freezing Micro- 
tome.™-The gas, or liquid carbonate, as commonly 
known, is obtainable in ten- or twenty-pound cylinders. 
For laboratory use certain changes must be made in the 
cylinder. " A. circular block of iron, an inch in thick- 
ness and of the diameter of the handle of the valve, was 
fastened to the latter by two screws w'ith nuts. Into this 
block were bored four holes ninety degrees apart, and of 
a size sufficient to admit the end of an eight-inch handle, 
B (Fig. 279). This greater leverage affords much better 
and more even control over the escape of the gas. 
" The cap covering the escape-pipe was unscrewed, and 
a hole bored through it large enough to admit of a small 
brass tube with a fine bore being driven tightly into it. 
The cap thus prepared can be kept and used on any 
other cylinder received. One end of a small but thick 
rubber tube, C, was then slipped over the brass tube and 
tied firmly on ; the other end was fitted over the tube 
leading into the freezing-chamber of the microtome, but 
was not tied on, so that it might act as a safety-valve and 
slip off if the pressure became too great ; 
otherwise the tube is likely to inflate and 
explode. In connecting the cylinder with 
the freezing microtome it must be inverted, so that the 
valve handle is below, and raised enough above 
table to bring the escape-pipe on a level with the freez- 
ing-chamber. A projecting support at A and two bands 
FiG. 279.-Carbonic Acid Gas Cylinder, for Freezing Microtome. 
at D, sufficiently snug to keep the cylinder from turn- 
ing, were found necessary. The freezing chamber of 
the microtome should be shallow (about five milli- 
metres) so that the gas, which by its own evapora- 
tion becomes frozen solid in it, may continue to free the 
specimen above it. The brass plate above 
the chamber should be thin, but still strong 
enough to stand considerable pressure, and 
the fioor of the chamber ought to be made 
of a block of solid hard rubber, in order 
to render the loss of cold as small as possi- 
ble." (F. B. Mallory.) This method is much 
cheaper than that by ether or rhigolene. If 
a specimen is frozen too hard, so that it chips, 
simply passing the finger wet with water 
or salt solution over its surface, will soften 
it. A carpenter's plane properly mounted 
makes the best knife for cutting. 
Ryder's Automatic Microtome.^ - "The 
working parts are an oscillating lever, which 
is provided with a clamp at one end into 
which the paraffin-holders are adjusted, and 
at the other with a simple handle. This 
lever rests upon trunnions on either side, 
and these in turn rest in triangular notches 
at the top of the two pillars between which 
the lever oscillates. At the cutting end of fhe 
Fig. 278.-Minot's Improved Microtome. Rear view. 
440 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Histological 
Formulae. 
lever a spring pulls the lever down and effects the section- 
ing and also the adjustment for the next section. The 
lever is pushed over and adjusted for the successive sec- 
tions by a hollow screw, through which passes the trun- 
nion on the side away from the knife. This screw is 
fixed to a toothed wheel, three inches in diameter, which 
revolves close by the side of the oscillating lever. The 
toothed wheel and screw are actuated by a pawl fixed to 
the side of the lever near the handle. The number of 
teeth which this pawl can pass in a single vibration down- 
ward is controlled by a fixed stop screwed into the under 
side of the oscillating lever near the handle ; the end of 
this stop striking on the top of the bed-plate thus brings 
the lever to rest at a constant point in its downward ex- 
cursion. An adjustable sector by the side of the toothed 
wdieel throws the pawl out of gear after a given radius of 
the wheel has been turned through an arc embracing the 
desired number of teeth. This adjustment is also effected 
before the block containing the object to be cut reaches 
the knife. The adjustment for the next section is there- 
fore effected while the surface of the block is not in con- 
tact with the under side of the knife, so that no flatten- 
ing or scraping effect is produced on the surface of the 
block in its upward passage past the knife. 
"The movement of the vibrating lever being ar- 
rested at each down-stroke at one point, and the pawl 
(SUPPLEMENT.) 
strument. The knife is attached to a heavy nickel-plated 
iron carriage A (Fig. 281) by a steel clamp and shoe, b and 
c, with milled-head screws, a. The carriage runs on a 
solid iron track, h and B, which is held to a table by 
clamp screw, k. 
For cutting very hard objects, like the wiry stems of 
plants, or the chitinous skeletons of insects, there is an 
attachment with a very stout blade, on the principle of a 
carpenter's plane, d, which screws on to the carriage in 
place of the knife, and like it can be used for transverse 
or oblique cutting. Two forms are made ; No. 1 will cut 
paraffin objects to two and a half microns in thickness ; 
No. 2, only to twelve and a half microns. 
An Inexpensive Section-smoother,61-A very simple de- 
vice. It is prepared by cutting off the head and point of 
an ordinary pin and fixing it parallel to the edge of the 
knife by pressing its ends into two small pellets of bees- 
wax. (Fig. 282.) The proper elevation can be determined 
by experimenting on waste paraffin before the object is 
reached. The pin is used only for transverse cutting. 
Fig. 280.-Ryder's Microtome. 
Fig. 281. 
which catches into the notches in the toothed wheel being 
released at any desired point by the action of the adjust- 
able sector, it is possible to adjust the apparatus with 
great accuracy for cutting sections of any desired thick- 
ness. If a given radius of the wheel is moved through 
the arc embraced by a single tooth, sections are cut hav- 
ing a thickness of only two and a half microns, a thick- 
ness which is only practically possible with paraffin im- 
bedding and a very keen razor. If more teeth are taken 
by the pawl, any thickness of section is possible up to 
about sixty-two and a half microns. 
" A freezing attachment which has lately been appended 
to the apparatus shows that frozen sections can be made 
with as great rapidity and success as those cut from ob- 
jects imbedded in the paraffin block, and very nearly, if 
not quite, as thin. The freezing attachment is as simple 
and efficient as the self-adjusting and cutting devices of 
the instrument. Other auxiliary apparatus makes it pos- 
sible to cut celloidin sections. This is effected by means 
of alcohol, conducted by a tube from a reservoir to the 
knife, over which the fluid will run and drain into a tray 
below in such a way as not to come in contact with any 
other part of the machine. This tray fits into a recess 
in the side of the bed-plate of the instrument, just below 
the knife, and into this tray the celloidin sections may be 
allowed to drop as fast as cut. The knife can be placed 
at any desired angle, which, for some kinds of work, is 
quite a desideratum." 
King's Microtome.-A microtome designed especially 
for hard service in botanical work or for cutting any 
hard material which requires absolute rigidity in the in- 
Decolorizing Preparations Over-blackened by Osmic 
Acid}*-Dr. E. Overton reminds histologists of a method 
introduced by Fol. The solution is not permanent and 
should be prepared afresh whenever needed. 
Commercial peroxide of hydrogen. .. 1 part. 
Alcohol (seventy to eighty per cent.). 10-25 parts. 
The treatment lasts but a few minutes, after which the 
preparations stain excellently. 
Fig. 282. - Section smoother. 
Schiefferdecker's Microscope Screen}'1-The general form 
and relative size are well shown in the figure (Fig. 283). 
The framework is made of light wire, around which is 
sewed some dark cloth. At the lower part, and forming a 
support to the screen, is a metal rectangle; from this there 
extends upward a vertical strip which a little above the 
level of the coarse adjustment is bent at right angles to 
join two pairs of arms embracing the tube of the micro- 
scope. The base of the rectangle rests upon the front of 
the stage. By moving the tube of the microscope the 
whole screen is moved up or down. From the lower 
edge of the rectangle there hangs down a small piece of 
cloth to screen the condenser, while the main portion 
441 Histological 
Form ulte. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
amply protects the eyes and the object under examina- 
tion. With a little ingenuity less elaborate but equally 
efficient screens may be made ; their usefulness is well 
worth the time expended. 
(SUPPLEMENT.) 
formly good results, it was found that the restored solu- 
tions, with the exception of a gradual weakening, acted 
in the same manner as the fresh solutions and produced 
the same results. 
The chemistry of the restoration and the bleaching 
further demonstrate that no injurious factor enters into 
the result, as is shown by the following equations : 
OsO4 + organic substance = OsO2 + oxidized organic 
substances. 
OsO2 + 2H.O2 = OsO4 + 2H2O. 
That is, in bleaching a tissue its OsO2 is converted 
into OsO4 and water is formed. 
To restore 100 c.c. of a one per cent, solution of osmium 
tetroxide requires from ten to twenty drops of fresh 
peroxide of hydrogen, and clearing goes on better in full 
sunlight. To bleach tissue with peroxide requires about 
the same amount in 100 c.c. of water, and the bleach- 
ing takes place in the sunlight also. The amount needed 
cannot be stated with any more precision, because the 
peroxide loses its strength somewhat with age. 
Reconstruction Points.™-An ordinary metallic imbed- 
ding box, Fig. 285, made of two L-shaped pieces, a and 
Fig. 285.-Imbedding Box. 
a , held m place by the overlapping strips b, is perforated 
at the ends and sides, in as many places as are desired, by 
a very small drill. These should be so arranged that 
the silk threads when drawn through are parallel. The 
threads are cemented to the sides of the box with five or 
six centimetres left hanging. A heavy piece of blot- 
ting-paper is fitted in for a bottom. The object is 
placed upon the threads in the desired position and the 
imbedding mass poured in. When hardened the cel- 
loidin holding the thread is dissolved with ether. The 
loose ends are soaked in a weak solution of celloidin to 
which has been added some lamp-black. The threads 
are then drawn through, leaving the lampblack adhering 
to the celloidin, thereby forming excellent 
reconstruction points. 
For small objects, where reconstruction 
points are not needed, Mr. Eycleshymer 
recommends the following method : The 
heads are clipped from tine insect pins, 
which are then placed in handles in such a 
way that they may be easily removed. On 
these pins the objects are oriented in the 
desired position; the pins are then re- 
moved from the handles and fixed in a 
cork, a (Fig. 286), previously perforated 
by a somewhat larger pin. As fast as the 
pins carrying the objects are inserted, the 
cork is replaced in the tube, which is tilled 
with alcohol. A half-dozen fish or am- 
phibian ova may be oriented on the same 
cork. If desirable to draw the objects in 
situ a piece of lead may be pinned to the 
cork and the whole immersed in a small 
beaker of alcohol. The corks carrying the 
oriented objects are transferred successive- 
ly to tubes containing the different solu- 
tions. When ready for final imbedding, a 
piece of porous paper is wrapped about the tubes and 
cork, and pinned. The cork is now removed, allowing 
the imbedding solution to fill the paper tube thus formed. 
A lead is fastened to the cork and the whole placed in 
chloroform until hardened, after which the paper is cut 
from the mass and the pins drawn through the cork, 
when it is ready for sectioning. Several objects may be 
cut at the same time, drawings may be made after 
Fig. 283.-Screen for Microscope. (Schiefferdecker.) 
The Removal of Aniline Dyes from the Hands16 - Some 
dyes resist very stubbornly the action of alcohol or hy- 
drochloric acid, and require some bleaching agent. 
Unna recommends 'washing first in a solution containing 
a little common salt (about five per cent.), and then in a 
solution of hydrogen peroxide of about the same strength, 
and finally wiping with a cloth moistened with alcohol. 
Ward's Eye Shade16 - This device consists of a black 
disk, from which extends an arm curved at its end and 
somewhat elastic, in order to clasp the ocular. By its 
use both eyes may be kept open, thus avoiding fatigue. 
Fig. 284.-Eye Shade. (Ward.) 
Blau's Regeneration of Hematoxylin.2'2-As hematoxy- 
lin is rather expensive, a method for restoring it may be 
worth knowing. To about 200 c.c. of the used hematox- 
ylin, add from five to ten c.c. of baryta water (an aqueous 
solution of barium hydrate). A stream of carbon diox- 
ide, made from marble and hydrochloric acid, is then 
passed through it, and after twenty-four hours it is fil- 
tered. The filtered solution is said to be as good as the 
original. 
The Restoration of Osmic Acid Solutions.'11-Osmium 
tetroxide, OsO4, is readily reduced in the presence of or- 
ganic matter, giving up two atoms of oxygen and form- 
ing the deutoxide, OsO2. The tetroxide affects fatty 
substances first, and these are the substances that most 
readily undergo oxidation. After some preliminary ex- 
periments with peroxide of hydrogen, (H2O2), with uni- 
Fig. 286. -Vial 
for Orienting 
Small Objects. 
442 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Histological 
Formulae. 
orientation, and the objects may be transferred more 
rapidly from one solution to another. 
A Breath Screen.™-In order to avoid the accumulation 
of moisture along the tube of the microscope, especially 
in winter. Dr. P. Schiemenz has devised the screen 
shown in Fig. 287. 
It is made of a piece of stiff paper, the principal part 
of which is nearly circular (diameter, about 8 ctm.). The 
ctm. wide. Into one end there is glued a'closely-fitting 
block, 1 ctm. long, and in the other end one 5 ctm. long, 
leaving a trough for slides about 9 ctm. long. In the 
place where this last block is glued, is bored a hole 1.5 
ctm. in diameter, and 1 ctm. deep, into which tightly 
fits a paper pill-box for covers. The remainder of the 
block is provided with twro rows of five holes, each 2 
ctm. in diameter, and 3.5 ctm. deep, for reagent vials. 
Fig. 288.-Reagent Block. 
The first groove is used for razor and the second for 
pencils, pipette, forceps, etc. The block is easily made, 
costs very little, is very neat in appearance and con- 
venient in work." 
Bausch and LomUs Cover-glass Gauge.-The stand is 
made of japanned iron ; at the top, cut horizontally, is a 
thread inch pitch and inch outside diameter. A 
recess is cut below the line of the screw and at a right 
angle to it, for placing the covers. The portion of the 
stand :tt the side of the recess which receives the micro- 
meter screw, is slotted longitudinally to the depth of 
the screw, and is provided with a set screw to take up 
wear; the other side has the " fixed " screw, which is, 
however, adjustable. The end of the micrometer screw 
is milled so that no force can be exerted sufficient to en- 
danger the cover-glass. Fixed to the screw is a wheel, 
the surface of which is one-half inch wide. A knife- 
edge index-finger attached to the top of the stand pro- 
Fig. 287.-A Breath Screen. (Schiemenz.) 
smaller portion is pierced by two holes, through which 
passes a string by which the apparatus is attached to the 
microscope tube. The screen is easily fixed and moved 
to any desired position. 
Accurate Drawings by Amateurs.60-A blue print, not 
too dark, is traced over free-hand, with China ink. 
When dry the picture is passed through an aqueous solu- 
tion of caustic potash, 1 in 500 or 1,000, and washed after- 
ward with water and dried. The potash removes the 
blue printing, leaving the ink lines distinct. If the print 
is too dark, delicate outlines are not easily seen and the 
bleaching process is not so thorough, a brownish tint re- 
maining. 
The drying is an important part of the process. As 
soon as washed the picture should be placed between 
some sheets of blotting-paper, and dried quickly by 
rubbing the hands over it a few times. If this precau- 
tion is not taken, the ink particles are likely to run, giv- 
ing blurred and indistinct lines. "In this way draw- 
ings, with all the accuracy of photographs, and all the 
clearness of woodcuts or etchings, may be produced by 
persons who cannot make anything like an accurate draw- 
ing or a good picture of any natural object. There is a 
minimum of trouble and expense." 
A Waterproof Drawing Ink :16 
Powdered bleached shellac. 4 parts. 
Borax 1 part. 
Water 24 parts. 
Dissolve by the aid of heat. To this solution the color- 
ing principle, as India ink, lampblack, the 
different tints and shades of anilin colors, 
etc., is added after being dissolved in, or 
triturated with, a small quantity of water. 
An Inexpensive Reagent Block.69-" It is a 
plain white-wood block, 15 ctm. square and 
4 ctm. thick. On the upper side of this three 
grooves are cut, each 1.5 ctm. deep. The 
first is 1 ctm. from the edge, and 1 ctm. wide ; 
the second is 1 ctm. from it and 3.5 ctm. 
wide. The third is 1 ctm. from this and 2 
Fig. 289.-Gauge for Cover-glasses. 
443 Histological. 
Hospitals. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
jects over it. Along the circumference of the wheel is 
fixed a strip of glazed paper provided with a series of 
divisions. The first series gives the thickness of cover- 
glasses to one-thousandth inch, the second to one-hun- 
dredth millimetre, and the third indicates the proper 
tube-length with various thickness of cover-glass, with a 
non-adjustable i-inch objective corrected under a tube- 
length of inches and cover thickness of 0.16 mm. ; 
proper length are fastened into two strips of lead, 
slightly curved to fit around the margin of an ordinary 
bowl. Between the glass rods is a tin funnel, held in 
position by flanges of tin which may be bent around the 
rods and permit the funnel to slide back and forth. The 
rods are a convenient resting-place for the slide, while in 
Fig. 290.-Zeiss's apparatus for Measuring the Thickness of Cover- 
glasses. 
the fourth gives the tube length of a i-inch objective 
under the same conditions ; Hie fifth for a |, and the 
sixth for a -jV ; the seventh is for a £-inch objective with 
the same cover and tube-length of 160.0 mm. 
Zeiss's Cover-glass Tester.-For determining the thick- 
ness of cover-glasses, etc. A small lever projecting from 
the side of the apparatus regulates the opening and shut- 
ting of the jaws for holding the cover-glass. An indica- 
tor moving around a circular scale on the face of the box, 
registers the thickness of the object. The divisions of 
the scale show hundredths of a millimetre and thou- 
sandths of an inch. 
Micrometer Caliper.-Used chiefly in the "mechanic 
arts." It is, however, perfectly well adapted for testing 
the thickness of cover-glass. It can be obtained with 
either the English or metric scale, and is of convenient 
size so that it may be carried in the vest-pocket. 
Fig. 292.-Waste Bowl. 
process of preparation. The various solutions used in 
treating the sections may be readily drained from the 
slide by placing it for a few moments jn the funnel. 
4 Pierre A. Fish. 
Bibliography. 
In compiling these formulae it has been the aim of the writer to con- 
sult the original papers. It has been impossible in some cases, with the 
limited time at his disposal, to do more than to secure abstracts of them 
in other periodicals ; but it was deemed better, on the whole, to give the 
reference directly to the complete article. 
1 Zeit. f. wiss. Mikr., iv., 1887. 
3 Lee, A. B.: Microtomist's Vade Mecum. 1890. 
3 Morphologisches Jahrbuch, x.. 215, 1884. 
4 La Cellule, iii., 6, 1886 ; also 1887. 
5 Mitth. Zool. Sta. Neapel., ix., 118, 1889. 
6 Broca : Memolres sur le Cerveau de 1'Homme. 1888. 
7 Anat. Anzeiger. iv., 52, 1889. 
8 Comptes Rendus Soc. Biol., iv., 622, 1887. 
* Zeit. f. wiss. Mikr., viii.. 1891. 
10 M. T. Naturforsch. Gesell. Bern.,pp. xiv.-xv., 1887. 
11 Whitman, C. O.: Methods in Microscopical Anatomy and Embry- 
ology. 1885. 
42 Mitth. Zool. Sta. Neapel., x.. 170, 1891. 
13 Kahlden, C.: Technik der Histologischen Untersuchung. 1890. 
14 Zeit. f. wiss. Mikr., v., 1888. 
15 Carpenter, W. B.: The Microscope and Its Revelations. 1891. 
16 Jour, de Micrographic, xiii. 
17 Arch. f. Mikr. Anat., xiv., 180, 1877. 
18 Mitth. Zool. Sta. Neapel., x., 480, 1892. 
19 Arch, de Zool. Exp. et Gdn., iv., 1886, 
»20 Hamilton, D. J.: Text-Book of Pathology. 1889. 
21 Lustgarten : Med, Jahrb. k. Ges. d. Aerzte zu Wien. 1886. 
22 Zeit. f. wiss. Mikr., iii., 1886. 
23 Deutsche Zeit. f. Thiermed. u. Vergleich. Pathol., xiv., 1889. 
24 Zool. Anzeiger, p. 254, 1880. 
28 Wethered, F. J.: Medical Microscopy. 1892. 
26 Arch. f. Mikr. Anat., xxiv., 1885. 
27 Arch. Sci. Phys, et Nat., xxvi., 1891. 
28 La Riforma Medica, 1890. 
23 Zeit. f. wiss. Mikr., vi.. 1889. 
30 Revista trimestrial. 1888, 1889. 
31 La Cellule, vii., 1891. 
32 Arch. f. Anat. u. Phys., supplement, 1889. 
33 Anat. Anzeiger.. vii., 1892. 
34 Arch. ital. de Biologie, ix., 1888. 
35 Berkley, H. J.: Johns Hopkins University Bulletin, 1891 or 1892. 
36 Archivio per le Scienze Mediche, 1878. 
37 Gazz. degli Ospitali, 1886. 
38 Boll. Accad. Med. di Roma. 1886. 
39 Arch. f. Mikr. Anat., xxxvii., 1891. 
40 Verh. d. X. Internationalen Med. Cong., ii., 1891. 
41 Arch. ital. de Biologic., xvii. 
42 Ibid., xv., 1891. 
43 Neurologisches Centralblatt, No. 9. 1892. 
44 Ibid., No. 3, 1891. 
46 Zeit. f. wiss. Mikr., vii., 1890. 
Fig. 291.-Micrometer Caliper. 
Cleaning Mixture for Glass.10-Various formulae have 
been given for cleaning new and used slides and cover- 
glasses. The following have been well-tested and de- 
serve high recommendation : 
Bichromate of potash 200 gms. 
Water 1,000 c.c. 
Sulphuric acid 1,000 c.c. 
Dissolve the bichromate in the water by the aid of 
heat, pour into a bottle wrapped with a wet cloth, and 
add the sulphuric acid slowly and at intervals. The 
mixture may be used more than once, but when markedly 
of a greenish tinge it should be discarded. Another 
good mixture is : 
Nitric acid 200 c.c. 
Sulphuric acid 300 c.c. 
The two acids should be mixed slowly and, like the 
preceding, kept in a glass-stoppered bottle. It is a 
more rapidly acting mixture, but the fumes render it 
less desirable. 
Waste Boicl.-The apparatus is easily constructed and 
exceedingly useful. The ends of two glass rods of the 
444 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Histological* 
Hospitals. 
48 Schaeffer : Essentials of Histology. 1892. 
47 N. Y. Medical Record, xl., 1891. 
48 Anat. Anzeiger, vi., 1891. 
45 Miinchener Med. Wochenschr.. No. 8, 1891. 
60 Boll dei Musei di Zool. ed Anat. Compar. della R. Univ, di Torino, 
v., 1890. 
61 Abh. k. Akad. Wiss. Berlin, 1885. 
62 Anat. Anzeiger, ii., 1887. 
63 Zool. Anzeiger, xv., 1892. 
54 Anat. Anzeiger, v., 1890. 
48 Proceed. Amer. Soc. Microscopists, 1891. 
86 Gage, S. H. and S. P.: Proceed. Amer. Soc. Microscopists, 1889. 
87 Centndbl. f. Allgem. Path. u. path. Anat., 1890. 
88 Journ. Pathol, and Bacteriol., i.. 1892. 
89 Quart. Jour. Mier. Science, xxxiii., 1891. 
60 Jour. Anat, and Phys., xxvi., xxv., 1891. 
61 American Naturalist, xxii., 1888. 
63 Zeit. f. wiss. Mikr., ii., 1885. 
63 American Naturalist, xxvi., 1892. 
64 Ibid., p. 354. 
88 Queen's Microscopical Bulletin, 1887. 
68 Arch. f. Mikr. Anat., xxxviii., 1891. 
87 Jour. Roy. Mier. Soc., vi., 1886, 1889, 1891, 1892. 
88 Behrens, Kossel, u. Schiefferdecker : Das Mikroskop. u. d. Meth. d. 
Mik. Unters. Braunschweig. 1889. 
89 Amer. Mo. Mier. Journal, xii.. 1891 ; xi., 1890. 
70 Gage, S. H.: Histology and the Microscope. 1892. 
71 The Microscope, x., 1890. 
72 Zeit. f. wiss. Mikr.. ix., 1892. 
73 Boston Medical and Surgical Journal, cxxviii., 1893. 
74 American Naturalist, xxi., 1887. 
78 The Microscope, ix., 1889. 
78 Druggists' Circular. 1892, 1890. 
77 Bristol, C. L.: American Naturalist, xxvii., 1893. 
78 Proceed. Amer. Mier. Soc., xiv.. 1892. 
79 Arch. f. Anat. n. Physiol., 1886. 
89 International Jour, of Mier, and Nat. Science, iii., 78, 1893. 
HONFLEUR. A seaside resort facing Havre, on the 
other side of the river Seine. Although the place is de- 
cidedly popular and even fashionubte, the beach is muddy 
and bathing is not of the best. The sea-air is, however, 
bracing, and many English have selected Honfleur as a 
place of residence. The hotels are fairly good, the prin- 
cipal one being the Cheval Blanc, situated on the quay. 
There are good opportunities for excursions, both by 
land and on the sea. The town itself is not especially at- 
tractive. Edmund C. Wendt. 
HOSPITALS, CONSTRUCTION AND MANAGE- 
MENT OF. The history of hospital construction during 
the last decade is especially interesting in some of its 
particulars. There has been ample evidence of advance- 
ment in the application of the principles that were largely 
evolved from the experiences of the civilized world in the 
care of the sick and wounded of the great wars in the 
third quarter of the century. There is now not only a 
more general understanding of the way to build good 
hospitals, but other influences have been at work, making 
it comparatively easy to build, administer, and support 
them. 
The science of hospital construction has been taking a 
more definite form, as is shown by the literature of the 
subject, which has received some notable additions since 
the publication of the valuable work of Mouat and Snell, 
ten years ago. The description of the Johns Hopkins Hos- 
pital, in a quarto volume, with its plans admirably com- 
plete in the detail they give, is an instructive source of 
information for all builders of hospitals. The recent pub- 
lication of Burdett's great work on the " Hospitals and 
Asylums of the World," with its four volumes and port- 
folio of plans, is the most excellent presentation of the 
subject, in all its departments, that the world has yet seen. 
A distinctly new phase of hospital work has reached a 
fuller development than ever before. It is the more gen- 
eral distribution of small hospitals in the smaller cities 
and towns. The tendency in this direction, though long 
existing, has been slow in its results until the rapid pro- 
gress of the last few years. It is not many years since 
there were few hospitals for general medicine and sur- 
gery outside of the large cities. The great hospitals, 
while being local charities for the treatment of the more 
ordinary ills, were almost the sole seats of hospital work 
and its medical and surgical clinics, with their notable 
cases, and capital operations by notable men. But there 
was bad hospital construction, with its evil consequences, 
and the lack of modern skilled nursing, that now makes 
(SUPPLEMENT.) 
it possible to do good work even in some bad hospitals. 
The physician in private practice, at that early day, had 
conditions often better than those of the hospitals for the 
splendid work that Ayas done by individual men under 
circumstances in many ways adverse to success. Almost 
any healthy house gave the sick man a better chance than 
the hospitals, except for the pre-eminent skill derived 
from the experience gained in them. 
The great change that has come about in hospitals and 
their work, particularly in that of surgery, was first 
largely due to the use of anaesthetics. After that the 
world learned how to make hospitals healthy, and the 
skilled nurse came to multiply the resources of the phy- 
sician and surgeon. But while the mechanism of hospital 
work was becoming more complex, it became more pre- 
cise. Successful surgery, for example, formerly de- 
manded certain qualities of boldness, swiftness, and the 
like, as well as scientific knowledge. There were fewer 
surgeons then than now. Modern progress has tended to 
the development of specialties, particularly in those in- 
volving surgical manipulations. These are now applied 
with more deliberate judgment, and more of the precision 
of an exact science. With the safeguards of asepsis, 
conservative surgery, and medicine as well, have made 
possible some of the greatest scientific advances. The 
modern surgeon may achieve success through study, 
time, and practice of very definite methods. Boldness 
and swiftness are largely supplanted, or tempered, by 
caution and painstaking attention to details. These are 
still consistent with the courage that is based upon better 
knowledge. With more complexity of manipulation in 
the art, special conditions for its practice have become 
more necessary. The increasing wealth of the country 
and its growing philanthropy, are in happy union with 
the greater need of hospitals, which has come because so 
many things can be done only in them, or so much better 
done than in private homes. The appreciation of this 
has led to the establishment of many small hospitals 
within a few years. They are aided in their support by 
the custom that requires patients to pay according to 
their means. In New England especially many of the 
smaller towns have their hospitals, or are beginning to 
get them. They have become possible also, as to their 
successful management, through the services of trained 
women. 
We are witnessing, in one generation in civilized 
countries, both a great change in social life in some of the 
particulars here referred to, and the evolution of prevent- 
ive and conservative medicine in ways that were never 
possible before. The skilled nursing that was at first 
taught only in the schools of the great hospitals, was 
elsewhere chiefly the luxury of the rich. It is now get- 
ting nearer to the poor in their homes, and becoming the 
boon of the greater public that has heretofore been so 
much beyond the reach of the common hospital privi- 
leges of the large cities. It is not meant to say that these 
conditions are peculiar to New England, but in the eastern 
section of it they have reached a further development than 
elsewhere in this country. Within less than a dozen 
years a number of small hospitals have been built in 
that section, and it does not need a prophet to predict 
the coming of the time when there will be the " cottage" 
in every town adapted to hospital uses for its locality, 
and supported in part by public money. They will be 
the common schools of nursing for the local service. 
While there has been an extension of hospital construc- 
tion, on the lines of the correct principles now so well es- 
tablished in these small hospitals, a departure has been 
made from previous ideas in the invention of special 
constructional devices for promoting aseptic surgery. 
A few unique examples of such surgical buildings are 
now in existence. 
The great advances in bacteriology have also stimulated 
much attention to infectious diseases, and the building of 
special hospitals for their isolation and treatment is be- 
coming more common. This affords another example of 
the progress of preventive medicine, and the village hos- 
pital should become a part of the general system of pre- 
ventive care of infectious diseases. 
445 Hospitals. 
Hospitals. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
The purpose of this article is to note recent progress in 
hospital construction in the three ways that have been 
mentioned. The first of these relates to the extension 
of the English cottage hospital system in America in 
recent years. In some cases dwelling-houses have been 
inexpensively adapted to the purpose ; and slow progress 
was made, at first, because the cost of specially construct- 
ed buildings was beyond the available means. But while 
it has been sought to get what is wanted at a moderate 
cost, the value of the thing itself has become better ap- 
preciated. The ways of raising money for such purposes 
have been learned, and there is more liberal giving. Still 
the demand is for small effective hospitals at such an ex- 
pense that every thriving community in the country can 
make available for the common need the proper condi- 
tions for modern medical and surgical treatment. 
The City Hospital of Quincy, Mass., is an excellent 
example of what has been done in providing a hospital 
that, in the three years of its existence, has made a cred- 
itable record, and become a model of construction that 
others have followed. The hospital, with the adminis- 
tration house and one of its two wings, cost when com- 
pleted for use $16,500, and with three and one-quarter 
acres of land, valued at $8,000, was given to the city by 
Mr. W. B. Rice. The furnishing cost about $3,000, and, 
with almost all the equipment, was paid for by societies 
and individuals ; the hospital on completion was free from 
debt. The endowment fund for free beds reached the 
amount of $33,600 in the second year. The support of 
the hospital is aided by the city, by receipts from private 
patients, and by collections from various sources. A 
" Hospital Aid Association" also makes valuable contri- 
butions from its membership of seven hundred, at an 
annual fee of one dollar each, besides rendering aid in 
other ways. 
The hospital has a capacity of twenty-five beds ; it was 
opened in June, 1890, and admitted one hundred and two 
patients the first year, and one hundred and forty-six the 
second year. The net cost of support is something over 
$8,000 per year. 
The building, designed by W. P. Wentworth, the archi- 
tect, is of wood, and occupies a fine, elevated site with a 
southerly aspect. The plan (Fig. 293) shows two one- 
story pavilions, one of which is not yet built. The pa- 
vilion contains fourteen beds; there are six rooms for 
private patients and a small ward in the second floo? of 
the administration house. The heating is by steam, by 
indirect radiation ; there are ventilating openings under 
(SUPPLEMENT.) 
the beds leading to a vent shaft two feet square, and 
others in the ceilings are connected with ventilators in 
the roof; there are also fireplaces in the wards and 
rooms. All rooms have rounded corners in the plaster- 
ing ; the hard-pine floors, and white-wood finish, also 
have all angles rounded. The plumbing is modern with 
all pipes, etc., exposed, and the drainage is good. 
The hospital is under the charge of a matron, who is 
required to be " an educated and skilful nurse." There 
Fig. 294.-The Waltham Hospital. First Floor Plan. 
is a regularly organized training-school, and some in- 
come is derived from the employment of pupil nurses 
outside of the hospital. A corporation of-over three 
hundred members elects twelve trustees, who control the 
management of the hospital through an executive com- 
mittee. There is a medical board that nominates the 
members of the medical and surgical staff, which in- 
cludes physicians of both regular and homoeopathic 
schools. The details of organization and management 
here given afford a good example of the method adopted 
in many of the small hospitals. 
A new hospital at Waltham, Mass., opened within the 
past year, is built upon a plan in which the " mill prin- 
ciple " is applied for the first time in such a structure, 
'' thereby securing numerous advantages at a compara- 
tively small cost.'* The architect was William Atkin- 
son. There are two plain, rectangular, substantial 
buildings of brick. The administration house, three 
stories high, contains the ottices on the first floor, six 
private rooms on the second, and the kitchen and laun- 
dry on the third floor. A two-story pavilion contains 
on each floor a ward of eight beds, and one bed in each 
Fig. 293.-City Hospital of Quincy, Mass. First Floor Plan. 
446 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Hospitals. 
Hospitals. 
of three separate rooms. The capacity of the hospital is 
twenty-eight beds, and Fig. 294 shows the general ar- 
rangement of the buildings. Their oblique position is 
due to the peculiar conformation of the lot upon which 
the hospital stands. The outside walls diminish four 
(SUPPLEMENT.) 
ing," it being possible to have no concealed spaces in the 
walls or elsewhere. The heating is by steam, and the 
distribution of the 'warm air is aided by a propulsion fan. 
The inlets are seven feet above the floor, and the ven- 
tilating outlets are at the floor level ; all the flues are 
built into the brick walls. The cost of the completed 
building, including plumbing and heating apparatus, 
was about thirty-eight thousand dollars. 
There is an endowment fund for free beds, and sub- 
stantial contributions to the support of the hospital are 
received through the work of the "Ladies' Hospital Aid 
Society." The executive officer of the hospital is a 
matron, who is a trained nurse. The nursing service is 
entrusted to the Waltham Training-school for Nurses, 
which is a peculiar institution ; it was a successful or- 
ganization before there was any hospital, and the train- 
ing was given entirely in the work of " home nursing." 
The novel plan of this school and its foundation are due 
to Dr. Alfred Worcester ; it is worthy of careful study 
and imitation, for it makes possible the advantages of 
trained and skilful nursing in places where hospitals can- 
not be afforded. It provides also a way for the helpful 
enlargement of the facilities for instruction in the small 
hospitals. The trustees are preparing for the reception 
of infectious and contagious cases, a disinfecting station, 
and an ambulance service. 
An interesting variation of a one-story pavilion plan 
for a general hospital is given in Fig. 295, showing the 
arrangement of wards and rooms in the Convalescent 
Home, at Wellesley, connected with the Children's Hos- 
pital in Boston. 
The building is of brick ; it is beautifully situated in 
grounds that have liberal space and shade ; and it is ad- 
mirably adapted to its special purpose. It is so situated 
that the windows opening upon the piazza look to the 
south. The administration building is of three stories ; 
and each of the pavilion wards contains twenty-three 
beds. The cost of the completed hospital approximated 
fifty thousand dollars. 
A fine example of the double pavilion plan of con- 
struction has just been completed at Hanover, N. H., in 
the neighborhood of Dartmouth College. The Mary 
Fig. 295.-Convalescent Home for Children, Wellesley, Mass. 
inches in thickness at each story. The peculiarity of 
construction is that the floors and roof are of plank, 
laid on hard-pine timbers : and the interior partitions are 
of three-inch spruce plank, grooved and splined and set 
Fig. 296.-Mary Hitchcock Memorial Hospital. 
up vertically. The walls and ceilings of the ward build- 
ing are finished throughout in adamant plaster, as are 
also the six pay-wards for single beds, and the accident 
and operating-rooms of the main building. For the rest 
of the building, the brick walls and the plank partitions 
are finished in varnish. The object gained in this method 
of construction is that it is economical and " slow-burn- 
Hitchcock Memorial Hospital is the generous gift of Mr. 
Hiram Hitchcock, of New York ; its benefits will be 
felt by the College, Medical School, and the town and 
country around. The perfection of the building is due 
to the aim of the donor to provide everything desirable 
as a hospital requirement, and the construction is of the 
best in materials and workmanship. The architects 
447 Hospitals. 
Hospitals. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
were Rand & Taylor, of Boston, and the writer has acted 
in an advisory capacity. A brief description will be 
given here, and for a more detailed one, reference is made 
to Burdett's new work on hospitals. 
The hospital consists of four buildings, three belong- 
ing properly to it, and the fourth, a surgical operating 
theatre, being designed for the special purposes of the 
medical college. The cut (Fig. 296) shows in part the ex- 
teriors of the four buildings. The material is of Pompeian 
brick of a mottled yellow-gray color, and the orna- 
mentations are in a light-colored terra-cotta. The roofs 
are of light-red Spanish tiles. Their domed form is an 
outward expression of the fact that the interior construc- 
tion throughout is of the "cohesive system," by which 
(SUPPLEMENT.) 
leading to the pavilions, there are tiled floors. In the 
lavatory and bath-rooms, operating theatre, and conser- 
vatory or sun-room, and in all of the basements, the floors 
are of granolithic cement. The stairs are of marble, slate, 
or cement. The outer walls are hollow, and the plaster- 
ing is upon the brick. The cost of the building, ready 
for use, will be something over one hundred thousand 
dollars, exclusive of the surgical building. 
The plan of the first floor (Fig. 297) presents the ar- 
rangement of the wards and rooms with much detail, to 
which little need be added. 
The entrance hall of the administration building, which 
faces the south, leads to a rotunda which is finished in 
marble and oak, with an appropriate tablet giving it a 
•MARY HITCHCOCK- 
MEMORIAL HOSPITAL- 
HAP1OVER, H.H. 
•Rand Taylor -.Architects 
• Boston,'Mass 
Fig. 297.-Mary Hitchcock Memorial Hospital. First Floor Plan. 
all ceilings are formed of layers of vitreous tiles laid as 
shallow arches, or higher domes, over the rooms, and 
sustaining the floors above. This is an adaptation to 
modern use of the early Italian and Spanish dome-con- 
struction, and this building is the first in America planned 
especially for the modern application of this method 
throughout. The inner partition walls being all of brick, 
there is a unity of fire-proof construction, largely of 
vitreous and non-absorptive materials, including the outer 
walls. There is no iron or wood for the support of stair- 
ways or other construction, and only the floors and slight 
finishing around doors and windows are of hard pine, 
except where the woodwork is of oak, in the first and 
second stories of the administration building. Here, in 
the main hall, the first floor is laid in marble mosaic ; and 
in the connecting corridors, serving as sun-rooms and 
memorial character. The second floor contains eight 
private rooms in the main building, and the service 
rooms, etc., are in the rear extension, with an intervening 
cross lobby. The third floor has accommodations for 
twelve nurses. The one-story pavilions contain each a 
ward for ten beds and four private rooms ; the capacity 
of the hospital is thirty-six beds. The ward, 28 x 36 feet, 
has an arched ceiling at the height of 13 feet, and while 
it has all the advantages of a round or octagon wrard with 
a central chimney and vent-shaft, its general rectangular 
shape is better for convenience of service and arrange- 
ment of furniture. The bath-room and lavatory, with a 
screen between, form together a lobby surrounding the 
inner apartment containing the water-closet, etc. The 
surgical building has a high-domed roof, showing hand- 
somely the tiled construction, in which are ample sky- 
448 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Hospitals. 
Hospitals. 
lights. 1 he heating is by steam and indirect radiation 
in all wards and rooms. The warm air inlets are near 
the floor and mainly under or near to windows. The 
boilers are placed in a deep basement under the surgical 
building. The ventilation of the latter is by the chimney 
with a central smoke-flue. In the wards it is by the cen- 
tral chimneys also; elsewhere there are vent-chambers in 
the roof to which the ducts are led from the rooms. 
There are openings under the beds in the large wards, 
connecting with the base of the large chimney, and in 
other rooms near the floor and ceiling into ducts, which 
rise mainly in connection with the chimney stacks. The 
rooms for nurses and servants, in the second and third 
stories, are warmed and ventilated by the transom system, 
the warm air abundantly supplied in the halls enters 
through the open transoms, and after traversing the room, 
aided by the chilling it receives at the windows, makes 
its exit by vent-openings near the floor in the interior 
walls. The ventilation, as a whole, is accomplished 
by a simple and effective application of the extrac- 
the St. Luke Free Hospital and the Michael Reese 
Jewish Hospital in Chicago. In England two especially 
interesting plans are those of the West Bromwich and the 
Swansea Hospitals. In Germany the Augusta Hospital 
at Berlin is particularly noteworthy. 
The Presbyterian Hospital in New York is an impor- 
tant example of a recently constructed large hospital, it 
having been rebuilt and greatly enlarged since its destruc- 
tion by fire a few years ago. It now has 315 beds in 30 
wards, mainly in three pavilions of three stories each, 
with one or two subjacent stories used for other pur- 
poses. It is expensively and finely built, fire-proof, ami 
at a cost of $875,000. Its arrangements are elaborate, 
and include a model operating pavilion, a dispensary, 
and pathological department. In the value of the land 
upon which it stands, its high buildings, and the conse- 
quent complexity of its heating and ventilating arrange- 
ments, it illustrates the tendency that sometimes 
prevails under such conditions, to depart from the 
rule of simplicity of construction. The Methodist 
East Pavilion. 
Mioole Pavilion. 
Fl R ST rLOOR Pl a n. 
West Pavilion. 
Fig. 298.-Memorial Wards, Pennsylvania Hospital, 
tion system, and renders it easy to change the air of the 
wards and rooms at least three or four times per hour 
when desired. 
The plumbing is fitted with the best modern appliances, 
all pipes and traps are exposed, and discharge into risers 
of soil-pipe in pipe-shafts which serve also for the venti- 
lation of these special apartments. All water-pipes also 
have their risers in these shafts, the waste heat from those 
for hot water aiding the ventilation. The furnishing 
selected by Mr. Hitchcock is of the best materials and 
admirably suited to the strictest hospital requirements. 
There are now, in this country, so many small hospitals 
of the class here illustrated that the mere mention of them 
would make a long list. Among the newer and notable 
ones are the Arnot-Ogden Memorial Hospital at Elmira, 
N. Y. ; the Margaret Pillsbury General Hospital at Con- 
cord, N. H. ; the Memorial Hospital at AVorcester, Mass. 
Burdett gives some interesting examples of small hospital 
construction. Among them there are, in this country, 
Episcopal Hospital in Philadelphia is an excellent exam- 
ple of a two-story pavilion hospital built upon a plan 
admirably elaborated by Dr. Billings, and designed to 
accommodate, when fully carried out, 300 patients. The 
Presbyterian Hospital in the same city has some new 
surgical wards that well represent the strict application 
of the principles of construction of one-story pavilions. 
The Pennsylvania Hospital has an excellent new house 
for nurses, and an out-patient department; and a new 
surgical hospital is now in process of construction on the 
grounds in Pine Street of this historic institution, which 
was built in 1750. There will be three separate pavilions 
built upon plans by the architect, Addison Hutton, in 
conference with the writer. The limitations as to the 
area and form of the lot, led to a variation from the gen- 
erally adopted plan of construction in the pavilions, in 
order to utilize best the whole space for these and fut- 
ure structures, and preserve the pavilion principle. The 
buildings are of brick and granite, and harmonize with 
449 Hospitals. 
Hospitals. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
the colonial style of the old hospital; they are so placed 
that their head-houses face in the opposite direction and 
toward the northern boundary of the lot, at a distance 
from it of twenty-five feet. The grade becomes lower 
here, permitting, for the central building, a carriage 
approach and an entresol entrance in the basement story, 
which is ten feet high. A large bay 
is formed upon this end of the build- 
ing and affords a fine oval room on 
the first floor, which with this mode 
of entrance is treated to give a special 
memorial character to this part of the 
structure. Beyond this the base- 
ments are mainly used for purposes 
of ventilation and warming. 
The first floor plan of the three 
buildings is given in Fig. 298. They 
are connected by a basement corri- 
dor which extends to the central part 
of the old hospital ; the corridor 
forms a covered way with open sides 
between the pavilions on the first 
floor, and a terrace on the second floor. The distance be- 
tween the buildings is 45 feet at the narrowest, and 50 feet 
where the large wards are. The sides of the buildings are 
free from projections. The central pavilion is of three 
(SUPPLEMENT.) 
stories ; the rear half of the corridor on the first floor be- 
ing a passage to the other wards, the adjoining rooms are 
arranged for special uses, and are not commonly occupied 
by patients. The memorial rooms and four special 
tf yURQlCAk WARD AMD OPERATI/sq THEATRE. 
Fig. 300.-Biadlee Memorial Ward, Massachusetts General Hospital. 
wards occupy the front end of the building. The east 
and west pavilions, two stories high, have each two 
large wards of 20 beds each, and two special wards, be- 
sides the service-rooms. The large wards are 35 by 60 
feet, with a central chimney and vent shaft, and fire- 
places. The height is 13| feet, and the ceiling is some- 
what arched at the sides and ends. It may be described 
as a long octagon ward with the advantages both of that 
and of the rectangular form. It is exposed to sunlight 
and air on the east, south, and west, and nearly all of its 
exterior walls. 
The second floor of the central pavilion is shown in 
Fig. 299. This is for the gynecological service, with a 
large ward of 10 beds, and smaller special wards, an 
operating-room, etc. The third floor has a similar ar- 
rangement of rooms, to be used for women and children; 
the latter have two wards containing 19 beds. The total 
capacity of the three pavilions is 140 beds. 
The floors of the first story and all rooms in which 
there is any water-service will be constructed through- 
out of iron beams and hollow bricks. The finish is to 
be plain and substantial with all angles rounded; mar- 
ble and tiles will be freely used in appropriate places, in- 
cluding the operating-rooms, etc. All toilet-rooms have 
plumbing exposed, and are arranged with a central shaft 
for all pipes and for the independent ventilation of these 
special apartments fvhich are cut off by a screened lobby 
from the main halls. 
The heating is by steam and indirect radiation. Else- 
where than in the large wards, which have special vent- 
chimneys, the ventilation is by ducts leading to cham- 
bers in the roof. The outflow in all of these may be 
accelerated by heat from steam-pipes. The extraction 
system is applied in its simplest form, so as to work auto- 
matically with the smallest need of attention. 
The demand for aseptic conditions in modern opera- 
tive surgery has been met by the invention of special 
constructional devices in rooms to be used for that pur- 
pose. The first notable building of this kind was 
erected at the Massachusetts General Hospital, in 1888, 
as a memorial building. It is a one-story pavilion, and 
its plan is shown in Fig. 300. The building is ap- 
proached from the other parts of the hospital by an un- 
covered way. 
The ward itself has the general arrangement of rooms 
designed for isolation, the corridor between them being 
8 feet wide and 24 feet high, with a monitor roof with 
many windows that may be freely opened. This gives 
the corridor, in relation to the rooms, the effect of their 
opening upon the outer air. The lavatory, scullery, etc., 
are outside of the building, with an intervening lobby 
protected at the side only by a screen. The passage is 
guarded by double doors swinging both ways. The 
heating is by steam and indirect radiation, the inlets be- 
ing under the windows. These have transom lights over 
them. The ventilation is by an independent duct in the 
chimney for each room. The walls and ceilings are 
Mioolc Pavilion 
Second Floor Plan 
Fig. 299.-Memorial Wards, Pennsylvania Hospital. 
450 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Hospital*. 
Hospitals. 
painted, the floors are of hard pine, and the finishing in 
wood and plaster has all corners rounded. 
The special feature of the building is the operating 
theatre. At the northerly end a door from the main cor- 
ridor opens into a connecting lobby, which is divided 
midway by swinging doors. A door to the right opens 
upon a flight of steps intended for the entrance and exit 
of the hospital attendants. Beyond the swinging doors, 
one in front opens directly to the amphitheatre floor, one 
on the right to the surgeons' consultation-room, and one 
on the left to an etherizing-room. Doors from either 
room connect with the theaFre. The walls are of pressed 
brick ; the floors, like those of the corridor and theatre, 
are of asphalt. 
The floor of the amphitheatre is circular in outline, 
with a diametei of 18 feet. Directly over this is a moni- 
tor roof of hammered glass, with an area of 280 square 
feet. Contiguous with this glass roof, at the northerly 
end of the theatre, is a window made of four sheets of 
plate glass, the combined area of which is 192 square 
feet. Beginning at either side of this window is a wain- 
scoting of polished white Italian marble, continued so that 
it encircles the whole operating space. Above this wain- 
scoting, and projecting Over it, is the first circle or tier of 
the balcony, guarded in front by a heavy iron and brass 
railing. The balcony affords standing room for about 
one hundred spectators. Opening out of the amphithea- 
tre, on the westerly side, is a general supply-room. The 
corresponding space on the easterly side is a passage-way 
from an outside entrance to a flight of granite stairs 
leading to the balcony. From this passage-way, through 
an arched opening in the marble wall, access is had to 
additional standing - room for twenty - five spectators. 
This standing-room is obtained by three semicircular 
tiers of marble and flagging, extending from the amphi- 
theatre floor to the sill of the large northern window. 
The entire basement is concreted. It has no stairway 
connection with the floor above. The ward and theatre 
are lighted by electricity. 
The gynecological department of the Johns Hopkins 
Hospital being found to need a place to be used exclu- 
sively for operative work, a building was erected for that 
purpose in 1891. It was placed conveniently near the 
private ward for women. A plan of it is shown in Fig. 
301. Its convenient and simple arrangement, and its in- 
genious special devices, make it an admirable model of a 
fitting provision for its work. 
The building comprises a large operating-room, 25.8 
by 25.9 feet, the floor of which is covered with Sinsig 
tiles laid upon lime of Teil arches, and the walls are 
wainscoted to the height of four feet with Tennessee 
(SUPPLEMENT.) 
main corridor, and the building is one story in height. 
The operating-room is lighted by two windows looking 
west, a large double window looking north, and a large 
skylight. The windows and skylight are of obscured 
glass, so that the light which enters is thoroughly dif- 
fused, and strong and annoying cross-lights are pre- 
vented. The interior lighting is both by gas and elec- 
tricity. The structure is of brick, with a slate roof, and 
corresponds in general appearance with the other build- 
ings upon the grounds. The only departure from the 
ETHERIZING 
ROOM 
ELEVATOR 
INSTRUMENT 
ROOM 
MICROSCOPE. 
ROOM 
L^RCE. OPERATING ROOM 
Fig. 302.-Presbyterian Hospital, New York. Operating Pavilion. 
method of heating adopted in the remainder of the build- 
ings was in the location of the heating flues at a height 
of six feet from the floor, it having been found by expe- 
rience that this arrangement prevents annoying draughts 
of air upon patients. 
The new operating pavilion of the Presbyterian Hos- 
pital in New York has just been completed. The seating 
capacity of the main amphitheatre is one hundred per- 
sons ; it is in the upper story of the two in the building, 
and is shown in Fig. 302. It is finely lighted by large 
skylights and three great side lights on the north, south, 
and east. The wainscoting and floors are of marble, and 
the doors are heavy slabs of the same material. In the 
basement story, which is on a level with the corridor com- 
municating with other parts of the hospital, there are two 
other operating-rooms to be used when seclusion is desir- 
able ; there are also a recovery- and an etherizing-room, 
and those for instruments, etc. This building is a re- 
markable example of the adaptation of stone and iron to 
special devices of construction, excluding the use of wood 
almost entirely. 
The Roosevelt Hospital, in New York City, presents 
the most remarkable structure of this kind that is now 
in existence. It is the William J. Syms operating the- 
atre, a memorial building for which the bequest was 
$350,000. It has just been completed and equipped at a 
cost of about two hundred thousand dollars, and the res- 
idue provides a fund for its maintenance. It is two 
stories high in front and three stories in the rear. The 
amphitheatre occupies the centre of the building, and is 
lighted by a glass dome with a northern exposure, admit- 
ting the rays of light above and behind the audience ; as 
far as possible, the light that illuminates the operating- 
table is made to enter the room from behind the observer, 
and nearly parallel with his line of vision, with the ex- 
clusion of all cross-rays. The plan of the first floor may 
be seen in Fig. 303. 
The architect was W. Wheeler Smith, but Dr. Charles 
McBurney, the Attending Surgeon to the Hospital, was 
made responsible, in the will of the donor, for the con- 
struction and equipment of the building. 
The main entrance on Fifty-ninth Street is intended for 
the students of the College of Physicians and Surgeons 
that stands on the opposite side of the street. The broad 
xecovexv I ETHeKizizYq 
ROOM ■ ROOM 
OPEXATIZKS XOOM 
Covered Corridor 
Fig. 301.-Gynecological Operating-room, Johns Hopkins Hospital. 
marble. The walls are plastered with King's cement, 
which furnishes a hard, smooth, and non-absorbent sur- 
face, with little opportunity for the lodgement of infec- 
tious germs. Adjoining the operating-room is an ether- 
izing-room, 10 by 12 feet. Communicating with this is 
a recovery-room of the same size, with an adjoining 
bath-room and -water-closet. The building has also a 
supply-closet, dressing-room, and photographic room. 
It is heated by steam and ventilated by a shaft. The 
floor of the building is on a level with the floor of the 
451 Hospitals. 
Hospitals. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
vestibule has a marble mosaic floor, and Italian marble is 
used for the interior finishing and the stairway leading 
to the upper seats of the amphitheatre. This has a seat- 
ing capacity for 185 students, but 330 could easily be 
accommodated within its space if it were desirable to 
admit that number of persons to a clinic. The seats, in 
six tiers, are of wood, with wooden backs only ; they are 
supported by being fastened to iron standards. A wain- 
scot of pure white marble, 5 feet high, encircles the room 
at the top of the amphitheatre, while behind the operator 
an unbroken surface of marble rises from the pit to a 
line on a level with the top of the wainscot before re- 
ferred to. Part of the pit extends backward to a recess 
lined with marble on every side, including its ceiling. 
The floor is of marble mosaic, and its immediate sur- 
(SUPPLEMENT.) 
The front part of the building rises to two stories, and 
the central and rear portion to three stories above a base- 
ment. On the ground floor the outer rooms, east and 
west, are only one story high and admit light by sky- 
lights as well as by large windows in the outer wall, 
which, from their situation, have to be fitted with semi- 
opaque glass. The rooms are carefully and ingeniously 
fitted for the uses indicated in the plan ; the instrument- 
rooms, for example, have cases of metal frames with 
glass doors, sides, and shelves, which were imported es- 
pecially for their purpose ; and there are many devices 
for promoting asepsis. An inclined plane has been pro- 
vided, in place of an elevator, by which patients may be 
wheeled to the recovery-rooms, four in number, on the 
second floor. 
STERILIZ- 
ING 
ROOM 
•OPERATING • 
! ROOM • 
[SPECIAL 
: cases ; 
BANDAGES 
| WASHING I-' 
INSTRUMENTS 
SPLINT 
ROOM 
PREPARATION 
OF 
BAN PAGES 
SURGEONS 
ROOM 
CONNECTING CORRIDOR 
PARK 
KOOM 
•OPERATING 
• special! 
!cases ! 
photographing 
KOOM 
ENTRANCE 
HALL 
FIRST FLOOR PLAN 
Fig. 303.-Roosevelt Hospital. William J. Syms's Operating Theatre. 
roundings are finished in marble and iron. The steps 
leading to the seats of the amphitheatre are of slate. 
Under the seats the sloping surface is of asphalt over 
thin concrete on wire lath. At the top of the entrance 
stairway are two rooms, one for surgical records and the 
other for the house staff. 
A covered corridor leads from the Hospital to the first 
floor of the building, all of which is laid in marble mo- 
saic with angles rounded to meet a marble wainscot 5 feet 
high. 
Several of the most important rooms, where it is de- 
sirable to promote aseptic conditions, are fitted with 
doors of pure white Italian marble, inch thick, hung 
on massive metal hinges, a single slab in each case form- 
ing a door. The special operating-rooms for septic and 
other cases are fitted with all conveniences, the interior 
and equipment being chiefly of marble, glass, and metal. 
The amphitheatre, as indeed every other part of the 
structure, is supplied with gas as well as electric lights, to 
insure the building never being without efficient means 
of lighting. 
The warming is by steam, the air, taken at an eleva- 
tion of 22 ft. 8 in. from the ground, passes over steam 
pipes in great inlet ducts in the basement, and is forced 
by fans throughout the building ; it is driven by one fan 
to the amphitheatre alone, and by a second fan to all 
other parts of the building. 
Fresh air, either hot or cold, as may be desired, is sup- 
plied to the amphitheatre through one hundred four-inch 
cast-iron inlets, commercially described as goose-necks, 
penetrating the inclined plane under the seats and direct- 
ing the air, as it is received from the chamber under- 
neath, upon the surface of the inclined plane. Ventila- 
tion is by aspiration through a large register near the 
452 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Hospitals. 
Hospitals. 
(SUPPLEMENT.) 
ceiling, into a heated chamber which thence discharges 
its contents, at the highest point of the structure, to the 
outer air. In all other rooms of the building separate 
vent-ducts rise directly upward to their exit openings, 
like chimney-flues-a system which entails the risk of 
down drafts of cold air in some of them if a careful bal- 
ance of the forcing and extracting power is not always 
maintained. 
Mention should be made of the sterilizing apparatus, 
occupying a room by itself and adding, in a marked de- 
gree, to the efficiency of the agencies employed to pro- 
mote asepsis. The building is a most notable one in its 
elaborate perfection and practical fitness for carrying the 
work of operative surgery to the last degree of refine- 
ment. 
The rapid development in recent years of the relation 
between the hospital and the community is bringing it 
about that the hospital is less exclusively the refuge of 
the poor, but a " palace of health " for all. In a recently 
published book on " The Nationalisation of Health," 
Havelock Ellis advocates a more complete legislative - 
control than is now had, of these interests in which the 
guardianship of. life is concerned. It is his view that, 
" in the end every medical man in the country would be 
attached to a hospital, and every person would be living 
within the district of a great institution of health.'' 
In England there is greater advancement in these mat- 
ters than in America. But it may be that here the great 
ends of preventive medicine are to be gained in a differ- 
ent way, by the more general distribution of smaller 
centres of sanitary control, and the education of the local 
practitioner through the reflex influence of the local hos- 
pital in which he works. One needs to go no farther 
than Waltham to witness the invention, already referred 
to, of a new kind of training-school that is destined to 
popularize the principles of nursing as a matter of com- 
mon knowledge and use, and to find also the beginning 
of a movement which should be successful there and 
elsewhere in bringing into the smaller cities and towns 
the life-saving appliances of a disinfecting station, of 
which there are too few even in the largest cities of the 
country. To the social economist, whose doctrine is that 
public health is public wealth, no more helpful aid has 
come than by the advancement of knowledge of the cau- 
sation of disease, which teaches the means of prevention. 
A broader socialism, acting upon the highest motives of 
philanthropy, is being developed in like manner through 
better knowledge of the laws of life which must be 
obeyed to cure both physical and moral ills. 
The admirable work of the Metropolitan Asylums Board 
in London stands as a model for the effective organiza- 
tion of hospitals and disinfecting stations for the protec- 
tion of the poor, and the whole community alike, from 
the dangers of infectious and contagious disease. It has 
been demonstrated by experience that the value of a per- 
manent isolation hospital is in its providing the means of 
isolating at once the earliest cases of disease, and thus 
preventing the epidemic, instead of leaving it to be bat- 
tled with when it has got full sway. In Burdett's work 
the admirable chapters on this subject are most instruc- 
tive. Valuable and precise information as to the best 
methods may be found in this work, and in Dr. Thorne's 
report " On the Use and Influence of Hospitals for 
Infectious Diseases," which forms a part of the " Tenth 
Annual Report of the Local Government Board for 1882." 
Among the plans given by Dr. Thorne is that of the 
Warrington Hospital. As a good type of such English 
hospitals, a plan of one of its small pavilions is shown 
in Fig. 304. 
A common arrangement is to group together a number 
of such small pavilions, and to connect them by a cov- 
ered way, open at the sides, with an administration block. 
The Warrington Hospital is of brick ; its arrangement 
is shown in the block plan, Fig. 305. There is a two-story 
administration block, a; two ordinary ward pavilions, 
w, w ; a special detached pavilion with like interior ar- 
rangements, except that its wards are reduced to a capa- 
city of one bed each, w ; a lodge at the entrance, c; and 
two groups of out-buildings, 5, d. One of the latter con- 
tains a laundry, disinfecting chamber, ambulance-shed, 
mortuary, and store for wood, coals, etc.; the other con- 
tains two hand-vans to be used in connection with the 
stove, and a store for garden tools, etc. These forms of 
pavilions are two of the four prescribed by the Local 
Government Board. 
The disinfecting apparatus is a "Ransome stove," 
otherwise well known as the Nottingham self-regulating 
of feet 
«•» TWELVE BED PAVILION 
Fig. 304.-Warrington Infectious Diseases Hospital. 
disinfecting apparatus, in which articles passed through 
it are subjected to a temperature of 250° F. by dry heat. 
It consists of a cubical iron chamber encased in wood 
with an intervening layer of felt, access to the interior 
being had by double doors. For disinfecting stations 
the chamber has doors on opposite sides, and is placed in 
the partition wall between two rooms, an * ' infected " 
side into which articles are carried, and a " clean " side 
from which they are removed. The furnace is placed at 
a lower level, and heat is generated by burning gas. 
There is an automatic regulator. A full description is 
given in Dr. Thorne's Report, pp. 210 to 214. An ap- 
proved form of apparatus employing steam confined 
under pressure, is Lyons's patent steam disinfector, one 
of which is in use at the Johns Hopkins Hospital. This 
is an expensive apparatus and somewhat difficult in its 
method of working. These and other forms of appara- 
Fig. 305.-Warrington Hospital. Block Plan. 
tus and experiments in testing them are described by Dr. 
Parsons in his report on disinfecting by heat, to the 
Local Government Board, in 1884. 
The Fever and Small-pox Hospitals of the city of Glas- 
gow form an extensive establishment, which was com- 
pleted in 1887. The Small-pox Hospital has ten wards 
in five pavilions, and the Fever Hospital has twenty-six 
wards in thirteen pavilions. The pavilions are of one 
story and are alike in form and arrangement; they are 
detached and arranged in groups with respect to their 
453 Hospitals. 
Hospitals. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
isolation, and to the administration and service build- 
ings. One of these pavilions is shown in Fig. 306. The 
two hospitals occupy a country estate of 33 acres, with 
large gardens and pleasure-grounds, at Belvidere. The 
Fever Hospital was begun in 1870, the first pavilion being 
of wood. In 1879 the erection of brick pavilions was 
begun, and now all are substantial structures of that 
material. Ample and excellent accommodations are fur- 
nished for physicians and nurses. The cost of the Fever 
Hospital was about £76,000. The Small-pox Hospital is 
an outside platform or balcony from which there are sep- 
arate entrances to the rooms, for four patients, occupy- 
ing the corners of the building. From the ground level 
the balcony is reached through an opening therein, and 
by a stairway. The serving-room in the centre of the 
ATTENDANT 
PATIENT 
PATIENT 
NURSE 
NURSE 
'SERVING ROOIA ' 
PLAN OF ONE PAVILION 
PATIENT 
NURSE 
NURSE 
PATIENT 
Fig. 306.-City of Glasgow Hospital. 
completely isolated by a boundary wall. The whole cost 
of it was about £30,000. A remarkable reduction has 
been made in the death-rate of the city since the opening 
of this hospital, due to a variety of causes, not the least 
among them being the efficient labors of Dr. Russell, the 
Officer of Health. This hospital affords the most strik- 
ing demonstration of the profit of guarding the public 
health. 
The Cambridge Hospital, in Massachusetts, has recently 
received an addition of a building for infectious and con- 
tagious diseases. It is on the grounds of the hospital, at 
an effective distance from it, and near the bank of the 
Charles River. The material is brick, and the symmetri- 
cal halves of the building are so arranged as to be entirely 
independent, and without means of communication ex- 
cept by going around the house, out of doors. It is of 
one story, except that a nurse's room in the attic for each 
section is accessible by an outside stairway. 
The plan is shown in Fig. 307. The construction is 
simple and substantial, as designed by Dr. Wyman ; it 
is for the treatment of diphtheria, scarlet fever, etc., 
VESTIBULE 
VESTIBULE. 
CORFtlDOa 
Fig. 308.-Isolated Pavilion, Presbyterian Hospital. 
building, and that of the attendant in charge of it, are 
accessible only by way of the basement. 
The Boston City Hospital is now being enlarged by a 
new and important hospital for contagious diseases. It 
is known as the Chester Park Hospital, and is subject to 
the limitations of a city lot. It is to receive cases occur- 
ring in the wards of the hospital proper and from the 
city at large. There is requirement for its accommoda- 
tions to be centrally situated in so large a city, rather 
than in any suburban locality that is available, which 
would be at a great distance from the major part of the 
population it serves. It is a handsome structure of brick, 
consisting of six principal buildings, 
with the adjuncts of a boiler-house, 
laundry, and morgue, and room for a 
small pavilion to be added in future. 
These adjuncts are not shown in the 
first-floor plan, which is given in Fig. 
309. In the lettering of the plan B is 
bath-room, I) duty-room, E elevator, 
and 0, operating-room. 
The plans were designed by the city 
architect, Mr. Wheelwright, in con- 
ference with Dr. Rowe, the superin- 
tendent of the hospital, after an exten- 
sive study of the subject, and with the 
approval of its medical staff. 
The entrance gate is at the centre 
of the one-story lodge, which all per- 
sons who enter the hospital must pass 
through. The administration block, 
occupying a central position, is three stories high, and 
contains offices, and quarters for officers, nurses, and 
servants. Covered passageways, with open-air walks 
over them on the first-floor level, connect the basements 
of the buildings. The domestic building in the rear con- 
tains the kitchen, etc.; a dispensary, and a dining-room 
for servants, their chambers being on the second floor. 
A nurses' home, not shown in the plan, is a detached 
building to accommodate sixty nurses. 
The wards are in two pavilions, each two stories high, 
and are designed to accommodate 136 patients, including 
men, women, and children. At the junction of the com- 
municatinsr corridors with each navdion there are stens 
Fig. 307.-Contagious Disease Ward, Cambridge Hospital. 
such cases as may occur in the hospital, or may be re- 
ceived from the vicinity. This plan is a modification of 
one of those of the Local Government Board already re- 
ferred to. Here it is improved by entrance lobbies to the 
wards, more windows, and access to closet without ex- 
posure in cold weather. A bath-room would further im- 
prove it. 
An interesting example of a building for isolating the 
cases that may require it, occurring in a large hospital, 
is to be seen at the Presbyterian Hospital in New York. 
The plan is given in Fig. 308. It is situated within the 
hospital enclosure in the limited area of a paved court. 
At the level of the main floor, shown in the plan, there is 
454 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Hospitals. 
Hospitals. 
leading up from the ground level to the first floors, and 
others to the basement floors underneath. Here there is 
an open way across the corridor from side to side, at the 
basement level, disconnecting the covered passage in the 
corridor from the building. 
The conditions for the treatment of patients in these 
wards require a classification, not only regarding the sex 
of patients and their being adults or children-permitting 
the latter to have their mothers with them in some cases- 
but there must be proper provision for isolating extreme 
cases of each of the special forms of disease, and the vary- 
ing and numerous complications of different contagious 
diseases. This grouping and isolation 
of patients is accomplished by the divi 
sion of each floor into four wards. 
There is an open ward of ten beds, and 
four*beds in three rooms, in the rear 
section. This large ward is for con- 
(SUPPLEMENT.) 
by an air-space like a lobby, isolating them from the main 
hallway. The plumbing fixtures of each section are ar- 
ranged around a shaft affording independent ventilation 
for these apartments, and a pipeway for all waste and 
supply pipes. Each section has its own linen and medi- 
cine closets ; and the shutes to the basement for soiled 
clothing are from the open-air cross corridors. 
The basements, reached by separate staircases from 
each section, contain the rooms for patients' clothing. 
At the entrance to the building, in the basement, is a 
series of rooms through which all visitors must pass. In 
the first room the outer clothing is left ; thence by a 
lobby another room is entered where a 
gown is put on to be worn while visit- 
ing the sick. On returning, this gown 
is left in a room on the opposite side 
of the building, and thence through an- 
other lobbv the visitor reaches the first 
Fig. 309.-Boston City Hospital for Contagious Diseases. 
J'CAUE. OF FEET 
valescents and looks southward. This section is separ- 
ated from the middle section by across corridor, opening 
broadly to the outer air at each end. An isolated stair- 
way, starting from the outside of the building, here leads 
to the second floor. The middle section is, in like man- 
ner, isolated from the front section, which also is divided 
in two parts in the same way by a broad opening leading 
to a wide loggia on the front of the building. Here are 
the two small probation wards near the front entrance. 
The floors of these rooms are of asphalt, the walls of 
white enamelled brick, and the ceiling of Keene's ce- 
ment. They have their own service- and bath-rooms, as 
does each section of the whole building. The walls of 
the isolating passages are also lined with enamelled brick, 
have mosaic flooring, and cement ceilings. The toilet- 
rooms are finished in like manner, and are surrounded 
room, where the outer clothing is resumed. Like pre- 
cautions are exercised by the attending physicians. 
The heating is by steam and indirect radiation. Each 
room has one or more ventilating outlets, one near the 
floor and ceiling for every duct in each room. These 
ducts lead to a vent-chamber in the roof for each divis- 
ion of the building. The whole lot is enclosed by a 
brick wall eight feet high. 
The application of sanitary science has made very slow 
progress in America, considering the great advancements 
in knowledge of the causation of disease. In the few 
States and cities where attention has been given to this 
subject, experience has shown the necessity of govern- 
mental control of sanitary matters. The work of the 
States of Massachusetts and Michigan in this regard has 
reached a development of methods that ought to be fol- 
455 Hospitals. 
Hospital Steward. 
DEFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
lowed in every State. A department of public health, to 
be established by the national government, is the demand 
of the time. 
The definite knowledge that has now been gained by 
the scientific tests of disinfection establishes a basis for 
its practical application. According to Parsons, Stern- 
berg. Blyth, and others, heat is undoubtedly entitled to 
the first place among the agents available for the de- 
struction of infectious material external to the bodies 
of living animals. In nearly all the important infec- 
tious diseases of man and the lower animals, it is safe 
to assume that the temperature which kills the tuber- 
cle bacilli, 212° F., will be sufficient to accomplish dis- 
infection. Ample allowance is made, in directing the 
disinfection of all kinds of infectious material, by sub- 
jecting it to a boiling temperature for half an hour, 
either in water or steam. Exposure for ten minutes to 
steam under pressure to raise the temperature to 221° F., 
will accomplish the object. The fact that the spores of 
certain bacilli found in the soil resist a considerably 
higher temperature than this has led to undue exactions 
in the use of heat. Esmarch has shown that dry heat is 
less effective than moist heat, superheated steam being 
less so than streaming steam at 212° F. Exposure to the 
moist heat of steam at twenty pounds pressure-temper- 
ature about 230° F.-destroys the most resistant spores 
in twenty minutes. A temperature of 240° F. is effective 
almost immediately. The simplest way of disinfecting 
articles of clothing and other articles not injured thereby, 
is to immerse them in boiling water. Cholera germs are 
killed at 126.6° F., and typhoid germs at 138.8° F., by 
exposure for four and ten minutes, respectively. Infec- 
tious excreta of these diseases may be disinfected by add- 
ing three or four times their amount of boiling water. 
Sulphate of iron or chloride of zinc, in solution there- 
with, will deodorize and disinfect at the same time. This 
is a good rule for domestic and hospital use. The chem- 
ical disinfectant that is of practical value, and prompt in 
its action, is good chlorinated lime, which should con- 
tain at least twenty-five per cent, of available chlorine. 
A solution in the proportion of six ounces to one gallon 
of pure water being made, one quart of it may be used 
for the disinfection of each discharge in'typhoid fever, 
cholera, vomited matter, etc. Then the contents of the 
vessel being well mixed, it should stand for at least one 
hour before they are thrown out. Infected sputum 
should be discharged directly into a cup half full of the 
solution. 
The warming and ventilating of hospital wards is 
rightly regarded as a matter of great importance. The 
history of the subject, for the last thirty years or more, 
shows some curious changes of usage. There had pre- 
viously come about the development of very complex 
systems in large hospitals, and particularly in asylums. 
Forced distribution of air, and ventilation aided by the 
propulsion of a fan, were much in vogue. The experience 
in military barrack hospitals, and in those of the simple 
construction that followed, taught hospital men the 
effectiveness of natural means when employed in the use 
of simple constructional devices, under the laws govern- 
ing the movement of heated air. Very satisfactory re- 
sults were gained by the adaptation of the principles of 
the extraction system, by means of vent-chambers and 
chimneys, even in such establishments as the Massachu- 
setts General Hospital, Boston City Hospital, and Johns 
Hopkins Hospital, without the use of fans. It is perhaps 
through some failure to apply correctly the methods 
found so effective there, that there appears to be a reviv- 
ing tendency to resort to mechanisms driven by steam 
power or electricity for the propulsion of warm air into 
buildings, or for extraction of foul air. The practical 
fact is that the more machinery there is, the more the 
trouble from defective working, inattention, or ignorance 
in managing it, or its disuse after a time as ineffective or 
too expensive. The best way is to devise a simple sys- 
tem that will work if let alone, or requires the least pos- 
sible interference. It is only necessary to follow the 
simple law that a body of air relatively warmer than that 
which surrounds it will rise. Let it be conducted from 
the room to be ventilated to a chamber at a higher level, 
so that a body of warm air is held at a point intermediate 
between the room and the outer air. Artificial heat may 
sometimes be an aid in giving that chamber the requisite 
excess of heat. Under these conditions the chamber will 
discharge itself upward and outward through proper 
openings, without any danger of the reversal of currents 
downward through the ventilating ducts. Such rever- 
sals will occur in vent-ducts that open upward like chim- 
ney flues. Difficulty often arises simply from making 
the air-ducts and chambers inadequate in size, or attempt- 
ing to combine too many ducts, of different lengths, in 
one system. 
Hospital management comes next in order after the 
hospital is gained. A good hospital may become a bad 
one by bad keeping. Administrative troubles are often 
relatively worse and more disastrous in a small institution 
than in a large one ; when there is a tempest in a teapot 
there is no room even for a small tempest. In the or- 
ganization of the small hospitals the same principles 
should be regarded as in the larger ones ; there should be 
only one resident head of the administration, and all 
other resident persons should be subordinate. This is a 
simple business principle, and it is remarkable that intel- 
ligent people of business experience will, as trustees, try 
over again experiments in organization and control that 
have so often proved the error of departing from a funda- 
mental principle. It requires experience in the govern- 
ing board, as in any other business, before this special 
business can be understood. 
The small hospitals are being successfully managed by 
women trained in nursing, and who become skilled in 
executive work by doing it. The paramount object of 
the hospital is the business of caring for the sick. The 
position of the skilled nurse at the head of a small hospi- 
tal is precisely the same in principle as that of the medical 
superintendent of a large one. The maxim of Dr. 
Mouat is equally applicable in each case : "Those are 
best qualified to conduct a business successfully who are 
best acquainted with its requirements." 
There are two special sources of trouble-fundamental 
conditions from which trouble and failure are sure to 
come some time or other. They are either faults of the 
system, w'hich even good people cannot get on with ; or 
faults of the individual under a good system. It is true 
that a dual arrangement is sometimes successful ; that 
proves the goodness of exceptional persons. Again, 
when the organization is correct in principle there are 
examples of the failure of individuals in executive capa- 
city and tact, and the governors proceed to change both 
the individuals and the system. A vast amount of heart- 
breaking care and trouble could be saved, and disaster 
averted, in a struggling hospital that means so much to 
the community that supports it, by the recognition of a 
simple truth. There should be one head of every hos- 
pital household, who, under the controlling board, 
should have the sole and entire direction of its business. 
That head should be a person educated to the business, 
a medical man or woman, or an educated and skilled 
nurse. 
There is one fundamental element in this matter that 
strangely appears never to be recognized as it ought to 
be. It is something more than the recognition of the 
business principle of one executive head. It is worth the 
utterance of many words to get it made clear, for the 
sake of the helpfulness it may bring to many a devoted 
and hard-working hospital officer, whose life is one of 
trial at the best. This fundamental principle is that, 
while the management of a hospital is a business, it is 
not like the business of managing a factory, ora mercan- 
tile house. The hospital, besides being the place of busi- 
ness, is the home of all the people in it. The household 
element is there ; it is a family. The head of the family 
has a personal, protective relation to its members, con- 
trolling their peace and comfort. The fundamental rule 
therefore is, never disregard the principle of family 
headship in the hospital household. This applies alike to 
the man or woman who is at the head of it. A woman 
superintendent should be a trained and skilled nurse to 
456 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Hospitals. 
Hospital Steward. 
(SUPPLEMENT.) 
begin with ; she should have executive capacity ; and she 
should be helped by affording her time in the work to 
gain the efficiency that only experience can give. All 
other persons in the hospital should be subordinate to 
her. After this is done there remains one most important 
principle to be regarded : give the superintendent full 
authority, and hold him or her responsible for all that 
happens, but afford a chance for the exercise and protec- 
tion of the responsibility. Above all things, the subor- 
dinates should not be meddled with, they should be 
managed only through the head of the house. This is 
perfectly safe, for they can always be accorded the right 
of appeal. Then it is fair, and only then, to expect suc- 
cessful work from the executive officer ; and then, if 
there is failure of a well-supported officer to get good 
results, it is the fault of the individual alone, and the 
course to be pursued is plain. By such a plan of organ- 
ization the relations of all concerned are made definite 
and intelligible, and there is no going against nature and 
the family principle, which always underlies the mixed 
organization of a civil hospital. Edward Cowles. 
HOSPITAL STEWARD, DUTIES OF, IN THE U. S. 
ARMY.-The Hospital Steward is the executive officer of 
the hospital, in the post and in the field. Under the 
supervision of the medical officer, on the steward de- 
volves the care of property, the maintenance of official 
records and correspondence, the management of food 
supplies, the dispensing of medicines, the extraction of 
teeth, and the application of minor surgical dressings. 
He fills the place of the house physician of a civil hospi- 
tal in minor accidents and emergencies ; he is responsi- 
ble for the instruction and discipline of the members of 
the hospital corps under his command ; on his vigilance 
largely depends the zeal and efficiency of the cook, 
nurses, and other attendants ; he must see that all orders 
are obeyed, all work fairly apportioned and properly 
done. 
To fit a steward for these multifarious duties he must 
have served at least a year in the line of the army, than 
which there is no better school of discipline ; he must 
have served at least a year as a private of the hospital 
corps, and at least another year as an acting hospital 
steward. He is given access to works on chemistry, 
pharmacy, anatomy, and minor surgery. For his in- 
struction there is a Handbook for the Hospital Corps, 
The Soldier's First-Aid Handbook, and The Drill-book 
for the Hospital Corps. He can study Army Regulations, 
General Orders, and Circulars, and the blanks for the 
various reports. Beyond all these there is still much to 
be learned that has heretofore been left to haphazard 
observation of the methods-not always the best methods 
-of the stewards under whom he has served. Unwrit- 
ten tradition perpetuates error, shackles truth, prevents 
progress; to gather and arrange these neglected trifles, 
to till the ground uncovered by the above-mentioned lit- 
erature, is the aim and scope of this article. 
I. In Garrison. 
The Routine Duties of a hospital steward in the United 
States Army intermit for sleep, remit for recreation, but 
are practically one continuous round. Where the cares 
of the passing day overlap the prospective duties of the 
morrow is a good initial point for their survey. We 
will begin with the 
Meteorological Observation, taken at 6 p.m., and entered 
at once in the Register and on the Blank Report which 
is to be forwarded at the end of the month to such 
Weather Bureau centre as may be directed for the sta- 
tion. Both must be kept neatly ; there will never be a 
more leisure moment. Scratch-block memoranda are so 
much extra work, increase the chances for errors, and 
are a useless waste of time. After the last observation 
for the month, totals and averages are computed on the 
Register and Blank separately, results compared to de- 
tect errors, and both are ready for signature. 
After recording the meteorological observation the 
events of the day will be recalled to discover any possi- 
bly unfinished business-to be completed now. The 
desk is put in perfect order, with an eye for memoranda 
possibly overlooked. As far as possible to-morrow's 
Morning Reports for the sick and for the hospital corps 
will be prepared. In a blank-book, ruled as in Table L, 
are entered the names of all the sick remaining, or taken 
up during the day, arranged by organizations. 
May 15, 1900. 
Table I. 
Name. 
Rank. 
Co. 
Rcg't. 
Dis. 
Diagnosis. 
Treatment. 
Stein, Jacob .. 
S. M. 
8 C. 
H. 
Sprain R. ankle. 
Misstep on pa- 
rade. 
Hot water ; 
bandage; 
rest. 
Pugh, Henry.. 
0. S. 
G.N.C.S. 
Q. 
Powder burn R. 
hand and cheek. 
Def. primer. 
Ext. g r s. 
carb, oil, 1- 
40. 
Atkins, Peter.. 
C. 
I. 
24 I. 
H. 
Ac. diarrhoea ... 
01. ric., X 
oz. ; tr. op., 
Hl XX. 
Jones, John... 
P. 
A. 
9 C. 
D. 
Toothache 
Ext'd R. U. 
A. molar. 
This book is for convenience, and the following ab- 
breviations are admissible if care be taken not to trans- 
fer them to the permanent records, viz., IL, Hospital; 
Q., Quarters; D., Duty; G- N. C. S., General Non- 
commissioned Staff; P. Q. S., Post Quartermaster Ser- 
geant ; O. S., Ordnance Sergeant; C. S., Commissary 
Sergeant; S. M., Sergeant-Major; H. C., Hospital 
Corps; H. S., Hospital Steward ; B. L., Band Leader ; 
C. M., Chief Musician ; S., Sergeant ; C., Corporal ; P., 
Private ; F. Farrier. For regimental designation cardi- 
nal numbers are as good as ordinals ; d, nd, st, and th 
consume time, occupy space, and obscure the record. 
1 A., 3 C., and 8 I. are sufficiently distinctive for First 
Artillery, Third Cavalry, and Eighth Infantry. 
If to-morrow will be the 10th, 20th, or last day of the 
month, Ration Returnswill be prepared as far as prac- 
ticable ; also, if the last of the month, the Requisition 
for Fuel, Forage, and Straw. 
" In the gloaming"-from six to seven o'clock-is the 
best hour for effective work, an hour of quiet and free- 
dom from interruptions. If, habitually, all possible work 
is done at this time, daily tasks will be so lightened that 
fatigue will not now unfit for close application. With 
all work complete, the steward will have an evening for 
reading or recreation. With an assistant to put up the 
prescriptions that will come straggling in toward tattoo, 
he can safely leave the hospital. 
Just before going to bed a look through the building 
and about the grounds must be taken. If anything be 
amiss, the proper man will be called to adjust it. The 
steward will do nothing himself ; if he goes about at 
night putting out lamps, securing gates, and locking 
doors, his detachment will soon depend upon his vigi- 
lance, and negligence will grow apace. 
The steward must see that helpless patients have pro- 
vision for all their needs during the night ; must satisfy 
himself that all-patients and members of the detach- 
ment-are present and in their proper places. Let 
everyone feel that absentees will surely be detected and 
reported. The hours allotted to repose are none too 
long; and effective work by day cannot be expected 
from men who travel about by night. 
From Reveille to Surgeon's Call.-The presence 
of each member of the detachment must be verified. 
Breakfast is now on the table ; consider its quantity, 
quality, and variety. The steward must see that the 
men who come to the dining-room are fully dressed, neat 
and soldierly in appearance. A bright dawn betokens a 
clear day ; and men who habitually start right in the 
morning will rarely need correction before night. The 
patients must be counted, and each receive a careful 
scrutiny. There may have been changes during the 
night requiring an immediate report to the medical offi- 
cer when he comes. Men in collapse, small-pox erup- 
tions, and many other things ought not to await the sur- 
geon's visit at a later hour. The steward will see that 
457 Hospital Steward. 
Hospital Steward. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
the ward is properly warmed and ventilated, and have 
corrections made at once. Conditions, not seasons, must 
be the guide. After a cold rain in July, the ward may 
be chill and damp, and tire be as essential as in Decem- 
ber. Quiet throughout the hospital will be enforced. 
Reveille is not sounded for the very ill. Undisturbed 
rest in these early morning hours may turn the scale 
toward health in critical cases. Let the invalids sleep ; 
their breakfasts can be kept for them. 
The steward now takes a complete survey of the build- 
ing and grounds, and gets the general run of the hos- 
pital work. Frozen water-pipes, defective flues, things 
done improperly or left undone the day before, are all 
proper subjects for consideration in his early morning 
round. Each attendant knows his allotted task and will 
be doing it now ; but the steward's judgment will be 
tried by never-ceasing variations. Each contingency 
must be met with prompt decision. If many helpless 
patients await their morning toilet before breakfast, the 
regular nurse is supplemented by utilizing the more in- 
telligent convalescents and as many attendants as may be 
necessary. If snow-drifts are to be cleared away before 
Surgeon's Call, the man who attends to the outside police 
must be reinforced by other attendants, and less impor- 
tant work delayed. 
A good beginning will save much trouble and annoy- 
ance throughout the day; but inattention to these duties 
may bring trouble and humiliation later. Should the 
steward offer for the surgeon's signature morning re- 
ports showing all present and learn later that a member 
of his detachment, or a patient, had been arrested in 
town during the night and was still in jail, he would 
justly forfeit the confidence of his superiors. 
Surgeon's Call.-On the desk is the suitably ruled 
blank book containing a list-arranged by organizations 
-of all excused from duty yesterday on account of sick- 
ness, with the rank, company, and regiment of each. 
An interrogation point in the appropriate column tells for 
which men a diagnosis is needed. As the Company Sick- 
books are brought in, they are compared with the hos- 
pital list and new names entered below. Care must be 
taken to get the full name, correctly spelled. This is 
specially important with the Sick-book for Prisoners; 
for sergeants of the guard are apt to know the prisoners 
simply as Brown, Jones, or Johnson, and so enter them 
in the book. Now, there may be several Browns, 
Joneses, and Johnsons in the command, and confusion 
may sometimes deprive a deserving man of a pension, or 
blot index and register with unseemly erasures. The time 
to settle doubtful points is now. 
As the men are called in by the medical officer, record 
is made of whatever treatment may be directed. Should 
a new case be one of injury, what the man says was the 
cause is noted, also the limb or location, whether on the 
right or left side. These points are difficult to remem- 
ber for even a short time ; and now that outline cards are 
prepared for every recruit, the correct location of each 
new scar is important. Should a case be returned to 
duty with an interrogation point in the column for diag- 
nosis, the medical officer should be asked for one now to 
complete the record Should the man go away without 
this, the medical officer may forget the case entirely or 
confound it with some other, and great injustice may be 
done. In the column for disposition is entered a Q., II., 
or D., according as each case is marked for quarters, 
hospital, or duty. 
Before returning the Company Sick-books to the first 
sergeants, an entry will be made of the numbers taken 
sick, returned to duty, or otherwise disposed of, in the 
proper columns of the Morning Report for Sick and 
Wounded. Each organization has a line for these en- 
tries. The sum of those remaining from yesterday and 
the new cases must equal the sum of those remaining, re- 
turned to duty, and otherwise disposed of. Footing the 
columns a like equality must exist between the totals. 
This double system insures accuracy ; and now is the 
time to adjust discrepancies. It is humiliating to make 
errors in a report that is prepared every morning, and 
awkward to make subsequent corrections. If the post 
surgeon does not attend the call, the Morning Reports 
are sent to him for signature, and then to the Adjutant's 
Office. The steward must be prompt in this, for the 
sergeant-major compiles a Post Morning Report from 
these and has many other things to do before guard 
mounting. 
Patients taken in Hospital must now be assigned to a 
ward, put in bed, and given such other treatment as may 
have been directed ; those marked " quarters'' are, pre- 
sumably, better able to wait. For convenience of nurs- 
ing, if there is more than one ward, it is well to place 
the more serious cases together. Among all men there 
are social affinities worthy of consideration. Sick 
"birds of a feather" do better if their gregarious ten- 
dency is respected. The victims of indiscretion-the 
men whom common frailties bring to hospital-should 
usually be gathered into one ward. The influence of 
example may be remotely beneficial-the mote in our 
neighbor's eye is frequently a useful guide to our own oc- 
ular defects. Men with barking coughs or noisy de- 
lirium must not be allowed to disturb the rest of critical 
cases of fever or pneumonia-the pay-day penitents are 
better able to endure this annoyance ; and it may be bet- 
ter to so accentuate the bitter dregs from pleasure's cup. 
When the rosy-cheeked music-boy is brought to hos- 
pital, he will not be sandwiched between the reckless 
or the depraved ; he will be better near that staid old 
sergeant whose grizzled hair and furrowed cheek may 
recall happy memories to cheer him in his loneliness- 
may inspire him with hope and courage to tide him over 
the hour of danger. The old man's friendship, now 
formed, may prove a useful ballast to the youthful 
bark throughout life's voyage. It is useless and unwise 
to be an outspoken reformer ; but by attention to such 
details the steward can silently contribute his mite 
toward making better men, better soldiers. In a ward 
containing several helpless patients, to lighten the labor 
of the nurse and insure increased comfort for the sick, 
one or two convalescents may be utilized. 
As a rule the American soldier is cleanly in his habits 
and does not need a bath upon admission ; in exceptional 
cases it is for the steward or surgeon to decide. If this 
duty is delegated to a nurse, sooner or later a case of 
fainting and death in the bath-tub will bring sorrow. 
After men come under medical charge the steward is re- 
sponsible for their condition and should see that they 
have a full bath once a week, in addition to daily ablu- 
tions. In all serious cases the directions of the medical 
officer must first be obtained. 
Personal attention must be given to the effects that 
each soldier brings into hospital ; and an inventory en- 
tered in the register for that purpose. The steward 
should be able to testify, from personal knowledge, what 
articles of clothing or other property are brought into 
the hospital ; for, if the soldier has sold it before, he may 
claim to have lost it after, admission. Money, watches, 
and other articles of value must be enclosed in a suitably 
marked package and given to the post surgeon for stor- 
age in the hospital safe. If they so desire, patients may 
retain their money, at their own risk ; but a nurse must 
never be exposed to the suspicion or temptation of pick- 
ing the pockets of a drunken or delirious patient. Be- 
fore leaving the hospital each patient must sign the Reg- 
ister as an acknowledgment that he has received all of 
his effects. 
The Sick in Quarters will now receive their prescribed 
treatment. This is aiways an unsatisfactory class. The 
expenditure of medicines is much greater, the results 
less by far, than for an equal number treated in hospital. 
The steward can do much toward obviating the diffi- 
culty. If possible he should see that one dose is swal- 
lowed at the counter ; he will dispense a quantity just 
sufficient for the twenty-four hours ; will give directions 
clearly, both orally and in writing. Salts, salicylates, 
and many other drugs can be dispensed in powders, to be 
dissolved, when taken. If a bottle be necessary its return 
to-morrow will be enjoined ; the contents may be poured 
on the highway, but the hospital will in this way re- 
cover a few vials. If only a second dose be required, it is 
458 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Hospital Steward. 
Hospital Steward. 
generally better to have the man come to the dispensary 
for it when needed. A stimulant narcotic, like Squibb's 
mixture, must be dispensed with great caution as to 
quantity ; a toper may poison himself by taking all at 
once. Ulcers and abrasions will be dressed occlusively, 
so that the steward can tell if the dressings have been 
disturbed when the patient returns to-morrow. He will 
not improve its condition if he has access to it, and a 
small ulcer is sometimes considered less inconvenient 
than a detail with water-wagon or ice-cutting party. As 
the medicines are dispensed your list must be checked 
carefully, so that those who do not wait for their treat- 
ment may be reported to the surgeon. Care not to re- 
port the wrong man is important. The steward must 
treat all courteously, and never show signs of suspicion ; 
to subject a sick man to unjust doubt is cruelty ; to cau- 
tion a malingerer is to render discovery more difficult. 
It is well to provide for the lame men last, and watch 
them depart; the non-commissioned officer has gone, 
long ago, and some of them may not limp all the way 
to their quarters. 
After providing for the last sick man, a second round 
is made to see that everything is now in readiness for the 
surgeon's visit. The cook is told how many men are to 
be fed, and given orders for what he requires. Pre- 
pared for the post-surgeon's signature will be a list of 
needed commissary stores. It must be seen that all the 
men are employed-the morning is the time for work. 
The temperatures in all febrile cases will be taken and 
recorded-the surgeon will be sure to ask for them. 
Before the surgeon's visit there will be time to enter 
all new cases in the register. The Index must be care- 
fully searched, and the names not already there be en- 
tered ; also the new hospital number of each case, and 
the last previous numbers will be noted on the Register. 
The age, nationality, previous service of each new addi- 
tion to the Index will be ascertained. The record of 
each case returned to duty will be completed at once ; if 
any point be doubtful, a memorandum for reference to 
the surgeon when he conies will be prepared. If the 
register be completed as far as practicable each day, the 
work at the end of the month will be greatly reduced. 
Morning Visit of the Post Surgeon. - The 
steward precedes the surgeon, and, as he enters each 
ward, calls "Attention!" when each nurse and those 
patients who are out of bed will rise, and remain standing 
in a line at the foot of the beds until the officer's departure. 
Should much time be required in the ward, the surgeon 
may direct the men to sit down ; then each will rise at 
the surgeon's approach, and remain standing until the 
next patient is addressed. The same direction may be 
given to individuals. The nurse in charge of the ward 
will follow the surgeon and steward from bed to bed. 
The steward should verify the number of men in the 
ward and call attention to absentees. This is better than 
to have the surgeon call attention to a discrepancy be- 
tween the Morning Report and the number of cases that 
he has seen. On a memorandum block is noted the pre- 
scribed treatment for each case and any operation done 
by the surgeon ; if an abscess is opened, if a man com- 
plain of pain or lameness, the anatomical locality is 
noted ; if a tooth be extracted, a record of which tooth. 
These seeming trifles frequently have a remote impor- 
tance ; and the completeness of the record will be a source 
of gratification to the surgeon and to the steward. Note 
is made of which cases are to be allowed to leave their 
beds, to visit the dining-room for meals, to have special 
diet, to be provided with crutches, etc. These memo- 
randa will be carefully copied in the proper column, and 
opposite each man's name, in the blank-book described 
and illustrated by Table I., p. 457. 
The prescribed treatment for each case will now be 
provided. The nurse should apply bandages, poultices, 
and other dressings, under the immediate supervision of 
the steward. Neatness, cleanliness, and efficiency must 
be secured. This may take more time than to do it him- 
self, but this instruction given is like bread cast upon 
the waters-it will return as a diminution of labor here- 
after. All unused vials are taken to the dispensary, 
(SUPPLEMENT.) 
carefully washed, and stored .for future use. Corks, 
once used should be washed and kept in a separate 
drawer for use with liniments and other external appli- 
cations. These little economies will prevent a shortage 
toward the end of the year. A mental inventory of 
medicines left in the ward will be taken, so that if a pa- 
tient takes too much or too little, the defect may be dis- 
covered and corrected promptly. Instruction will be 
given the cook as to special diets. 
The Daily Mail now lies on the surgeon's desk ; he will 
indicate whatever action is to be taken upon each paper. 
Each communication will be stamped with the date of 
receipt, and such as have not already received that at- 
tention will be briefed. Each is numbered to correspond 
with the records. In the Letters-received Book will be 
noted the number, source, date, date of receipt, import, 
and disposition of each communication ; if sent away, 
cross-reference will be made to the Endorsement-book ; 
if a reply to a letter sent, make cross-reference to the 
Letters-sent Book, in which will be noted the number of 
this reply. If an important letter is not for file in the 
office, it is safer to copy it in full-a brief may not con- 
vey the full meaning of the writer. All letters sent must 
be copied in full in the proper book, and all endorse- 
ments in the Endorsement-book. The letter-press does 
not give an official record and can seldom be used to ad- 
vantage. When bringing letters and endorsements to 
the surgeon for signature, it is well to also present the 
Record-book that he may verify and sign the retained 
copy at the same time, and the books are always ready 
for an inspector. Careful comparison will insure that 
all retained copies correspond exactly with the papers 
forwarded. This little extra work will often save mis- 
understanding, which ever breeds voluminous corre- 
spondence. If reports are returned for correction, a spe- 
cial list of such errors will be a useful supplement to the 
files of orders and circulars, and a safeguard against 
stumbling twice on the same stone. A growing list will 
warn the steward of a flaw in his habits. 
The mail brings also general orders, circulars, letters 
of instruction, decisions, etc. These are compared with 
Army Regulations, the Epitome of Orders and Decisions, 
the Handbook of the Hospital Corps, or the Drill-book, 
whichever may be affected, and marginal references 
made to the new modification, giving the number, date, 
and source of order. An R for revoked, or an M for 
modified, will often save the necessity for searching the 
files. 
First-Sergeant'8 Call will now summon the steward to 
the last of his morning duties. He goes himself to the 
Adjutant's Office and obtains with the Morning Reports 
a copy of all orders and circulars affecting the Medical 
Department for entry in the Order-book. The strength 
of the command is to be entered in the Morning Report 
of Sick, by the sergeant-major. The causes of any 
changes in the command will be ascertained, as they are 
required to furnish explanatory remarks. 
Dinner is now ready to be served. The steward will 
look through the dining-room, kitchen, and wards, with 
an eye for defects. He will ask the seriously ill if there 
is anything else that they would relish ; such little atten- 
tions are highly appreciated by invalids and make the 
days of confinement seem shorter and less irksome. The 
attendants, also, are cheered by his constant supervision ; 
that his critical eye approves, is sufficient reward for 
what would otherwise be deemed thankless drudgery. 
We have thus far considered duties that come every 
day with the certainty of each succeeding sun ; others 
come periodically, at various intervals, and will suffi- 
ciently occupy the steward's afternoons. 
Rations are usually drawn on the 10th, 20th, and the 
last day of each month. At surgeon's call a Ration Re- 
turn, prepared as far as practicable the preceding even- 
ing, is completed. The columns for number of men 
and number of rations are filled in ; the spaces for 
quantity of each component are left blank. It is speci- 
fied for whom the rations are drawn : for so many sick 
in hospital, so many privates of the Hospital Corps ; 
when a return is made for individuals, they are specified 
459 Hospital Steward. 
Hospital Steward. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
by name and rank. Entered in the column for remarks 
is a tabular statement of balances due to, or from, each 
company. If the resultant balance is in favor of, or 
against, the hospital, the amount is added or subtracted 
from number of rations. The word Add (or Deduct) 
will render the matter sufficiently intelligible. 
This settlement with the companies is a matter for fre- 
quent dispute ; and the steward will save himself much 
annoyance if he is careful to be always right. To verify 
the work, find the sum total of the sick in hospital for 
all the days covered by the previous return, as shown by 
the Morning Report ; to this amount, add one ration for 
each man admitted to hospital after surgeon's call, and 
before dinner, during that period. To this amount add 
the present balance due companies, or deduct the present 
balance due hospital ; and the result should equal the 
product of the number of men drawn for on the last re- 
turn, by the number of days. When men are admitted 
after dinner, it is better to lose a supper and breakfast 
than to dispute about fractional trifles ; but when a man 
is fed an entire day, the ration belongs to the hospital and 
must be insisted upon. This may seem a trifle, too ; but 
economy in trifles is the secret of successful hospital fund 
management. A ration so lost but once a week will in a 
year amount to the subsistence of a man for fifty-two 
days. Further, if the steward is found careless in this 
matter, first sergeants may soon find valid excuses for 
having sick men reach the hospital too late for surgeon's 
call, to the inconvenience of the medical officer and de- 
cided loss to the fund. Keep a separate memorandum 
of these cases, as an account of them does not appear on 
your Morning Report. Table II. is a convenient form for 
this : the first column is a list of all organizations with 
which accounts are kept ; the second column showshow 
many rations are drawn for men of each at the com- 
mencement of the period ; a column for each day of the 
period shows how many men of each are fed. These 
numbers should be entered every evening, and, when a 
new return is made, the numbers in hospital that morn- 
ing are entered and balances computed. 
Table III. shows the dates included in a return and the 
total number of rations. The first column is a list of 
the several components of the ration ; the second shows 
the number of each to which the hospital is entitled ; the 
third is the number left in the subsistence department, to 
be paid for in cash at the end of the month ; the fourth 
column shows the number of rations .of each component 
that you desire to draw out ; the fifth, and last, is the 
cook's column, and tells him the exact quantity of each 
article that he is to receive. He takes this paper with 
him when he goes for the rations, and there can be no er- 
rors of computation. 
Table IV. is a convenient slip to have on your desk 
when you make the computations in Table III. It it 
well to compute quantities by two methods, as a check to 
possible errors ; or to verify by reversing the process and 
reducing the determined quantities back to number of ra- 
tions. 
(SUPPLEMENT.) 
Table III. 
Rations drawn, May 1 to 10, 1896. inclusive. Number 140. 
Components. 
Rations. 
Saved. 
Drawn. 
Bulk drawn. 
Salt pork .... 
20 
4 
16 
12 lbs. 
Bacon 
24 
8 
16 
12 lbs. 
Beef, fresh 
Soft bread 
98 
120 
14 
84 
120 
105 lbs. 
Flour 
20 
20 
15 lbs.* 
Beans 
C>0 
60 
9 lbs. 
Rice 
44 
14 
30 
3 lbs. 
Hominy 
20 
20 
2 lbs. 
Coffee, green 
140 
40 
100 
10 lbs. 
Sugar 
140 
140 
21 lbs. 
Soap 
140 
is 
125 
5 lbs. 
Salt 
140 
15 
125 
5 lbs. 
Pepper 
140 
40 
100 
X lb. 
Vinegar 
140 
15 
125 
IX gal. 
Potatoes 
112 
112 
112 lbs. 
Onions 
28 
28 
28 lbs. 
* Two ounces of flour is drawn for each ration of soft bread. 
Table IV. 
Components. 
Rations to bulk. 
Bulk to rations. 
Quantity, 
100 rations. 
Salt pork 
Deduct X pounds .. 
Add 3^ 
75 lbs. 
Bacon 
Deduct X 
Add 3i 
75 lbs. 
Canned beef ... 
Deduct X 
Add 3^ 
Fresh beef 
Add % 
Deduct ]/B 
125 lbs. 
Salt beef 
Multiply by 11 and 
divide by 8. 
Multiply by 8 and di- 
vide by 11. 
1373^ lbs. 
Flour 
Add V 
Deduct J/y 
112X lbs. 
112X lbs. 
Soit bread .... 
Add 
Deduct '/a ... 
Hard bread.... 
Number of rations is 
number lbs. 
Number of lbs. is 
number of rations. 
100 lbs. 
Corn-meal 
Add 
Deduct >/6 
125 lbs. 
Beans 
,dd % and divide 
by 10. 
Multiply by 10 and 
deduct 3i. 
Multiply by 10 and 
deduct 3i- 
15 lbs. 
Peas 
Add 3^ and divide 
bv 10. 
15 lbs. 
Rice 
Divide by 10 
Multiply by 10 
10 lbs 
Hominy 
Coffee, green... 
Coffee, roasted. 
Divide by 10 
Divide by 10.... 
Multiply bv 10 
10 lbs. 
Multiply by 10 
10 lbs. 
Multiply by 8 and di- 
vide by 100. 
Annex (K) and divide 
bv 8. 
8 lbs. 
Tea 
Multiply by 2 and di- 
vide by i00. 
Annex 00 and divide 
by 2. 
2 lbs. 
Sugai- 
Add % and divide 
by 10. 
Multiply' by 10 and 
deduct 34. 
15 lbs. 
Vinegar 
Divide by 100. gal- 
lons. 
Multiply by 100 
1 gal. 
Soap 
Multiply by 4 and di- 
vide by 100. 
Annex 00 and divide 
by- 4. 
4 lbs. 
Salt 
Multiply by 4 and di 
vide bv 100. 
Annex 00 and divide 
by 4. 
4 lbs. 
Pepper 
Divide by 400 
Multiply bv 400 
K lb. 
Potatoes 
The same number... 
The same number... 
100 lbs. 
Onions 
The same number... 
The same number... 
100 lbs. 
Candles 
Add 3^ and divide 
by 100. 
Multiply by 100 and 
deduct 34. 
lb. 
Yeast powder.. 
Multiply by 4 and di- 
vide by 100. 
Multiply by 100 and 
divide by 4. 
4 lbs. 
Ration of U. S. Soldier. 
Decimal Rule.-Rations to bulk : Multiply by quantity in one hundred 
rations and point off two decimal places. Bulk to rations: Annex two 
ciphers and divide by quantity in one hundred rations. Reduce common 
fractions to decimals and annex additional ciphers to dividend for each 
decimal place in divisor. 
Table II. 
Ration Memoranda. 
Patients fed, May 1 to 10, 1896, inclusive. 
The Quantities tobe Saved vary with the character of the 
cases under treatment, and can only be determined by 
judgment and experience. A number of cases on low 
diet, and severe febrile cases subsisting chiefly on hospi- 
tal stores, will allow a saving of some rations of meat and 
flour. The allowance of sugar is always required for 
use. Beans, being a nitrogenous food and supplement- 
ing the meat ration, for use are preferable to rice-a 
pure starch ; but, as the money value is greater, it is 
better to save rice than beans. You will draw enough 
rice to give variety and supply convalescents from severe 
illness. Generally, one third of the coffee may be ad- 
vantageously saved, and the money value invested in 
other luxuries. Tea can seldom be drawn or saved pro- 
fitably. The quantities drawn should be, if possible, an 
even measure or weight, and all fractions computed in 
the savings ; when the commissary-sergeant guesses at a 
fractional measure or weight, the hospital is sure to 
lose. 
Organization. 
Drawn. 
1. 
2. 
3. 
4- 
5. 
6. 
7. 
8. 
9. 
10. 
Due 
Cos. 
Due 
Hosp. 
Band, 9th Cav 
19 
1 
1 
1 
1 
.. 
6 
Tr. A, 9th Cav.... 
40 
3 
4 
2 
5 
4 
3 
2 
4 
3 
10 
Tr. C, 9th Cav. ... 
20 
1 
3 
4 
5 
5 
4 
3 
3 
2 
10 
Bat. A. 5th Art.... 
1 
1 
1 
2 
2 
1 
1 
1 
1 
11 
Co. 1), 8th Inf 
io 
2 
2 
2 
2 
1 
1 
1 
1 
2 
2 
6 
Co. G. 8th Inf 
20 
3 
3 
4 
5 
4 
1 
1 
1 
1 
2 
5 
Ord. Sergt 
10 
1 
1 
1 
1 
6 
Ind. Scouts... 
10 
1 
1 
1 
1 
1 
5 
Casuals 
20 
2 
2 
1 
1 
1 
11* 
Totals 
.. 
38 
32 
Due U. S. for two men three days + 
6 
Deduct from next return 
12 
44 
44 
* Due U. S., one transferred, one discharged. + Field rations issued. 
460 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Hospital Steward. 
Hospital Steward. 
Where the fund is small, enough must be saved on 
each return to cover all purchases that it may be desira- 
ble to make during the ten days, to avoid indebtedness ; 
otherwise, it is more convenient to draw all but frac- 
tional quantities on the first two returns of the month 
and make up the savings on the last. There should be 
a balance left over in the kitchen ; if the cook thinks his 
quantities are for an exact ten days, he will not estimate 
the amounts required for each day, but will use one- 
tenth of the whole-with consequent waste. 
Purchases from the Hospital Fund, under the super- 
vision of the post-surgeon, will always be the steward's 
especial province-a duty that he can never delegate to 
an assistant. This is a subject of very complex bearings, 
about which a volume might be written. To expend the 
money received for unconsumed rations would be simple 
enough ; to do so judiciously, to the best advantage, 
will deserve his life-long study and prove a subject about 
which he can learn something until the last day of his 
service. He must constantly consider the nutritive, the 
economic, and the commercial values of the various ar- 
ticles of diet, the habits and tastes of the men, the skill 
of the cook in the various methods of preparation, and 
the class of diseases under his charge. 
The aim of any system of dietary is to supply in due 
proportion all the elements required by the human body 
under the conditions in which it is placed. The bulk 
consumed will be such as to secure a sufficiency of pro- 
portionately deficient elements. The sense of satiety 
comes with such a distention of the stomach as expe- 
rience with the accustomed diet has shown to be neces- 
sary for that purpose. The surest and most economical 
method of securing all elements in due proportion is to 
give variety to the daily fare. The cook who provides 
but one dish for each meal will prove expensive and un- 
satisfactory. The Esquimau consumes an astonishing 
amount of blubber, not so much because the climate re- 
quires a large proportion of fat-of which he consumes 
a great excess-as because such a quantity is necessary 
to secure a sufficiency of elements proportionately defi- 
cient in such a diet. This lack of variety also explains 
the voracity of the American Indian. On our Mexican 
border, where the costume favors such observations, the 
protuberant abdomens of the little Mexicans is a subject 
for frequent remark ; to a physiologist this tells a tale of 
a long-continued monotonous diet of jerked beef and 
tortillas. 
The farmer's boy reared on a diet of salted meats, 
robbed of many of their nutritive elements by the brine, 
when he enters the army, astonishes by his gluttony the 
old soldiers accustomed to a diet of fresh meat, and 
grumbles at the insufficiency of the soldier's ration. It 
is well to give such recruits a proper sense of fulness by 
a liberal supply of cheap and bulky articles of low nutri- 
tive value, as potatoes, cabbage, fruit, etc. To freely 
supply such men with a concentrated diet is to make 
them ill. The excessive percentage of sickness among 
recruits is largely due to cloying the system with an ex- 
cess of nutritive elements ; and confinement to bed on 
light diet is curative of many ills. With such cases it is 
important to know that additional food is not smuggled 
into the ward byi njudicious friends. In diet as in other 
things, a few months will convert the recruit into a sol- 
dier. A captain told me of a man whose appetite ex- 
cited general remark. A non-commissioned officer was 
detailed to observe and record the amounts consumed, 
with a view to making application for the man's dis- 
charge from the service. He ate forty ounces of bread 
daily, and other things in proportion, for a fortnight ; 
then his appetite rapidly diminished until he ate no more 
than other men. The captain thought that the man 
discovered that he was being watched, or that a sense of 
incongruity aroused his self-denial; but a more probable 
explanation is, that his system became cloyed by excess, 
and that his stomach finally adjusted itself to the unac- 
customed richness of a soldier's fare. 
Purchases should be made with a view to present vari- 
ety, and to effecting a saving of some component of the 
ration from which future purchases can be made. 
(SUPPLEMENT 
Fresh Pork, at the contract price of beef, will give 
pleasing variety and prove an economy during the cold 
season, when it can be kept. The cook will render the 
lard and save all unconsumed grease for culinary use, so 
saving an otherwise necessary purchase from the com- 
missary. 
Turkeys, Chickens, and Oysters, bought for invalids or 
holiday dinners, often prove surprisingly economical in- 
vestments. Much depends upon the market price, but 
the small percentage of bone, as compared with beef, 
must also be considered. 
Kyys have a high nutritive value, but lack the bulk re- 
quired to give a sense of satiety. Served in unlimited 
quantity, they seldom prove an economy. On toast, or 
in cake or custard, an egg will be highly relished, give 
pleasing variety, and allow of a certain saving of meat. 
But bulky food must be served at the same meal. 
Milk is an ideal food, containing all the elements neces- 
sary to maintain life. An animal food, it will take the 
place of a part of the meat ration. When supplied freely 
it should be served with bread, oat- or corn-meal mush, 
or other coarse diluent, as its undigested residue is so 
small that troublesome constipation will result from long- 
continued use by itself. Except as a flavoring for coffee, 
occasional use in puddings and custards, and as special 
diet for invalids, the hospital fund will seldom jus- 
tify the purchase of milk. Aside from adulterations, its 
market price generally exceeds its nutritive and economic 
value ; the milkman must be paid for his life of drudg- 
ery, for the use of his horse, cart, and bell. Where 
there is sufficient fund to pay for her, a good cow is 
probably the best investment that can be made from the 
hospital fund. The attendant who does the outside po- 
licing will not feel the additional work ; the kitchen 
waste will supply a large part of her food ; and an un- 
stinted supply of milk will reduce the demand for vari- 
ous components of the ration and cut off an otherwise 
necessary monthly milk bill of five or ten dollars. 
Where more than twenty men are fed, a second cow will 
be advantageous. 
Butter is a judicious investment if the price is not more 
than three or four times that of beef. Where fresh beef 
is the chief part of the meat ration consumed, there is 
apt to be a deficiency of animal fats, and butter is a use- 
ful and highly relished addition to the soldier's fare. 
There is less demand for it when fresh pork and gravies 
are served. It is not essential, and may be omitted when 
a reduction of expenditure is required. Care is neces- 
sary to secure it of constantly good quality. 
Cheese is a food whose nutritive value constantly ex- 
ceeds its market price. A concentrated food, its econo- 
mic value is impaired by its deficient bulk. If served in 
unlimited quantity, the excess taken to produce accus- 
tomed distention of the stomach will speedily induce di- 
gestive derangements ; but a daily allowance of two or 
three ounces for each man will prove a useful and grate- 
ful substitute for a part of the meat ration. 
Fresh, Fish, when attainable, make a useful variation 
in the bill of fare ; but money paid for transportation 
does not help to nourish the soldier. Salted fish are of 
but little use except to satisfy the longings of a petulant 
invalid. When fish are served at all, let it be on Fridays, 
to show a proper deference to the religious feeling of 
some of the men. 
Oatmeal, Cracked Wheat, and Hominy may often be ad- 
vantageously substituted for a part of the flour ration. 
Vigilance is required to insure that they are always 
thoroughly cooked. 
Sirup is always a cheap and useful luxury, relished by 
all. 
■ Fruits are a valuable addition to the dietary, where we 
pay for fruit only, and not for long transportation. At 
many stations, desiccated fruits and canned tomatoes are 
the only resource. The vegetable acids fill a useful role 
in the processes of assimilation ; and their only repre- 
sentative in the soldier's ration is vinegar, of which the 
allowance, though small, is rarely consumed. Beans 
and boiled pork are the only components of the ration 
that are rendered more palatable by the addition of vine- 
461 Hospital Steward. 
Hospital Steward. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
gar ; hence, as incentives to an increased consumption of 
a vegetable acid, such products from the garden as 
pickled onions, cabbage, and tomatoes assume in the 
dietary an importance far in excess of their trifling nu- 
tritive elements. The commissary substitutes are be- 
yond our means, as we can ill afford to pay for glass, 
long transportation, and insurance to middlemen against 
breakage. Oranges, lemons, grapes, and the more ex- 
pensive canned fruits can be served only as special diet 
for invalids. 
Salt and Pepper, as condiments, require passing notice. 
Salt, being a constituent of every fluid and tissue of the 
body, except the dental enamel, is a very important 
nutritive element ; but it is naturally present in every 
article of food, and in drinking-water. Its culinary use 
to render food more palatable, is generally in excess of 
the requirements of the system ; and in such excess it 
must be considered as a condiment. The failing of 
nearly all cooks is to use these articles in excessive 
quantity. Salt and pepper must always be within reach, 
that each man may flavor his food to his taste ; and 
the cook should be instructed to limit his seasoning to a 
minimum requirement. We would not compel a horse 
to take more salt than he wants by mixing it with his 
oats ; and man is deserving of equal consideration. 
These are a few general landmarks given to guide 
the steward in hospital fund management. lie will add 
to and modify them as experience dictates. Curious 
fluctuations, beyond explanation, will be observed ; in 
some months there will be large savings ; in others, 
under apparently similar conditions, it will be difficult 
to avoid a deficiency. To provide for these refractory 
variations is an important function of a hospital fund. 
It is well to keep the expenditures well below the sav- 
ings, accumulating a few dollars each month, until there 
is a constant balance on hand proportionate to the size 
of the post. Thirty or forty dollars is enough at a sta- 
tion of one or two companies ; a hundred and fifty or 
two hundred is not too large an amount for a regimental 
post. Until there has been accumulated such a fund, 
there will be constant trouble " to make both ends meet," 
and the hospital mess will be of the plainest. With a suit- 
able reserve we can indulge in various luxuries ; a short- 
age of ten or fifteen dolFars in one month, which may 
readily be made up in the next, will be of little im- 
portance. Expenditure for games, reading matter, etc., 
will then be proper ; but, to give variety to the soldier's 
fare, is always the main object of a hospital fund. 
With constant attention the steward will improve his 
methods from year to year ; the ultimate possibilities 
of hospital fund management have never yet been at- 
tained. The steward of a lake steamer, whose table was 
laden with every luxury of the season, told me that the 
average daily cost to feed a passenger was nineteen cents. 
Near the end of the month every item of receipts 
and expenditures is entered in the record of the hos- 
pital fund, and in an exact copy to be sent away. A 
careful steward will compare the two, item by item, 
and go over the computations again to know that they 
are correct, before he presents them for the surgeon's 
signature. We cannot rely upon the commissary ser- 
geant's accuracy ; all are fallible, and he has much to do. 
Fuel, Mineral Oil, Forage, etc., are obtained by re- 
quisition, sent to the adjutant's office on the last day of 
each month. The authorized number of fires and lights 
are required for, care being taken to ask for enough ; 
the quartermaster takes up unconsumed balances ; but 
should a change of weather necessitate more fires than 
have been estimated for, he cannot supply the fuel. 
The supply of these things is liberal, and it is our duty 
to guard against waste or misappropriation. We can 
compute the aggregate capacity of all lamps in use, they 
are filled but once a day, and a lamp rarely fails for 
lack of oil, and oil must not be used for kindling fires. 
When the daily expenditure of oil approaches the total 
capacity of the lamps, it is time for increased vigilance. 
Man is largely a creature of circumstance, and it is well 
to let all feel that the steward's supervision extends over 
everything about the hospital. 
(SUPPLEMENT.) 
Where a large civilian population is unprovided with 
the means of obtaining fuel, the wood and coal bins will 
be subject to nocturnal visits. Gates will be left open, 
scattered coal will derange the policing, and in many 
other ways these visits are objectionable. All that can 
be done is to render access to the fuel as difficult as 
possible, with a hope that such visitors may go else- 
where, like electricity, choosing the course of least resist- 
ance. 
The Monthly Report of Sick and Wounded is a record of 
completed cases, arranged to accord with the hospital 
numbers. As each case is returned to duty, or other- 
wise disposed of, its record in the register is completed, 
but the monthly report cannot be begun before the encl 
of the month, unless all back numbers are complete. 
There is no trouble with cases admitted during the 
month, but without great care, some of the cases scat- 
tered through the records of preceding months will be 
skipped, ami the sequence of the hospital numbers will 
be broken. To avoid this, at the end of each month 
prepare a memorandum slip of all remaining cases ; 
verify this with the numerical summary, and check off 
each number as the cases are completed. When all are 
checked off, the monthly report can be begun, and the 
record be brought down to the oldest remaining case, 
which will sometimes greatly reduce the work at the end 
of the month. 
Changes in the command will be noted, and the re- 
quired data concerning births, marriages, and deaths, be 
obtained as they occur. A careful record of the data 
given will relieve the steward from responsibility for 
future trouble about personal identification, legitimacy, 
and other points that may be raised by the Bureau of 
Pensions. 
Muster- and Pay-rolls have sufficiently explicit printed 
directions. As is true of other papers, accuracy, legi- 
bility, and completeness are qualities which are essential 
to them. They cannot be prepared long beforehand, as 
changes may occur at the last moment. At the end of 
each alternate month, when no muster-roll is sent to the 
adjutant-general, a report of strength and changes in the 
command must be forwarded. 
The Report of Examination of Recruits can be kept up 
with the record, of which it is an exact copy, and need 
not consume time at the end of the month. That a 
recruit is not " accepted " when he has passed the medi- 
cal examination, but must be actually sworn into the 
service, is to be remembered. 
The Report of Personnel, the Sanitary Report, and the 
Personal Reports of Medical Officers, complete the list of 
monthly papers. 
Returns of Ordnance Property, of Quartermaster's Stores, 
and of Clothing and Equipage are made quarterly. In 
military departments where an extra copy is required by 
department orders, a memorandum of such orders should 
be found in the hospital steward's digest of current or- 
ders and decisions. 
The Annual Return of Medical and Hospital Property 
is made at the close of each calendar year, and whenever 
a medical officer is relieved from responsibility. When 
this return has been examined and found correct in the 
office of the Surgeon-General, notice is sent to the officer 
interested. The receipt of this notification marks the 
time to begin one copy of a new Return. The quan- 
tities " on hand to be accounted for " can now be entered 
on the first line. Should the receipt of new articles dur- 
ing the preceding year have deranged the alphabetical 
arrangement-or classification-now is the time to make 
adjustment. Blank columns are left after each class for 
such new articles as may be received during the year. 
When invoices are received the amounts are entered at 
once in the proper columns ; the same is done under 
expenditures for property sent away, inspected and con- 
demned, or otherwise disposed of. We shall thus have at 
hand a complete statement of accountability, and be ready 
at all times to prepare correct invoices. Should a change 
of station or other cause necessitate a transfer of property 
accountability, an intelligent inventory, general or par- 
tial, can also be taken with accurate knowledge of what 
462 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Hospital Steward. 
Hospital Steward. 
(SUPPLEMENT.) 
ought to be found. That an article will be speedily 
missed, is a safeguard against loss. 
Care of Property.-Upon taking charge of a hospi- 
tal the steward's first duty is to ascertain what there is in 
it to be accounted for, and the location and condition of 
each article. Before beginning his inventory he must 
remember that there are eight classes of property to be 
considered, and he should obtain from his predecessor 
the retained returns and subsequent invoices, showing 
what must be found. 
1st. The post quartermaster issues stoves, pipe, lamps, 
bunks, and many other articles upon a memorandum 
receipt, of which the steward should possess a copy. 
The steward must go over this property carefully, that 
he may recognize the various articles and not confuse 
them with property of some other class-so counting the 
same article twice. For example, the galvanized iron 
bucket is stamped U. S., and a similar bucket, stamped 
M. D., is carried on the return of medical and hospital 
property. If we find a surplus of the one, we are likely 
to find the others deficient ; used for kitchen waste, 
fatigue parties exchange them, and the shortage is of 
medical and hospital buckets. Once wrong, it is very 
difficult to straighten the matter. 
2d. There is the return of quartermaster's stores- 
ambulances, harness, water-kegs, and other equipments, 
which it is very important to see in their proper places. 
3d. There is a return of clothing and equipage, of 
which all articles of bedding should be found, separate 
and distinct from similar articles of medical and hospital 
property. 
4th. The return of ordnance property. 
5th. Certain books may be carried on the muster-rolls 
and also on the return of medical and hospital property, 
so that the steward must find duplicate copies. 
6th. The return of durable property purchased with 
the hospital fund. 
7th. The annual return of medical and hospital prop- 
erty. 
8th. The return of record books. Of these the 
older ones have become ancient history and are liable to 
be stored in out-of-the-way places ; the assistance of his 
predecessor may be required to find them, and he may 
save himself hours of fruitless search if he finds them 
now. 
In taking the inventory it must be seen that every 
article is on hand ; and any excess of articles not expend- 
able carefully noted with the amount. Such excess is 
always a subject for suspicion, and may prove as trouble- 
some as a shortage ; it implies a blunder somewhere 
whose shade may arise again quite unexpectedly. An 
officer, in taking an inventory, found a surplus of several 
sets of tent-poles. Being a careful man, he took them 
upon his next return, "from source unknown." Sev- 
eral years after, he received official notice that a lieu- 
tenant claimed to have issued him this number of tents 
and poles, and, through error, to have omitted the poles 
from his invoices. The officer invited attention to his 
return for such a quarter of such a year on which these 
poles had been taken up and duly accounted for. Had 
he neglected this unaccountable surplus, the poles would 
have been worn out and thrown away, and he would now 
have found himself accountable for property that he no 
longer possessed. 
It is the duty of the steward to know, at all times, 
where every article is to be found. To do this his 
memory must be aided by a systematic arrangement. Of 
the articles in actual use, lists must be made for each 
division of the hospital-office, library, dispensary, wards, 
kitchen, and dining-room. The attendant in charge of 
each must be furnished with a duplicate list, and warned 
that he must report promptly any missing articles, with 
the circumstances of their disappearance, to avoid re- 
sponsibility for the loss. 
Each soldier is charged with his accoutrements, which 
are verified at inspections and must be turned in before 
he receives his discharge. 
Of property not in use, each class should be stored by 
itself ; and the articles, as far as practicable, arranged in 
the order in which they are borne on the returns. This 
will greatly facilitate the taking of inventories, and pre- 
vent loss of time in searching for any article when 
wanted. 
There will be noted in a memorandum-book the trans- 
fer of articles from one place to another. From this can 
be determined the rate of expenditure of medicines and 
stores from the dispensary and kitchen ; and can be 
traced unreturned appliances used in the treatment of 
cases outside the hospital. 
Attendants can be held responsible for the condition of 
articles in actual use under their charge ; but the prop- 
erty kept in the store-rooms requires the steward's con- 
stant and particular attention. Blankets and other 
woollen articles must be secured from moths by tarred 
paper, marine lint, or other device. Hospital stores 
must be guarded from the inroads of mice. Wooden 
articles, buckets, wash-tubs, etc., will become rickety in 
dry store-rooms and require to have hoops tightened, or 
to be soaked in water. Water may be left in the kegs 
during the summer, but they must be carefully emptied 
before there is danger from frost. If harness is hung in 
a basement near steam-pipes, the leather will become 
hard and lose its pliability ; if hung in the same basement 
without artificial heat, dampness may provoke the growth 
of mould. If the pack-saddle is not secured in tarred pa- 
per, the woollen pad must be protected from moths by fre- 
quent beating and exposure to air and sunlight. Garden 
tools must be carefully housed, and, after their season of 
use has passed, cleaned, oiled, and secured in a suit- 
able store-room. The empty barrels will be needed 
again for sauer-kraut and pickles, and must not be al- 
lowed to fall down for lack of attention. In careful 
housekeeping eternal vigilance is a useful watchword. 
The Ward is, to the hospital, the vital centre, the 
source of being ; all other parts are but accessories to its 
welfare ; and we may well study the conditions that pro- 
mote its usefulness. 
Upon the occurrence of sickness and death the savage 
moves his camp. This blind following of superstitious 
ignorance, or traditional experience, approximates in re- 
sults the most advanced sanitary philosophy. But in 
the ward there can be no change of camp ; suppurating 
wounds, gangrenous frost-bites, foul ulcers, erysipelas, 
consumption, pneumonia, infectious fevers, etc., form a 
continuous pathological chain of which some links are 
ever present; with modern knowledge of disease-produc- 
ing germs, the illustrated annals of a ward would appal 
the stoutest-hearted patient, and attendants might indeed 
shrink from the performance of their duties. On the 
contrary, experience teaches that there is less danger in 
the ward of an army hospital than in the ordinary walks 
of life. A man with small-pox lands on a wharf and 
proceeds up a street, stopping here for drink, there for 
food, and again for rest; in a fortnight, a trail of yellow 
flags will mark his line of march, and those who came in 
contact with him on the street will furnish other victims. 
A man with high fever is admitted to a ward full of pa- 
tients. On the third or fourth day a small-pox eruption 
appears, and he is then carried, with his bed and belong- 
ings, to an isolation ward or tent. Of the patients and 
attendants in that ward the probability is that not one 
will have small-pox. If one man does contract the dis- 
ease, it will be the attendant who came in contact with 
the patient upon admission and handled his clothes. The 
same is true of other infectious diseases. When typhoid 
fever appears in a house, several of the inmates contract 
the disease ; in a ward, the man with a broken leg is in no 
danger from the case of typhoid fever in an adjacent bed. 
Rarely will a patient contract another disease while con- 
fined to a bed in the ward. Convalescents, who are per- 
mitted to walk about, are in greater danger from the 
other inmates, but even they are more likely to have con- 
tracted the new complaint during surreptitious absence. 
When apparent exceptions occur, careful inquiry will 
generally elicit the fact that the germ of the second dis- 
ease was received before admission ; a man with two dis- 
eases may only complain of the one that causes him the 
greater inconvenience. 
463 Hospital Steward. 
Hospital Steward. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
We must not depend upon fortunate accidents; we 
must study the conditions that give the ward its freedom 
from contagion-its salubrity-that we may not interrupt 
them by injudicious interference ; that we may approxi- 
mate them in other buildings, used temporarily as hospi- 
tals ; that we may maintain the efficiency of the hospital 
corps by guarding its members, as far as possible, from 
contagion. 
A hospital ward is a parallelogram of floor space 25 feet 
wide, whose length is determined by the number of beds 
that it is to contain. The beds are placed with the 
heads to the lateral walls. There is a window in each 
alternate interval between them. Commencing in a cor- 
ner, we have a bed, a window, a bed, a space. Allow- 
ing 4 feet for each bed and each interval, 16 feet is the 
unit of length providing for two beds on a side. This 
unit may be repeated as often as desired ; generally, 
for economy and convenience of administration, it is re- 
peated three times, and, as the unit terminates with a 
space, an additional 4 feet is added for a seventh bed, 
and the last space provided with a window on one side, 
and, on the other, a door opening into the lavatory. 
This gives for each bed nearly 93 feet of floor-space and 
more than 1,000 cubic feet of air-space, with a ceiling 12 
feet from the floor. With ordinary percentages of dis- 
ease and accident this is satisfactory ; in epidemics of 
infectious disease, without extreme care of the ventila- 
tion, such a ward will be overcrowded. Under all cir- 
cumstances the corner beds are undesirable and should 
be assigned to sprains, bruises, and other slight ailments. 
The ventilation of a ward should be entirely indepen- 
dent of doors and windows. In the centre of the ceil- 
ing an open shaft of 2| feet in width, and 15 feet in 
length, should extend to a ridge ventilator. Twelve feet 
from each end of the ward, an opening of one square foot 
should be cut in the centre line of the floor, to communi- 
cate with an air-shaft extending across the building and 
opening at both ends outside. These shafts should have 
a sectional area of 16 by 16 inches, as the ends must be 
somewhat obstructed by wire netting to exclude small 
animals that might hide in the shaft to await death. 
Care must be exercised that the outer openings be not ob- 
structed by snow or rubbish, and that the ground in their 
vicinity be kept scrupulously clean. No slop-barrels, 
cesspools, or sewer openings can be tolerated in their 
neighborhood. In malarial regions the areas near fresh- 
air inlets should be covered by an unbroken turf. Pro- 
vision may be made for closing the windward end of 
these air-shafts, as rapidly moving air carries dust, bad 
odors, filth, and morbific germs for great distances ; and 
it is safer and more pleasant to get the fresh air from the 
lee side of the building. This arrangement for closing 
the ends of the air-shaft is preferable to a closing flue in 
the floor opening which cuts off the supply of fresh air 
altogether. If the ward be warmed by stoves, they will 
be placed ovei' the fresh-air inlets, and the pipes be 
carried out through the centre of the ventilating shaft. 
One stove cannot be so located as to satisfactorily warm 
a ward 52 feet long ; the required heat will render adja- 
cent beds untenable, while remote parts of the room are 
still cold ; further, only the radiant heat can be utilized 
from a stove placed in the centre of the room, as air 
warmed by contact will pass directly up the ventilating 
shaft. The stoves and pipe should present a heating sur- 
face sufficient to warm the room in all seasons without 
the fires being forced. No approach to redness should 
ever be tolerated in a ward stove. 
We will now consider the practical isolation of each 
patient in the ward. Disease germs may be communi- 
cated by contact, by food or drink contaminated by uten- 
sils used in common, and by floating particles of dust or 
moisture in the atmosphere drawn into the air-passages 
by inspiration. 
Direct contact between patients need never occur. An 
attendant's duties expose him to some danger which can 
be minimized by trifling precautions. The clothing of 
each new patient should be removed from the ware! at 
once, aired and dried if necessary, and then placed in 
a tight locker. If this is done in all cases, the unrecog- 
(SUPPLEMENT.) 
nized infective case will seldom cause trouble. Each 
patient has his own bedside table, medicine glass, spoon, 
etc.; his food is brought to him separately, and the soiled 
dishes are disinfected by boiling water in the kitchen. 
This obviates sources of infection more common than is 
generally supposed. I would not eat or drink in a house 
containing small-pox or diphtheria, and yet 1 attend such 
cases without anxiety. A cup of tea flavored with kero- 
sene, and other similar observations, lead me to doubt 
the effective cleanliness of apparently well - regulated 
households, and suggest how germs may travel beyond 
the hangings saturated with antiseptics. 
A drunken man besmears the sheets, or a patient uses 
a close stool or bed-pan in the ward without inconven- 
iencing his neighbors. There is no need for the burnt 
sugar whose odor is so unpleasantly suggestive of poor 
ventilation in the sick-room of many a mansion. The 
reason is, that the heads of the patients are next the out- 
side walls, and that all air-currents are toward the centre 
of the room, and upward toward the ventilating shaft. 
The man with the broken leg will wish to smoke in bed. 
Watch the course of the curling wreaths as they disap- 
pear ; by them the air-currents are rendered visible. No 
stagnant strata lie above his head ; no smoke crosses the 
interval to the next bed until it has risen high above it. 
If some smoke drifts against a cold window-pane, it 
grows heavy and falls directly to the floor-showing why 
it is not well to place a patient's head opposite a window, 
for all foul air takes the same course. This also illus- 
trates the advantages in winter of double sash with a 
dead-air space between, and teaches us to provide for 
ventilation elsewhere. You will also see why longtitudi- 
nal draughts are injurious, deranging the normal air-cur- 
rents and carrying foul air across the beds. In summer, 
open opposite windows that the stream of air may pass 
between the beds and tend to draw impure air from the 
beds toward its centre. 
A ray of sunlight through a shutter illuminates float- 
ing particles in the air ; these are the omnipresent dust. 
The sailor in mid-ocean sweeps his deck and wonders 
whence it comes. There is danger in it-morbific germs 
may ride upon those little particles. We cannot exclude it 
from the ward ; we can only change our dust as we do our 
air, by ventilation-judging that from the outside world 
to be less dangerous. The humble piece of soap, in the 
society of the rose, partook somewhat of its perfume ; so 
dust, allowed a long sojourn in award, will acquire mor- 
bific qualities. Daily sweeping and dusting is a wise 
sanitary precaution. The direction of normal air-cur- 
rents will be the guide for the sweeper-everything to- 
ward the centre is an invariable rule. The proceeds 
should be gathered on a dust-pan and consigned to the 
fire. To attempt to sweep through an open doorway, 
with the possibility that a gust of wind may scatter the 
dust over the beds, should be a punishable offence. 
There being but little travel through a ward, and all ac- 
cidental litter being removed at once, but little dust will 
be raised at each sweeping ; but a half-hour later, every 
projecting shelf, window-sill, casing, and cornice, to- 
gether with the furniture of the room, must be gone over 
with a moist cloth. 
The bed-linen is changed as soon as soiled, and at the 
departure of each patient; if there be a suspicion of con- 
tagion, it should be soaked in an antiseptic solution and 
dried before being sent to the matron. In all infec- 
tious cases the mattress, pillows, and blankets must be 
thoroughly fumigated ; the surgeon will decide if destruc- 
tion be necessary. Whenever a bed is vacant, the bed- 
ding should be exposed to air and sunshine. This will 
avoid the necessity for a complete change of outfit 
periodically. At times of little sickness patients may 
be so consolidated as to leave a ward vacant, which can 
then be fumigated and put in perfect condition. If such 
a ward can be allowed to lie fallow for a few days, this 
will make a desirable break in its pathological chain. 
Surgical Operations bring important duties to the stew- 
ard. The surgeon will select his instruments and give 
directions for antiseptics and dressings for each case; 
but the steward should be familiar with the general prin- 
464 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Hospital Steward. 
Hospital Steward. 
ciples underlying aseptic surgery, for his ignorance or 
inattention may nullify the most consummate surgical 
skill. To take antiseptic gauze from its hermetically 
sealed package, unroll it on a dusty counter, cut it with 
rusty old shears hanging in the dispensary for general 
use, and turn it over to the unwashed hands of a nurse 
for consignment to the first bedside table that he conies 
to, is a combination of errors too frequently excelled. 
After every operation, however trivial, the instruments 
must be washed, dried, placed in a covered tray, and, 
after twenty-four hours, rubbed carefully with chamois 
leather ; then, and not till then, can they be safely re- 
turned to the cases. The seams of a leather pocket-case 
may retain the germs of erysipelas while the ward is re- 
floored, re-ceiled, and re-painted-in vain. 
The Dying and the Dead will also claim the steward's 
consideration. The greatest tact and judgment must be 
used with the dangerously ill. We must not destroy the 
last chance of recovery by depriving the patient of hope ; 
but the steward can lead him to think of the general un- 
certainty of life, and to confide to him the names and 
addresses of friends whom he would wish to have in- 
formed, should his case prove unfortunate. We must 
note his expressed wishes and parting messages carefully 
-the words may have a meaning for friends which we 
cannot understand. Should the patient ask to see a 
friend or a clergyman, a messenger must be provided 
promptly. These wishes may have an importance that 
you cannot appreciate. You cannot put yourself in his 
place, and the bitterness of helpless disappointment may 
be more cruel than his physical sufferings. There is a 
sharp distinction between the friends that the patient asks 
to see, and those friends who ask to see the patient ; the 
latter may well be referred to the surgeon in charge. 
Upon the occurrence of death, carefully, tenderly, 
reverently, but promptly, let the body be removed to the 
dead-room. The steward need not assume the solemn 
airs of a professional undertaker ; but, if he considers 
the grief, the hushed awe, possibly the terror, of the 
other patients, his procedure will be marked by due de- 
corum. The effects of the deceased will be collected 
and stored for safe delivery to his company commander. 
The post surgeon will be notified immediately, and a 
messenger sent to the first sergeant of the company to 
which the deceased belonged. The blank forms in the 
register of deaths and interments will be prepared for 
signature. There can be obtained through his first ser- 
geant such required data as are not already at hand. 
After such an examination of the body as the surgeon 
may desire to make, it will be prepared for burial. After 
such preparation an attendant will await the visits of all 
who may desire to view the remains. We cannot exclude 
the idly curious, for the ties of a common humanity ex- 
tend beyond our ken. We may not appreciate the im- 
portance of a parting caress, a kiss, a little prayer ; but 
we must respect these as some of the mysteries of life. 
Post-mortem Examinations.-The steward must 
know that all instruments are clean ; must provide a 
bottle of olive-oil, buckets, sponges, etc. ; must have the 
needles threaded beforehand, and see that their points 
are sharp. We cannot have the entire detachment pres- 
ent, but by rotation we can gradually disseminate some 
knowledge of human anatomy throughout the corps. 
Some of our men will turn faint and sick ; we will send 
such into the fresh air and encourage them to try again. 
It is a matter of education, and preparation here will ren- 
der them useful in operations on the living body. At the 
end of the examination, it will be the steward's duty to 
replace the various organs and close up the incisions. 
Let him aim at neatness and dexterity in the use of the 
needle, and accuracy and efficiency in the adjustment of 
parts. These accomplishments may be of use in repair- 
ing rents in living flesh. When all is done, clean all the 
instruments as carefully-more carefully than you do 
those after a surgical operation. There is something in 
the dead human body which causes a fatal poisoning, if, 
even in the smallest quantity, it is inoculated into that of 
the living. The slightest crack or abrasion of the skin 
may receive and absorb this fatal by-product of mortal- 
(SUPPLEMENT.) 
ity. Before beginning a post-mortem examination the 
hands are protected by saturating the pores of the skin 
with oil, which can be saponified and washed away at its 
close, bearing away with it all other foreign matter. All 
bodies are not equally dangerous ; those are more so in 
which the processes of putrefaction have begun. Ery- 
sipelas, gangrene, and other diseases in which putrefac- 
tive changes, in effusions or tissues, may begin before 
death, have long been known to furnish the most dan- 
gerous bodies. In a perfectly fresh cadaver there is lit- 
tle or no danger. Cannibals, with all their experience, 
seem to have remained ignorant of this peculiar quality 
in dead human bodies. The putrefying corpse of one 
enemy would have poisoned the arrows of a tribe, and 
yet, among the arrow poisons, this one seems to have 
been overlooked. Bearing in mind that this poison is a 
product of putrefaction, you will know that there is but 
little danger from a scratch received in an examination 
made soon after death ; but you will understand that if 
you leave in the indentations of a knife handle, in the 
joint of the blade, or in the eye of a needle, particles of 
human flesh or oil, to putrefy in the cases, those instru- 
ments will be very dangerous when used again. If you 
are careful to clean your instruments immediately after 
use, I believe that those frightful cases of blood-poison- 
ing will forever remain things that we read about but 
never see. Buckets, large sponges, in fact everything 
used in the post-mortem room must be carefully cleaned 
and put away for future use, care being taken to so 
plainly label them that neither you nor your successors 
may ever unwittingly use them for other purposes. 
The Hospital Steward's Assistants.-This article 
is written to little purpose if its perusal does not con- 
vince all of the importance of having capable, willing 
men to assist the steward in the hospital work. He must 
appreciate the advantages of thoroughly understanding 
the members of the hospital corps; of knowing their 
capabilities and their defects; and of seeking the best 
methods for their training and management. It is the 
poor workman who grumbles at his tools-the best of 
steel has flaws; with even poor tools much useful work 
is wrought by skilful hands. Inferior tools require a 
careful consideration of their defects, and more constant 
care to keep them in serviceable condition. The study 
of defects is not a pleasant occupation ; to render it an 
improving one, it must be pursued with a philosophic 
spirit. We unravel the intricacies of foul ulcers, of 
loathsome diseases, that we may the more intelligently 
apply remedial measures, and we find a sweetness in 
success to soften the harshness, to assuage the bitterness 
of our preliminary studies. 
Of twelve carefully chosen apostles, one betrayed his 
Master, one denied Him, and one converted " Doubting 
Thomas" into a proverb. With every precaution, we 
cannot hope to improve that percentage among the mem- 
bers of the hospital corps. The men must be young, 
must have served a year in a company, and must volun- 
tarily ask for transfer. Their pay is now greater, but 
their duties, if not so severe, are more continuous and 
irksome, their chances for advancement are but little 
better than they were in the line. To study the motive 
for this transfer is to gain an important insight into their 
character. A little more than a year ago the young man 
was dissatisfied with his prospects and surroundings in 
civil life ; seeking novelty, he enlisted ; after a year in 
the company he feels that his world still lacks in bright- 
ness ; fancies that the Vale of Perpetual Content is just 
over the next divide, and he is transferred to the hospital 
corps. It is not surprising that such men become rest- 
less and discontented. This longing for change will pur- 
sue them wherever they go. No other class of men in 
the army will furnish an equal percentage of applications 
-for change of station to go anywhere-for transfer back 
to the line-for discharge. To a student of humanity 
there is a pathos in these appeals. 
There is much in their duties to aggravate this spirit 
of unrest. In a detachment of eight men, two in the 
kitchen will begin their duties long before Reveille, and 
the preparation of three daily meals, with the necessary 
465 Hospital Steward. 
Hospital Steward. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
dish-washing and cleaning-up, will keep them engaged 
until Retreat; two [one for each] must be constantly 
present, day and night, in the wards ; one must attend to 
the office, dispensary, halls, and dormitory, and be ready 
to act as messenger if required ; one attends to the out- 
side police, keeps the ambulances and harness in order, 
milks the cow, and makes the garden. Six of our eight 
men are constantly employed ; week days and Sundays 
the hospital work goes on. Change our men about as we 
will, the tours of duty are long, the intervals of relaxa- 
tion, of freedom, are brief. Then this freedom is not 
absolute ; the steward must know at all times where the 
men can be found. Accidents and emergencies are our 
especial province ; and we must be prepared to give im- 
mediate assistance. 
There is another restraint more irksome and continu- 
ous. The hospital is a place of sickness and suffering ; 
patients must not be disturbed by noise. There can be 
no unseemly laughter, no merry jests, no rough and 
boisterous play, to smooth the sharp angles of life. No 
barrack-room ballad can originate or be repeated in the 
dormitory of an army hospital-the only day-room for 
the men off duty. The air of solemn decorum that 
hangs about the building is not conducive to cheerful 
gayety among the men. 
This picture is not drawn to discourage. If the shad- 
ows are tinted too deeply, it is to more certainly fix the 
attention ; if the obstacles are drawn in too rugged an 
outline, it is that the steward may so form his estimates 
as to surmount them the more certainly. The hospital 
corps is a still recent organization. Difficulties will con- 
tinue to be remedied by legislation and orders as the con- 
ditions are recognized, and the means of correction fixed 
upon. A discussion now of many of them would neces- 
sarily be ephemeral ; but certain general principles un- 
derlie all and will be true through all variations. These 
are worth careful consideration. 
First in importance is the fact that the poorest man in 
the detachment is better for our purposes than the most 
promising recruit that comes to the post. There is some- 
thing in that year of military discipline and training that 
improves the man ; we must continue the good work. If 
the man does not go forward, he will slide backward ; 
we must exact a continuance of those habits of order, of 
regularity, of prompt obedience. The polish of a shoe, 
the brightness of a button, have a direct bearing upon 
the welfare of the sick. Teach your men to be systematic 
-even in their vices; for regulation is a species of re- 
straint, a step in the right direction. The steward's ex- 
ample is worth more than his precept. If he walks in 
the straight path, his men will follow him by instinct 
and without complaint; if he makes them his accom- 
plices in trifling peccadilloes, he will lose a standing that 
he may never regain. Let the men be taught to regard 
regulations as they do the processes of Nature-which 
rains alike upon the just and the unjust. The rigid let- 
ter of the law does not abrogate the necessity for judg- 
ment and discretion. When a man returns from pass 
drunk and disorderly, consider that drunkenness, in it- 
self, is a failing and not a crime ; consider that the resto- 
ration of this man to the duties which others are now 
performing is our main object. Order him to his bed in 
the dormitory ; when he has slept off his inebriation, he 
will be as useful as ever. Do not waste words in argu- 
ment or reproof. If the man awakes in the guard-house, 
let him understand that this humiliation is not because of 
his drunkenness, but because he did not retain sufficient 
sense to comply with an order that was intended to shield 
him from trouble. Exclude all personality from this ex- 
ercise of your authority. Aim to do these things as im- 
passively as you wind the clock. In the maintenance of 
discipline, "In essentials, unity, in non-essentials, lib- 
erty, in all things charity," is a motto that we may well 
borrow from the Church. 
For privates of the hospital corps much can be done 
to lighten the labor, to lengthen the intervals for recrea- 
tion. The acting hospital steward has charge of the 
wards and does the dispensary work. After the morn- 
ing work is done, he has little to do except to be on hand 
to put up occasional prescriptions. He will try to while 
away this leisure time by reading, and possibly by smok- 
ing. If left to himself, this sedentary life will have one 
of two effects : he will grow dyspeptic, morose, and ir- 
ritable, or he will become apathetic and lazy. This loss 
of energy will be so gradual that the steward may not 
notice it until he is greatly annoyed by the man's inat- 
tention to details entrusted to him ; and he injudiciously 
administers a sharp reproof, which makes him worse ; 
he has spoiled the man, who is no longer a help, but an 
incubus. With an understanding of the causes, with 
foreknowledge of the certain results, all this is easily 
avoided. When the rush of the morning is over, we 
will encourage him to leave the hospital and seek open 
air diversion. A private can watch the dispensary and 
call the steward if a chance prescription comes in. 
Walking, picnics, hunting, and fishing will increase 
greatly the efficiency of our acting steward, and, in the 
end, reduce the steward's labors. 
When the public health is at its best, the sick may be 
consolidated into one ward ; for, with our small detach- 
ment, the liberation of one man is a large percentage of 
gain. We will try to reapportion the work so that all 
may experience the advantage. If our men know that 
we do our best to relieve them, they will continue their 
work more cheerfully. 
With the present allotment of force, the necessity of 
utilizing the labor of convalescents is recognized in gen- 
eral orders. Every man who is able to be out of bed 
can make up his own bed, keep his bedside table in or- 
der, and, possibly, contribute his share toward the gen- 
eral police of the ward. The man whose sprained ankle 
permits him to be out of bed can get to the kitchen to 
pare potatoes and do other sedentary work. The musi- 
cian whose sore lips will not permit him to blow his 
trumpet, is lit for any work about the hospital ; if the 
change of avocation does not please him, he will take 
better care of his lips in future. The inebriate, too ner- 
vous to handle a musket, will sleep the better for hand- 
ling a broom. With no critical cases in the ward, a ser- 
geant or corporal may be charged to maintain order, and 
the nurse given a few hours for open air amusement. 
This use of convalescents requires great discretion, 
and the surgeon's opinion must first be obtained in any 
case of possible doubt. You would not expose inflamed 
eyes to sunshine, wind, or dust ; nor subject an inflamed 
arm to exercise. A convalescent who refuses to work is 
liable to punishment by court-martial ; but there are 
many objections to such attempts to discipline men of 
other organizations ; it is generally better to presume 
that the man is not able to work, that an error has been 
committed in allowing him to leave his bed so soon. If 
he cannot work, it is clearly right that he should go back 
to bed. 
Men enjoy doing those things that they can do well. 
The steward will greatly promote the efficiency and con- 
tentment of his detachment by carefully instructing its 
members. Poets may be born, but cooks, nurses, gar- 
deners, and the like must be moulded by education to fit 
those positions. If we spend our time seeking men ex- 
actly suited to each place, we will grow weary compar- 
ing square pegs with round holes-for us, the brightness 
of the world will be dimmed by many disappointments. 
If the steward evinces an interest in the work, his men 
will contract enthusiasm by contagion. If he shows his 
nurse the neatness, beauty, and efficiency of the reverses 
in a roller-bandage, the ease and comfort from its equal 
pressure, and the smooth skin, free from welts, upon its 
removal, the man will gladly peruse all works on minor 
surgery that may be given him, and soon become a happy 
adept in various bandages-spica and many-tailed. 
Encourage your cook to experiment in new dishes, to 
accumulate a variety of recipes. Cook-books will soon 
be to him more charming than the latest works of fiction. 
While the plant is still in blossom, it is time to begin the 
discussion of the possibilities of a green tomato. From 
almanacs and cook-books he will gather a variety of re- 
cipes ; encourage him to try small quantities by several 
of the most promising, and seek a decision of the rela- 
466 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Hospital Steward. 
Hospital Steward. 
tive merits from the gourmands among the patients and 
in the corps. When your hospital piccalilli attains a 
local celebrity, and ladies call to consult about ingredi- 
ents and proportions, you will have a happy, contented, 
and useful cook. But something more must be obtained 
from him. Let him feel that passes and other favors de- 
pend upon the ability of his assistant to take his place, 
and we will soon have two adepts in kitchen mysteries. 
If there is a hospital garden, there will be need of a 
gardener. The professed professional who seeks admis- 
sion to the corps is of doubtful utility. He is in the army 
probably because he has failed in that vocation in civil 
life ; and he will fail again, at the expense of the hospi- 
tal. The old Greek was wise who charged a double fee 
to those disciples who had enjoyed the teaching of an- 
other master. The man raised on a farm is only a little 
better than the professional gardener. He left the farm 
in disgust ; and it will be difficult to inspire him with 
enthusiasm for the work. If at home he dropped the 
corn in a depression made with his heel, he will despise 
a dissertation upon the advantages of sunshine and air, 
attained by scattering the seed in a broad hill ; he will 
inwardly groan at the military tyranny which compels 
him to depart from the ways of his ancestors ; and, when 
our back is toward him, he will revert to his original 
methods. We will have a much finer garden if we select 
a city-bred boy who has never seen a garden rake. There 
are many reasons for this. At the start, more personal 
attention must be given him. Then the charm of novelty 
will cheer him in Ids work. The proper adjustment of a 
clevis that the plough may glide easily to a proper width 
and depth of furrow, will be triumphs of his inventive 
genius. He will not take it as a personal affront if you 
showT him that the wilted plant was simply hung by the 
neck, with roots dangling in space beneath. He will 
consider the success of the garden a victory for which he 
has reason to be proud. In times of planting and weed- 
ing, we will put convalescents in charge of the wards and 
turn out our whole force. The w'ork is better done 
promptly; and our gardener will not become disheart- 
ened by the slowness of his achievement. 
For variety, usefulness, and general charm, there is no 
study equal to the study of men. With these few hints 
to guide him at starting, may the steward pursue it with 
profit and delight. 
Reading.-Considering the multiplicity of his -duties, 
the steward may feel that he has no time for study ; but, 
if he is systematic in this as in all things, he will accom- 
plish more than the average man. When he considers 
that a half-hour of effective study every day is sufficient 
each year to learn a new' language or master a new sci- 
ence, he will know that economy in small things is a se- 
cret of success. Because his time is limited, he will value 
it more highly, will use it more discreetly. The variety 
of learning required by his calling will suggest the im- 
portance of a systematic assortment of facts. He will 
make two great classes : those that he must have always 
with him, and those that can be found promptly when 
needed. 
The first class must be acquired, thought over, re- 
viewed, until mentally digested and assimilated into his 
personality, forming so many atoms of that sum total 
which the world calls common-sense. If one of these 
facts is used with a consciousness of the book from 
which he learned it, he has burdened his memory with a 
useless reference ; he has not sufficiently mastered the 
thing itself. When we acquire a new fact, let us con- 
sider it as a many-sided crystal, each facet of which must 
exactly coincide with every other fact in our possession. 
We will revolve the thing in our mind, and test the ac- 
curacy of its various angles and planes. If there are ap- 
parent irregularities that we cannot adjust, we will bear 
the defect in mind and seek a better illumination by fur- 
ther reading. Let us arrange our facts neatly and com- 
pactly, and study the common lines that extend through 
all. We will estimate the relative importance of our va- 
rious items ; if we post our markers properly, all minor 
facts will dress into line without trouble. 
The study of facts of the second class is the art of mak- 
(SUPPLEMENT.) 
ing useful memoranda. The steward cannot become a 
walking encyclopaedia of useful knowledge. To burden 
his brain with useful formulae and cosmetic recipes would 
be the sinful waste of an organ provided for better pur- 
poses. It is well to keep an index of things sought, in 
which can be entered every subject we are called upon to 
investigate, with references to the place or places where 
the information has been found. When we find the tale 
told better elsewhere, we enter a new reference. A scrap- 
book for newspaper clippings, a note-book for things that 
cannot be kept in the library, will often prove useful; but 
will grow cumbrous, without references in an index. 
The newspaper, the record of current events, and light 
literature, the record of current human fancies, are use- 
ful relaxations from more serious study. They must be 
held as incidents, not objects, of life. We must look upon 
them as we look at the passing pageant, at the varying 
lights and shadows of the sunshine on the hills, as things 
to be looked at, admired, and forgotten. We take a Sun- 
day walk to gather flowers by the wayside ; there is no 
use in the flowers, but we are grateful for the ability to 
admire their beauties ; we are better for having done so. 
Intelligent attention to details, and a constant aspira- 
tion for improvement, have rescued surgery from the 
barbers and converted it into a science whose devotees 
stand among the first of mankind ; by similar means may 
be elevated and improved the position and standing of 
hospital stewards ; to point the way is the highest aim 
and best wish of the writer. 
II. In tiie Field. 
Detachments.-Small parties without a medical offi- 
cer are frequently sent out to guard wagon trains, to cut 
logs or fuel, for hunting, and for many other purposes ; 
sometimes under a commissioned officer, sometimes un- 
der a sergeant or corporal. Whoever is in charge of 
such parties must be prepared to administer to accidents 
and minor ills. The change in diet and other conditions 
is almost certain to cause either constipation or diarrhoea ; 
and the officer in charge must be sent forth, like the 
apostles of old, with full powers to bind and to loose. 
He must be prepared to check vomiting before the occur- 
rence of dangerous prostration, and to relieve a stomach 
of injurious contents. He must be able to allay pain, 
promptly and safely, and must give rest and protection 
to inflamed parts. There is no region where a change of 
conditions and habits may not reawaken the slumbering 
germs of malaria, and quinine must not be forgotten. 
Expectorant cough-lozenges will be also required for 
bronchial troubles. Rheumatic cases are generally 
sent back to the post, but salicylates and alkalies may 
sometimes prove useful, and a bottle of turpentine, or 
other liniment, for slight muscular soreness may well be 
added as an incentive to massage. Ready-made plasters 
of mustard or of belladonna frequently relieve local pain 
and give men a comforting sense of being cared for. 
Tincture of iodine is frequently useful, but is difficult to 
pack securely ; if possible it should be issued in a bottle 
with a glass stopper carefully tied in with a string. A 
rag on the end of a stick for a swab, small enough to enter 
the neck of the bottle, is better than a camel's-hair brush, 
as, when lost, another is readily made; if the brush is 
lost, the amateur medicine-man may feel helpless. A 
similar bottle of water of ammonia for the stings or bites 
of insects will be useful. Vaseline, sheet-lint, roller- 
bandages, isinglass, and rubber adhesive plaster, absorb- 
ent cotton, and salicylated jute will make a very com- 
plete and useful medical packet. 
Each article must be plainly labelled with the moder- 
ate and maximum dose and the interval of safety between 
doses. The packages should be enclosed in yeast-pow- 
der cans or other similar receptacles, with a list of con- 
tents pasted on the outside of each, and all securely 
packed in a wooden box. Security and compactness are 
essential. 
In addition to the labels, it is well to prepare a list of 
contents with instructions for their use, that the officer 
in charge may take a frequent inventory of his medical 
467 Hospital Steward. 
Hospital Steward. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
resources and select the required remedy with greater 
judgment. The following example is intended as a 
form, to be modified to accord with varying conditions, 
and with ever-extending experience. 
Contents of Medical Packet for Ten Men, Thirty Days. 
- Ammonia, aromatic spirit of, two ounces. Dose, 
one-half teaspoonful in a tablespoonful of water every 
twenty minutes, if required. As a stimulant in fainting 
or shock. In drunkenness, or vomiting, first give a tea- 
spoonful of common salt and a tablespoonful of ground 
mustard in a glass of warm water. After the patient 
vomits twice, give the ammonia, and repeat as required. 
Ammonia, water of, two ounces. To bathe the bites 
or stings of insects. Will blister if confined by a dress- 
ing. 
Bandages, roller, three inches wide, six. For press- 
ure, protection, and support of inflamed parts, as blis- 
tered feet, ulcers of legs, etc.; for sprained joints, first 
soak the injured parts in hot water for half an hour. 
Bandages, triangular, two. As sling to support fore- 
arms, also to retain dressings and protect wounds of scalp. 
Bismuth, subnitrate of, one scruple, with powdered 
opium one grain in each paper. Twenty papers. In 
diarrhoea, first give a tablespoonful of Epsom salts and 
a teaspoonful of paregoric in a half-glass of water; 
after two movements of the bowels give one powder, 
and repeat after each movement, not exceeding four pa- 
pers in twelve hours. In place of the salts, a tablespoon- 
ful of castor-oil with twenty drops of laudanum may be 
given. Keep the patient in a recumbent posture. 
Castor-oil, six ounces. Dose, a tablespoonful. Acute 
constipation. Combined with laudanum in colic, or di- 
arrhoea. [See Bismuth.] 
Cotton, absorbent, four ounces. For an inflamed eye, 
douche with hot water, and apply a pad of cotton to 
closed lid ; retain with gentle pressure by roller bandage. 
This will give rest and protect from external irritants. 
Dress twice daily. May be used instead of sponge in 
cleansing wounds or ulcers. A pledget soaked in lauda- 
num may be packed in an aching tooth or ear. 
Cough lozenges, one hundred. One every hour, if 
needed, in troublesome cough. 
Iodine, tincture of, two ounces. Apply to inflamed 
tonsils externally, and, in severe cases, internally, with 
a swab made by tying a rag or a pledget of absorbent 
cotton on a stick ; to the gums in soreness of teeth ; to 
frost-bites ; to indurations or painful swellings ; to fa- 
cial erysipelas; to chest, for pleuritic pains; over the 
breast bone in painful cough. Prepare a new swab 
when you would exact one for your own person. 
Iodoform gauze, a roll to fit in a half-pound can. 
Cleanse wounds with boiled water, allowed to cool suffi- 
ciently in a covered dish, approximate edges w'ith rubber 
adhesive plaster, dry the surface, and apply several 
thicknesses of the gauze. A useful dressing for ulcers, 
also for abscesses after evacuation of contents. 
Ipecac, powdered, half an ounce. To induce vomit- 
ing, give half a teaspoonful with copious draughts of 
warm water. May be repeated every fifteen minutes. 
In minute doses frequently repeated until nausea super- 
venes (vomiting is undesirable) in incipient colds ; also 
in dysentery. 
Jute, salicylated, one-half pound. A useful protective 
for wounds and ulcers. Gives elastic pressure under 
roller bandage. 
Laudanum, two ounces. Dose, five to twenty drops, 
at four-hour intervals. To relieve pain-for local pain, 
see " Cotton Absorbent." For diarrhoea, see " Castor 
Oil " or " Bismuth. " 
Liniment, acetic turpentine (or some other), six 
ounces. Apply with massage to slight strains or sore- 
ness of muscles, chronic stiffness of joints, etc. 
Morphine pills of one-eighth grain each, forty. Dose, 
one. Two, every four hours, is the extreme limit of 
safety, and if drowsiness last through the period, reduce 
and postpone the dose. To relieve pain. When the 
pain is not excessive, one pill every hour until pain 
ceases or four pills are taken, is safer. 
(SUPPLEMENT.) 
Mustard, ground, two ounces. To induce vomiting, 
give a tablespoonful with a teaspoonful of common salt 
in a glass of water. 
Paregoric, four ounces. Dose, a teaspoonful in colic, 
or mild diarrhoea. 
Pills, compound cathartic, forty. Dose, two to four. 
Follow in six hours with Epsom salts, if required. 
Pills, camphor and opium, forty. Dose, one every 
two hours, in colic, or painful diarrhoea. 
Plaster, belladonna, six, each four by six inches. 
For chronic localized pain. 
Plaster, isinglass, a roll. For slight abrasions. 
Plaster, mustard, six. A counter-irritant for acute 
local pain. 
Plaster, rubber adhesive, two strips, a yard long and 
one inch wide. To approximate the edges of incised 
wounds or ulcers ; sometimes to retain dressings. Draw 
snugly around corns, bunions, or ingrown nails. 
Quinine, forty five-grain capsules. Dose, one to four. 
In malarial fever or periodical neuralgia, give four at 
once as long before expected attack as possible ; in fevers, 
during the sweating stage. 
Salts, Epsom, eight ounces. In acute constipation, 
give a tablespoonful in half a glass of water ; in habitual 
constipation, give a teaspoonful in a glass of water every 
evening, and, if required, in the morning; a like dose 
will relieve pain after meals in dyspepsia. In diarrhoea, 
see "Bismuth." 
Salts, Rochelle, four ounces. In urinary derange- 
ments, a tablespoonful in a glass of water, to be taken in 
small quantity at short intervals, to consume this amount 
every twelve hours. Add two teaspoonfuls of paregoric 
to the above solution, in lumbago, and other forms of 
muscular rheumatism. 
Soda, bicarbonate of, two ounces. Half a teaspoonful 
in water in nausea or acid dyspepsia. A teaspoonful in 
teacupful of water, as a lotion in burns-afterward cover 
with flour. 
Soda, salicylate of, two ounces. In rheumatism, a 
teaspoonful every two hours until ringing in the ears or 
relief of fever' and pain ; afterward continue in smaller 
doses at longer intervals. Half a teaspoonful is a useful 
addition to a solution of bicarbonate of soda, in digestive 
derangements. 
Vaseline and zinc ointment, of each six small imper- 
vious boxes. Protectives for chapped hands and lips, 
sunburn, chafing, and abrasions. 
To Arrest Hemorrhage. - Secure absolute rest. 
Douche open wound with hot water. Approximate 
edges with rubber plaster and apply a firm compress 
under a roller bandage. If blood continues to ooze, 
compress the main artery above the wound by field tour- 
niquet or knotted handkerchief and Spanish windlass ; 
and secure surgical assistance as soon as possible. 
N.B.-Please preserve empty bottles, boxes, and cans, 
and return to post hospital with all unconsumed medi- 
cines and dressings-when no longer required. 
The above schedule will be a useful reference when 
we prepare to take the field with larger commands. 
Medicine panniers, orderly and hospital corps pouches 
contain a very complete assortment of drugs and dress- 
ings, but no list can be so complete that a useful sup- 
plement may not be made by comparison with such a list 
and consultation with the individual preferences of the 
medical officer. Favorite prescriptions can be more 
conveniently compounded in the stationary dispensary 
of the post hospital. Splint material, bichloride of mer- 
cury in weighed packets for a one-to-two-thousand solu- 
tion in a quart bottle, carbolic acid, and styptics, should 
never be omitted when skilled attendance accompanies 
the command. A lamp with a reflector to concentrate 
the rays of light, candles, matches, and instruments, 
must also be provided. 
Thorough study must be made of the various pan- 
niers and pouches supplied by the medical department, 
to know the existence, tile quantity and the exact loca- 
tion of each article. In case of accidents, as a wetting, 
requiring that every article be set out to dry, or an 
468 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Hospital Steward. 
Hospital Steward. 
upset that throws all into a confused jumble, the steward 
should be able to recognize each article and restore it 
to its original position in pannier or chest. Let the 
privates remove the contents from a hospital corps pouch 
and try to replace them ; rarely will they be able to 
buckle the strap at the first attempt. This art of pack- 
ing is the first great lesson for field service ; its daily 
importance extends from pannier and mess-chest to the 
army wagon drawn by six mules. 
A thorough knowledge of the outfit provided by the 
medical department will be a useful guide for extem- 
porized substitutes as well as for supplementary pro- 
vision. The chief defect in the old pannier that came 
down to us from the Civil War, is the combination in 
one chest of medicines, surgical dressings, record books, 
and stationery. The tray containing dressings and in- 
struments had to be removed, with unavoidable exposure 
of contents, before a dose of medicine could be admin- 
istered. This suggests a division of the field outfit into 
medical and surgical, with a small, compact field desk 
for record books and stationery. Again, it is not wise 
to constantly expose our total resources to the many 
accidents of the field. It is better to divide them into 
medical and surgical packets for daily use. and medical 
and surgical reserve chests, to be drawn upon, as medi- 
cines are taken from the store-room to the dispensary of a 
stationary hospital. 
The amount of supplies for daily use will vary with 
the probable nature and duration of the service, with the 
more or less ready communication with the base of sup- 
plies. For instance, with a command of several com- 
panies, going to occupy a position thirty miles off for 
an indefinite period, you would take everything enumer- 
ated in the Medical Supply-Table ; for the same com- 
mand going on a reconnoitring or foraging expedition 
to return within a week, and leaving all invalids behind, 
the supply above indicated for a small detachment would 
require but little increase of quantities, and the addition 
of such surgical appliances as the nature of the service 
might indicate. A permanent camp will justify the 
transportation of bedsacks, blankets, and folding cots, 
benches, tables, and chairs ; for the bivouacs of the 
march, these things would be useless incumbrances. 
To grasp a thread to guide us through these endless 
variations, to study intelligently the analogies and dif- 
ferences in the hospital steward's duties when the hos- 
pital becomes movable, we will take an eight company 
post to which an unexpected order comes for six com- 
panies with a medical officer and a proper detachment 
of the hospital corps to proceed to a point one hundred 
miles away to camp an indefinite period. By the order, 
thirty days' rations will be taken, and the hospital will 
be provided with one ambulance and one six-mule wag- 
on. 
The Detachment.-Upon the receipt of such an 
order, the first question to be decided, and this must be 
done instantly, is which men will go, which remain ? 
This will be determined by the Post Surgeon ; but, as 
in all questions of hospital administration, the steward 
must be prepared to give an intelligent opinion. The 
full complement of men at an eight company post is two 
stewards, an acting steward and seven privates. The 
allotment for a two company post is a steward, an acting 
steward and four privates. But in our problem, it is 
something more than a two company post that is left 
behind ; the sick of eight companies are already here 
and the more serious cases will find their way back from 
the field. It is clear that in this division of force there 
is a shortage to be apportioned between the fractions. 
This will always be so. Non-combatants are impedi- 
ments to an army ; our problem will forever remain, to 
get the greatest amount of work from the fewest men. A 
steward, an acting steward and four privates constitute 
the maximum force that can take the field. The acting 
steward goes because the moving command is liable to 
further subdivision, and his skill may be urgently re- 
quired. 
The three privates left at the post must be thoroughly 
reliable, capable men. One must cook, one have charge 
(SUPPLEMENT.) 
of the wards and internal police, and one do the outside 
work, and be a general utility man to supply deficiencies 
everywhere. There is no margin for sickness or inebria- 
tion. Of the four privates for the field, one must be an 
efficient cook, and understand the management of ra- 
tions ; one must be able to drive the four-line ambulance 
team, and care for the animals. The latter has probably 
been milking the hospital cow ; but, with forethought 
for such emergencies, there is another private in the 
corps who can milk, and who must be kept at the post 
for that purpose. The other two privates for field serv- 
ice are so from necessity-their qualifications may be a 
subject for regret, but there is no remedy. In the hos- 
pital corps, there can be no roster for field service ; each 
man must take the place for which he is fitted. 
Equipment.-On the march-as in the desert-no man 
is a friend. Each man carries on his person the pro- 
vision for his individual needs ; and, transportation being 
so limited, he only carries enough for himself, and has 
every incentive to take good care of his own. Under 
these circumstances, he who goes borrowing will go 
sorrowing, and the outlook is equally bad for beggar 
or thief. "We have drunk from the same canteen," 
awakens sympathies in the heart of the civilian ; but to 
the soldier, the romance of this touching tie is crushed 
by the reflection that one-half of this friendship was 
misplaced, that one of the parties was a negligent vaga- 
bond who should have had a canteen of his own. This 
stern reality must be impressed upon the members of 
the hospital corps ; and the men detailed for field service 
must be w'arned immediately, to give them all the time 
possible to provide for their probable necessities. 
The official equipment is always ready : the extra 
pair of shoes, shirt, under-shirt, drawers, and socks are 
always on hand, ready to be packed with the blanket in 
the blanket-bag. The hospital corps pouch and can- 
teen hang ready for use with the belt, knife, and scab- 
bard, with the haversack always containing the meat- 
ration can, the knife, fork, and spoon. The overcoat, 
rubber blanket, and half shelter-tent with pole and pins, 
are ever ready to be rolled and strapped on the blanket- 
bag. When the hospital corps man has put on the 
above equipments, with a campaign hat and canvas leg- 
gings, he may think himself fairly equipped for the 
field ; but there are many little things for him to pro- 
vide. A hairbrush, a comb, a razor and strop, a tooth- 
brush, a cake of toilet soap, and a pocket mirror, should 
all be found in the small compartment of his haversack. 
Extra buttons, needles and thread, towels, pipes, tobac- 
co, matches, possibly fish-hooks and lines, are things 
that he must provide now, or go without. In the camp, 
the men must present a neat and soldierly appearance ; 
each will want shoe-blacking and brush, a button stick, 
and cleaning material. A few pairs of white gloves, for 
inspections and musters, will not greatly increase his 
burden. 
Is the soldier's clothing, now seasonable, such as he 
will require with the changing season ? Are woollen 
stockings, fur gloves, canvas-lined hood, and arctic over- 
shoes, liable to be wanted ? It is not enough that the 
soldier has these things; we must see that they are not 
left behind. The frozen members will be his own, but 
the resulting loss of service is an item affecting the 
general welfare. 
The equipment of the hospital corps varies with the 
command with which it serves. Without specific in- 
structions on the subject, our judgment must be guided by 
the necessities, conveniencies, and analogies of each case. 
When mounted, the blanket-bag is useless and incon- 
venient. Walking, this weight of twenty-four pounds 
moves with the body ; when mounted, the motion of 
the horse introduces a disturbing element of serious im- 
port ; the hospital corps man must learn to pack his sad- 
dle like a cavalryman, and turn in his blanket-bag for 
storage, until it is again needed. The rubber blanket may 
conveniently be replaced by a poncho with its central 
perforation to pass over the head and retain it in posi- 
tion without assistance from the hands. Vanity may 
inspire a longing for top-boots, but these are regarded 
469 Hospital Steward, 
Hospital Steward. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
as useless and unnecessary incumbrances. The mem- 
bers of the hospital corps are mounted only for trans- 
portation-their duties are all performed on foot. The 
infantry canvas leggings answer every purpose when 
mounted, and, being light and pliable, will not impede 
the performance of any duty. When the command dis- 
mounts to lead up the hot side of a mountain, the feeling 
of the booted troopers toward the infantry leggings will 
be one, not of derision, but of envy. As the evolutions of 
a mounted detachment of the hospital corps will ever be 
of the simplest, spurs may also be dispensed with. 
The accoutrements of a private of the hospital corps 
form a considerable burden; and his efficiency will be 
increased by every pound of diminution. What the 
weight is, and how it may be lightened, are important 
questions. The belt, belt-plate, knife, and scabbard 
weigh one and one-half pounds ; the empty haversack 
with knife, fork, and spoon, and meat-ration can, weighs 
three pounds ; the canteen filled with water, weighs four 
pounds ; the hospital corps pouch weighs four pounds ; 
the blanket-bag containing one blanket, one pair of shoes, 
one dark-blue shirt, one undershirt, one pair of drawers, 
and one pair of stockings, with one overcoat, one shelter- 
tent half with pole, and one rubber blanket strapped 
upon it, weighs twenty-four pounds. The mere adjust- 
ment of these things to a man's person, so that his arms 
may hang naturally by his sides, so that the heavy blan- 
ket-bag may not impinge upon the hospital corps pouch 
and cause chafing, so that the canteen may be readily ac- 
cessible, is a very difficult problem, further complicated, 
in savage warfare, by the revolver with which he is to 
be armed. Every increase of this burden is a serious 
matter. Leaving the post on a warm October day, he 
cannot be expected to carry arctic overshoes, canvas-lined 
hood, fur gloves, and German socks, that he will only 
require six weeks later. 
Without specific provision, it would seem advisable to 
have a packing-box with the cover secured by a padlock, 
or a detachment property chest, of sufficient capacity to 
hold all accoutrements not in actual use. To prevent 
confusion every article must be marked with the owner's 
official number. The likelihood of loss will be much 
less if the many packages are secured in one chest. In a 
battle, the men detailed for bearers will go upon the 
field, only equipped with a canteen of water, the hospital 
corps pouch, the belt, knife, and scabbard. The re- 
mainder of their accoutrements and their extra clothing 
must be left at the temporary field hospital. If secured 
in a property chest, the men may find their own again 
after the battle ; in case of a sudden move, the chest will 
be carried along ; if the ground be suddenly occupied by 
the enemy, the Geneva cross may afford this property 
protection. In no case can individual lockers be carried 
into the field. 
Mounts.-Upon the receipt of the order to accompany 
a moving command, the number of horses that will be 
required is a question for immediate decision. A requisi- 
tion for that number of horses upon the post quarter- 
master, and for a like number of horse-equipments upon 
the post ordnance officer, must be prepared for the signa- 
ture of the medical officer, and the approval of the post- 
commander. These may not be on hand for issue, but 
these requisitions will be on record to relieve the medical 
officer of responsibility for the defective equipment. 
Never ask for what is not wanted; and we do not want 
surplus animals to give the small detachment extra work 
in caring for them. Army Regulations specify the num- 
ber ; but I know of no better illustration, that no general 
order can obviate the necessity for individual discretion 
and judgment. With a mounted command, say the Reg- 
ulations, every member of the hospital corps shall be 
mounted ; but. if one of the men drives the ambulance 
he will be mounted in the driver's seat; the cook will 
habitually accompany the wagon containing his outfit ; to 
look out for his kettles and pans in case of accidents on 
the road, he will be much better mounted on the top of 
the wagon. It must first be ascertained if the quarter- 
master will send a civilian driver with the ambulance 
mules, as there will then be required an additional horse. 
The number of horses being determined, we must ask 
for an equal number of complete saddles, curb bridles, 
watering bridles, and halters ; also curry-combs, horse- 
brushes, lariats, snap-links, double spring snaps for lari- 
ats, picket - pins, nose-bags, saddle - blankets, pairs of 
leather saddle-bags, surcingles, and side lines (or hop- 
ples). There is a choice between side lines and hopples. 
Where Indians may try to stampede the herd, side lines 
will give greater security ; if an animal is a vicious 
kicker, the side line will render grooming a safe opera- 
tion. Generally, the hopple is to be preferred ; after a 
fatiguing march, we ourselves would not rest well with 
a hand and foot tied together. In an exhausting cam- 
paign, when the abandonment of worn-out horses wTas of 
hourly occurrence, it was observed that those horses 
went through all right whose riders began the campaign 
by losing their side lines. 
These horse equipments introduce a new kind of prop- 
erty. With an ordnance list in hand, the various articles 
must be gone over to see that the saddles, bridles, and 
halters are complete ; we must learn to recognize and 
name the several components, that we may know what 
to charge for on the muster roll, if any part be lost. The 
bridles, halters, and saddles must be fitted to the horses, 
and then an attempt should be made to assign them so 
that each man may fit his saddle. Now is the time to 
discover disparities and to remedy them by exchanges 
with the ordnance officer. 
Arms.-If the war is to be waged against savages who 
do not recognize the Geneva cross, the members of the 
hospital corps will be armed with revolvers. One revol- 
ver and twenty rounds of ammunition for each man will 
be obtained from the ordnance officer. Each revolver 
will be loaded with five cartridges when issued to the 
man ; the vacant chamber under the hammer will sup- 
plement the safety notch in preventing accidents. The 
balance of the ammunition must be kept for issue as re- 
quired. This provision will give the men greater assur- 
ance in searching for wounded over a field where a 
crippled savage may retain sufficient vitality to be dan- 
gerous. After camp-fire legends of skulking savages 
creeping into camp, the man will sleep better for having 
his revolver within reach. His rest will be undisturbed 
by the reflection that he would be more likely to kill a 
good ambulance mule than an Indian, and the camp 
guard is ample security against such an unfortunate oc- 
currence. All must be impressed with the fact that, in 
untrained hands, a pistol is a public danger; that the 
general weal will require the confiscation of all self-cock- 
ing bull-dogs, and other private weapons upon discovery. 
The medical officer may make an exception in the case 
of a shotgun that may help the hospital mess. 
Tents.-The post quartermaster has suitable store- 
rooms for these and keeps them on hand for issue when 
required. Suitable requisition must be prepared for the 
signature of the medical officer and the approval of the 
post commander. Army regulations fix the allowance 
"in camp or garrison" at three hospital and one com 
mon tents. Again, each varying circumstance of climate, 
season, and soil demands forethought and discretion to 
adapt a general order to the necessities of a special case. 
Those hospital tents will be wanted upon arrival in 
a permanent camp, but they cannot be used on the 
march. Here, as everywhere, economy of labor, and of 
time, is an ever-present condition of our problem. In 
calm weather our entire force can raise a hospital tent 
with its fly ; in a moderate gale, the assistance of a strong 
detachment from the companies will be required, and, 
even then, without extreme caution, the iron pin that 
secures the ridge-pole will be so bent or broken as to 
render the tent unserviceable. In a driving storm, we 
will not wish to await such a detail, only to be had after 
the company camps are in order ; nor will we wish to 
gain for our detachment the reputation of being helpless 
people who require to be taken care of. The common 
tent is for the cook, and receives the mess-chest, food- 
chest, cooking apparatus, and his accoutrements. He 
must habitually sleep in it, to secure his conveniences 
from the raids of improvident people who have forgotten 
470 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Hospital Steward. 
Hospital Steward. 
to bring along, or have already lost, the articles of prime 
necessity in camp life. There will be no room in the 
cook's tent for anything else. Panniers and other prop- 
erty must be unloaded immediately, for the ambulance 
and wagon must be parked with the other transportation 
under the one sentinel, and our animals must not be 
cheated of a single half-hour of their allotted time for 
grazing and rest. 
For daily use on the march, the best outfit of tentage 
that can be suggested, that will give the greatest amount 
of shelter with the least weight, with the greatest econ- 
omy of labor and time, is one conical wall-tent, one wall- 
tent with fly, and three common (laced corner) tents. 
The conical wall-tent gives the largest floor space for the 
weight, and will afford ample room for the property, for 
the detachment with equipments, and for sick men be- 
sides. The wall-tent is for the steward and acting steward, 
also giving room for the medical and surgical panniers 
and the field desk. One common tent is for the cook ; 
the two others will be found very convenient luxuries, 
not absolutely essential, but sufficiently useful to justify 
the additional weight of about fifty pounds each. In 
temporary halts the men need not be fatigued by pitch- 
ing and repacking the larger tents, the two common tents 
will afford ample shelter from the sun or rain for the 
hospital corps and the sick ; will give space to open pan- 
niers and dispense medicines or dress wounds. With a 
mounted command that frequently leaves the wagons 
hours behind, two of these common tents may well be 
packed with the litters under the ambulance seats. Im- 
mediately after halting, sick men can then be made com- 
fortable, the dispensary " opened for business," the am- 
bulance sent away, and the mules given equal grazing 
privileges with the cavalry horses, which will more than 
compensate for this trifling addition to their load. These 
two extra common tents will also greatly increase the 
capacity of our moving hospital in the stress of emergen- 
cies. In a storm or after a battle, the property can be 
packed into one of them, the hospital corps can pitch 
their shelter-tents, and the conical tent will shelter six- 
teen wounded men ; and there will still remain one wall 
and one common tent for operating-room and dispen- 
sary. 
The medical officer's tent goes with the head-quarters 
baggage, but it is well to draw it with the hospital tent- 
age and see that it is in good condition before start- 
ing. All tents should be marked " Medical Depart- 
ment," with name of post, with a stencil, in such place 
that the brand may be plainly visible when the tent 
is rolled. This will prevent confusion, if wagons break 
and the baggage is mixed with that of other organiza- 
tions. 
Tent-pins must be drawn in a free excess of immediate 
needs-especially if of wood. The extra ones must be 
packed in a box and well secured by nails. Those in use 
will habitually be rolled in the tent to which they per- 
tain. A hundred feet of small rope [ordinary clothes- 
line] for additional stays in high winds will complete 
our outfit of tentage. 
After receipt from the quartermaster, each tent should 
be pitched in the hospital yard-using only those imple- 
ments that are to be taken along. It can then be seen 
that the poles are perfect-and of proper size and length ; 
that all guy-ropes are in good condition ; that each tent 
has the required number of pins ; if torn, now is the time 
for mending. After the condition of each tent has been 
verified, it is taken down and the poles and pins are laid 
smoothly along its ridge and snugly rolled in. The roll 
is then bound by the ropes so that no pin can be shaken 
out; and the tent is ready for the wagon. This prelim- 
inary tent-pitching was once advised by a commanding 
officer, preparatory to a march the next day. One cap- 
tain said that, after his twenty years' of experience, this 
was entirely unnecessary; he would forget nothing. 
They camped eight miles from the post the next day, 
when this captain approached with crestfallen air and 
asked permission to send back a messenger-he had for- 
gotten his tent-pins. 
Tools and Implements.-From the quartermaster 
(SUPPLEMENT.) 
will be obtained three axes, three picks, two hatchets, 
two spades, one long-handled and one short-handled 
shovel, two mess-pans, two camp-kettles, and two galvan- 
ized iron buckets. On the march, there must always be 
found in the ambulance one bucket-for watering the 
animals by the way,-a hatchet, an axe, a spade, and a 
pick. With a wagon train, others will help to make the 
road passable ; but, the ambulance being the only 
wheeled vehicle with the command, you will constantly 
find gullies to be filled, creek crossings with banks to be 
sloped, and various obstructions to be removed from 
your road. Upon arrival in camp the cook will require 
one axe, and tent-pitching will be done more promptly 
if you have two for that purpose. When you can get 
one made, a wooden maul is a less destructive implement 
for driving tent pins ; a section from the trunk of a hard- 
wood tree, of suitable size, with ends supported by iron 
rings and a handle inserted through the centre, is all that 
is required. The picks and spades will be useful for 
trenching around tents, making sinks, and for various 
other purposes. A small coil of strong iron wire will 
prove frequently useful in repairing tent fixtures, guying 
up stove-pipes, etc. In a permanent camp, the hospital 
tool-chest will be a valuable addition to the outfit. A 
garden rake and a couple of brooms are policing luxu- 
ries that may well accompany the hospital tents for a per- 
manent camp. 
Mineral Oil, Matches, Etc.-For ordinary illumi- 
nation in moving camps, candles are most convenient- 
least troublesome. For surgical operations and clerical 
work at night there will be needed a supply of mineral 
oil for the Diamond reflector lamp. It is customary to 
take this oil, matches, wicks, etc., from the supplies of 
the post hospital. In a permanent camp these may be 
obtained by requisition upon the quartermaster, when 
candles will be no longer issued as a component of the 
ration, and hand lamps and oil lanterns will be re- 
quired. 
Rations.-The ration return will be prepared for 
" The Camp Hospital and Detachment of the Hospital 
Corps in the Field ; " the hospital has certain advantages 
over other organizations, in the sale of savings to the 
subsistence department, that may be needed. A list will 
be made of components as shown in Table III. (page 
460), with additional columns for bulk saved, price, and 
amount. The preparation of this list will always be a 
crucial test of the steward's discretion, judgment, and 
experience, an ever-varying, always perplexing problem. 
The climate, the season, the character of the country to 
be traversed, the probability of making advantageous 
purchases along the road, the probable demand and mar- 
ket price for unconsumed components of the fation, are 
all subjects for consideration now. If the route is to be 
away from railways, away from the competitive com- 
merce of large towns, as little as possible will be sold to 
the subsistence department-and the higher prices that 
can be received in barter by the way be awaited. As the 
channels of commerce become poorer, the prices of the 
staple articles of the ration will increase, and those of 
such agricultural products as may be desired will dimin- 
ish. You must have food enough to surely subsist your 
men for the period covered by the return ; and a little 
money will be required to pay for eggs, milk, green corn, 
etc., that the men may have a variety equal to that of 
their comrades in the line. The companies leave the 
post with the fund of each organization to give elasticity 
to their dietaries; our detachment starts with nothing 
but the bare ration-we must make and expend a fund as 
we go along-there is no margin for error or misfortune. 
Life in the open air and increased exercise sharpen the 
appetites of the men ; and the only compensating increase 
in the ration is in flour, of which each man receives the 
entire eighteen ounces, there being no deduction for bak- 
ery expenses. Four pounds of baking powder is issued 
with each hundred rations ; and there will be obtained 
from the subsistence department two dutch-ovens in 
which the cook will bake his own bread ; so that we can 
safely save four ounces of flour from each ration. This 
and about one-third of the coffee will be the chief sources 
471 Hospital Steward. 
Hospital Steward. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
of revenue for this incipient field hospital fund. The 
following sample statement of the first transactions with 
the subsistence department can only be a general guide, 
to be modified to accord with each special case : 
latter is especially true in regard to bacon, which deteri- 
orates in quality and loses weight during wagon trans- 
portation. 
The uncertainties of the future compel us to draw the 
moat ration chiefly in bacon ; but, as occasion occurs, the 
commanding officer will order the purchase and issue of 
fresh beef, when his order will be required for the camp 
commissary to take back an equivalent in bacon. Other- 
wise the detachment will have received double rations, 
the accounts of the commissary officer will be confused, 
and, if he attempts to straighten the matter by deductions 
from future returns, so much time will be required that 
the detachment may be split up into fragments, and a 
matter, simple at first, may become too complex for a 
just settlement. 
The five days' allowance of coffee will be roasted in 
the hospital range, ground, and secured in close cans in 
the food-chest. 
The Field Desk.-The folding desk furnished by the 
medical department is too small to contain a sufficient 
supply of blanks and stationery, and must be reserved 
for current work. In the absence of one specially de- 
vised, the ordinary company field desk furnished by the 
quartermaster's department will answer the requirements. 
In laying out the blanks to pack in it, we must consider 
that the post hospital is a camp hospital that circum- 
stances have rendered permanent; that the only change 
has been that record books have been substituted for the 
retained copies of various returns and reports which are 
still kept in the camp hospital ; and that a correspond- 
ingly increased number of blanks will be required. No 
meteorological observations are required from the mov- 
ing hospital. We must review the various departments 
with which we will have to deal, the various kinds of 
property for which we will have to account. Soldiers 
will enlist, be transferred to other commands, be dis- 
charged, die, be mustered, be paid, as at permanent 
posts ; sick men will be transferred to other hospitals ; 
the detachment will be reported monthly ; there may be 
lists of wounded, and reports of epidemics. Clothing 
and equipage, quartermaster's stores, and ordnance prop- 
erty, will each require a quarterly return. Changes of 
accountability will necessitate blank invoices, receipts, 
and requisitions; also returns of medical and hospital 
property. Completed cases and the hospital fund will 
be reported monthly. We shall need ration returns, 
requisitions for fuel, memorandum slips, a blank book 
for orders, letters, and endorsements, a copy of the Epi- 
tome of Current Orders and Decisions, corrected to date. 
With the exception of ink (which must be packed where 
the damage will be less in case of breakage), the station- 
ery may also be packed in the field desk. 
The Ambulance.-We must see that everything is in 
serviceable condition ; that no nut or brace is* loose; that 
the water-keg will hold water ; that there is provided an 
extra tongue, the required number of litters and rollers, 
a bucket, a lantern, an axe, a hatchet, a wrench, and a 
box of axle-grease. All bearings are lubricated before 
starting. 
The Army Wagon.-The busy day of preparation 
may well be closed by having the wagon brought to the 
hospital and loaded, ready to pull out with the train in 
the morning. This will obviate confusion and delay at 
the start ; the proverbial slip upon the threshold not only 
will bring misfortune, but is one in itself. With the in- 
terval of rest after loading, we can review our work, 
discover omissions, reconsider the relative importance of 
things taken and things left behind, and make desirable 
corrections before the hour of departure. 
With the average of American roads, thirty-five hun- 
dred pounds is the prudent maximum load for a six- 
mule team. The wagon box has a floor space of three 
and one-half by ten feet, and can be loaded to a height 
of somewhat over four feet, allowing for the curve of the 
bows. In determining the load, bulk as well as weight 
must be considered. Heavy packages must be placed 
nearest the ground ; articles required daily must be 
accessible without removing the entire load ; all must be 
packed as firmly and compactly as possible. The fol- 
Field rations from August 5 to September 4, 189-, inclusive. No. 180. 
Components. 
Due. 
Drawn. 
Saved. 
Bulk 
drawn. 
Bulk 
saved. 
Price. 
Amount. 
Fork 
8 
172 
18 
12 
150 
8 
124 
18 
12 
104 
48 
46 
60 
.. 
60 
80 
80 
6 lbs. 
93 lbs. 
0.078 
0.022 
0.042 
0.231 
0.13 
0.188 
$2.8i 
i'.ii 
0.38 
1.39 
0.05 
0.04 
Bacon 
36 lbs. 
Soft bread 
Hard bread 
Flour 
12 lbs. 
117 lbs. 
15 lbs. 
2 lbs. 
10 lbs. 
27 lbs. 
1 gal. 
2.7 lbs. 
7.2 lbs. 
7.2 lbs. 
X lb. 
6 lbs. 
144 lbs. 
36 lbs. 
51% lbs. 
9 lbs. 
6 lbs'. " 
6.4 gal. 
0.2 lb. 
Beans 
160 100 
20 20 
180 120 
180 180 
ISO 100 
Rice 
Coffee, green.... 
Sugar 
Vinegar 
Candles 
Soap 
Salt 
Pepper 
Yeast-powder... 
Potatoes 
Onions 
180 
180 
180 
180 
150 
144 
36 
180 
180 
180 
100 
150 
144 
36 
Total saving? 
$5.81 
Purchased from Subsistence Department: 
12 lbs. ham, at 0.093 $1.12 
9 lbs. Y. A. cheese, at 0.113 1 .02 
5 lbs. lard, at .088 0.44 
12 lbs. canned corned-beef, at 0.15 1.80 
% lb. mustard, at 0.422 0.11 
Total $4.49 
Balance in cash 1.32 
In the above transaction, including lard and cheese, 
there is no reduction in the weight of animal food. This 
will always be a safe provision ; the vegetables bought 
along the road will be starchy foods, substitutes for the 
flour ration only. The saving of flour is large, but 
within the limits of prudence when so large a percentage 
of the pound of vegetables can be drawn in potatoes. 
The prices are taken from a Commissary Price List cur- 
rent at the time of writing. The relative price of ham, 
as compared with bacon, is unusually low. Beans are 
saved instead of rice, because at the unusually high price 
the fund receives five cents more than would have been 
received from an equal number of rations of rice at five 
and one-half cents per pound ; the price of a quart of 
milk or a half-dozen eggs is an important gain for our 
fund in its birth struggle. The soft bread is drawn for 
use during the first few days of the march-as much 
as will remain fresh until consumed. The hard bread 
provides for accidents or irregularities of the march 
which may deprive the cook of the time necessary for 
baking. 
As soon as received, the ham will be boiled and some 
beans nicely baked-the pork was drawn to bake with 
them. These things can be more conveniently and better 
done on the range of the post hospital, and will greatly 
relieve the cook upon the march. Two slices of bread, 
a slice of ham, and a little mustard will make a sandwich 
to nicely fit in each meat-ration can ; and, with a bit of 
cheese, a little paper of salt, and an onion, will provide 
the men with a very satisfactory lunch at each mid-day 
halt. When the ham is gone, the canned corned-beef 
will replace it in the sandwich. There should be a mess- 
pan filled with the baked beans, which, served cold with 
vinegar, will economize time for the cook and prove a 
useful and popular addition to each early breakfast. 
When the rations are drawn, an allowance for five 
days will be put in the food-chest, and the remainder 
boxed up so that the cook can only have access to them 
by application to the steward. In this way waste, and 
consequent shortage, will be brought to the steward's 
attention before the matter becomes serious ; the rations 
will also be preserved in much better condition. The 
472 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Hospital Steward* 
Hospital Steward. 
lowing list of packages and approximate weights may be 
of use as a general guide : 
Pounds. 
Rations 550 
Food-chest, mess-chest, dutch-ovens, mess-pans, and eamp- 
kettles 300 
Medical and surgical panniers 250 
Medical and surgical reserve chests and hospital stores.... 500 
Field desk, packed 100 
Tentage for the road, with fixtures 350 
Axes, picks, shovels, spades, guidons, etc 100 
Tool-chest 90 
A table and two benches, with folding legs, and four stools 100 
Twenty-four blankets, in two cases 100 
Twenty bed-sacks and twelve hair pillows 125 
Stoves and pipe 125 
Twelve folding cots 400 
Twelve folding bedside tables 100 
Folding dining table 125 
Twelve folding chairs 125 
Commode set 35 
Pack saddle and fixtures 45 
Twelve mattresses 300 
Three hospital tents, flies, guys, and pins 600 
Total weight 4,440 
It will be seen how readily a prudent load is exceeded ; 
and the space is exhausted long before the maximum of 
weight is reached. The question is, What can be left be- 
hind with least inconvenience ? The twelve mattresses 
are not essential ; the folding cots are comfortable with- 
out them in warm weather, and in cold weather a folded 
blanket under each patient will insure sufficient warmth. 
Bed-sacks stuffed with hay or straw make clean, soft 
beds ; and, with rubber blankets to cover damp ground, 
the cots may be dispensed with. The ingenuity of the 
hospital corps will improvise a bunk if one be required. 
The bedside tables will never be missed. The folding 
chairs may be reduced to two or three. The dining table 
is a nearly useless luxury, as the lighter one with folding 
legs, made by the carpenter for use on the road, is a fair 
substitute, requiring less space. Pillows are so conven- 
ient for steadying an invalid's head, for supporting an 
inflamed limb, etc., that their exclusion must be a last 
necessity. The pack-saddle is carried in the wagon for 
use with expeditions without wagons. The quartermas- 
ter will provide an animal when required ; and you need 
not burden your detachment with another mule until it 
is needed. With the tentage for the march, you can im- 
provise a very satisfactory camp hospital by attaching 
the shelter-tents to the common ones for the use of the 
detachment, and reserving the conical wall-tent for a 
ward. One hospital tent will be a great convenience- 
but all three may be left behind if necessary. The med- 
ical and surgical panniers are consigned to the wagon as 
the orderly pouch, the instrument and emergency cases 
will be sufficient for all accidents on the road ; and the 
reduction of the ambulance load will be another ever- 
present and difficult problem of the utmost importance. 
Civilian Teamsters.-Army regulations direct that 
one member of each detachment of the hospital corps 
shall be designated as ambulance driver, evidently a wise 
provision in case of long-continued hostilities ; but while 
the corps remains on a peace footing it will generally 
be wise to accept the services of the civilian driver em- 
ployed by the quartermaster, and keep the designated am- 
bulance driver for other duties. The number of pri- 
vates that can be taken into the field is so small that this 
increase of force is of great advantage ; and to keep 
an extra man at every military post throughout the 
year to provide ambulance drivers for a field service 
aggregating but a few weeks, would not be an eco- 
nomical policy. The designated ambulance driver may 
be able to guide the mules safely along the excellent 
roads about the post, and still be unfit to follow a cavalry 
command across the country ; without the possibility of 
testing his skill beforehand, to entrust sick men to his 
care will involve great risks. Again, the mules cannot 
be kept for the exclusive use of the medical department- 
economy requires that they be used for other purposes 
during a great part of the year ; and the quartermaster 
does not like to discharge the civilian employee for so 
(SUPPLEMENT.) 
short an interval, as a good four-line driver is difficult to 
secure, and the man will find employment elsewhere. 
The quartermaster will send the mules in the harness 
to which they have been accustomed ; and it is better to 
leave behind the hospital harness. Your collars may fit 
the mules, but a new collar is like a new boot-a long 
march is not the proper time to begin its use ; and if your 
collars have been moulded by use to fit one team of mules, 
the next set of animals will surely be of a different size. 
At the last moment, there may be another little question 
to decide. Each organization has its own teams, and 
there will be no separate mess for the quartermaster's em- 
ployees ; the teamsters mess with the companies to which 
they are assigned. The drivers of the ambulance and hos- 
pital six-mule team will desire to turn in their rations and 
mess with the detachment of the hospital corps. These 
men must live somewhere, and cannot well cook forthem- 
selves. A company commander may take them as a favor 
that will be asked with hesitation ; but that company may 
be detached the next day and the trouble recur. The 
messing of outsiders in the hospital is prohibited, but 
these men are considered as civilian attaches to the hos- 
pital corps, who, if they turn in their rations, may prop- 
erly enjoy the services of our cook. This question has 
never been the subject of an authoritative decision, but 
such a ruling by the medical officer is supported by so 
many good reasons that it is likely to be sanctioned by 
higher authority if the question is ever raised. 
The Start.-At least an hour before the time fixed for 
starting, the men must be out to feed and groom their 
horses. Each man must care for his own-for they are 
strangers yet and prone to misunderstandings, and this 
early intimacy will beget a useful friendship. After 
stables the last home breakfast will be taken, each man 
provided with a mid-day lunch, saddles packed, canteens 
filled, and accoutrements made ready. The water-keg 
should be filled from the hospital cooler and wrapped in 
a wet gunnysack before being placed in the ambulance- 
to keep it cool by evaporation. The animals must be 
given an opportunity to drink. We will take a final in- 
ventory of the contents of the wagon and ambulance, and 
see that the emergency case and the instrument case are 
in the latter. The men will fail in for a final inspection, 
and, if there are no corrections to be made, may rest at 
ease until the warning call, " Boots and saddles." The 
wagon, with the cook on top, will pull out to take the 
place in the train that may be assigned by the sergeant in 
charge. The ambulance will follow in rear of the troops. 
The hospital corps, except the orderly who attends the 
medical officer, follow close behind the ambulance. 
Each start from camp will be a repetition of the above, 
with the addition of repacking and reloading whatever 
has been taken out for use. There is an instability about 
camp life that renders it important that, before sunset, 
everything about the hospital be so arranged that an order 
to move in the darkest part of the night can never cause 
delay, confusion, or loss. Breakfast is a great promoter 
of cheerfulness ; and, if the cook has done his baking, if 
he has his fire ready to light, his coffee ground and in 
the pot, no order to move out will be so sudden as to take 
the men out of camp without at least a piece of bread 
and a cup of hot coffee-as well as a suitable lunch in 
their haversacks. 
Habitually the cook must be called a sufficient time be- 
fore " Reveille" so that the men can take breakfast while 
the animals are munching their grain ; he can then wash 
and repack his dishes while the others are grooming, and 
be ready to assist in striking tents and reloading. It is 
customary to have all the tents in camp go down at a 
bugle-note ; but the medical department lias not men 
enough to handle all its tents at once, and it will be nec- 
essary to have the smaller ones repacked, and display our 
military precision upon the circular wall-tent. To have 
a place for everything and assign to each man his allotted 
share of the work-so that he may know what to do 
without orders-is the best means to insure celerity, to 
avoid confusion. After everything is reloaded, we will 
move our command a short distance away and go over the 
ground carefully-with a lantern if necessary-to see that 
473 Hospital Steward. 
Hospital Steward. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
no tent-pin, knife, fork, spoon, cup, or other article has 
been overlooked. 
The March.-The detachment will be observed as it 
moves out. The restless horse is probably uncomfort- 
able ; the girth has the nature of a compound pulley- 
an injudicious man may pinch the back and cause an 
abscess in a short time ; if a horse shakes and tosses 
his head, the curb strap may be so long as to allow the 
curb to turn forward and strike the upper incisor teeth. 
There will be a short halt after the first two miles and at 
the end of every hour, when the feet of the animals must 
be examined, girths tightened, if necessary, and saddles 
readjusted. 
Sick men are given a pass from their company com- 
mander and fall out to await the ambulance ; cavalrymen 
are generally accompanied by a non-commissioned offi- 
cer. The surgeon examines each man and endorses his 
recommendation on the pass. Each man who is ex- 
cused from any duty by the surgeon must appear on the 
hospital reports, as in the post; the steward must have 
a suitably ruled blankbook and enter his name and the 
other required data at once-as he may never see the man 
after he leaves the ambulance. Men faint from heat, or 
suffering from other slight ailments, only need a ride to 
camp, and may not appear again on the sick report. 
When admitted to the ambulance, the cavalryman's 
horse, arms, and accoutrements are taken back to his 
troop by the non-commissioned officer who accompanied 
him ; the foot-soldier is directed by regulations to turn 
in his arms and accoutrements before leaving the ranks. 
In actual war, these provisions are essential, when strag- 
gling becomes a considerable evil, and a provost guard 
arrests all men out of the ranks without written author- 
ity ; but are generally neglected under the conditions of 
Indian warfare. The writer has followed marching 
columns more than twenty-five hundred miles without 
having seen a company commander's pass or an infantry 
soldier carrying another's arms or accoutrements. The 
medical officer will not raise questions of discipline in 
other organizations until the results seriously affect his 
immediate command. Common sense and the Golden 
Rule are useful supplements to army regulations in the 
face of perplexing conditions. For example, an infantry- 
man is overcome by heat, he feels dizzy and short of 
breath, he does not know what the matter is, but thinks 
that if he can rest a moment he will be all right. When 
the ambulance reaches the spot, wre will find him there. 
His ghastly face bathed in perspiration tells the whole 
story. There is no question of a pass ; we will give him 
restoratives and load him-and his trappings-into the 
ambulance. This converts our ambulance into a trans- 
port for arms and munitions of war, despite the Articles 
of the Geneva Convention, in violation of a paragraph of 
Army Regulations which specifies what may be carried 
in an ambulance ; but any practical board of survey will 
make us pay for that gun if we throw it away. Of 
course, in civilized warfare, should we fall in with the 
enemy, there would be serious incongruity between the 
cross on the sleeve and the arms in our hands. Truly, 
circumstances alter cases and demand the exercise of a 
rational discretion. When sick men start from camp in 
the ambulance, their arms and accoutrements belong 
with the baggage of their respective companies, and we 
must refuse to receive them, for the ambulance would 
soon become an ordnance depot and be seriously ham- 
pered in its legitimate functions. 
Each hourly halt will give an opportunity to adjust 
defects. The ambulance curtains can be raised and low- 
ered to accord with the changed direction of the sun. 
The animals must be offered water frequently, if the 
chance occurs. If there be grass, riding animals must 
be relieved of their bits and allowed to graze. This 
kindness of his master is appreciated by the horse as 
highly as the dainty morsels snatched by the wayside ; 
and the friendly relations established between man and 
beast promote that cheerfulness of spirit so necessary 
for protracted physical endurance. The man who takes 
every opportunity to gather a few handfuls of mesquite 
beans or any other dainty relish, and allows his horse to 
(SUPPLEMENT.) 
eat from his hand, will rarely be compelled to abandon a 
worn-out animal and continue his journey on foot. 
Temporary Camps.-Each arm of service has its own 
normal rate of speed. The cavalry, including halts, will 
average four miles an hour ; the infantry, three miles ; 
the mule train, two and one-half miles. The train can- 
not be hastened ; and it is very irksome and fatiguing to 
hold back a marching column to the slower rate. With- 
out imperative military reasons, the command will not 
be kept together. Starting together, with a purely cav- 
alry command, we will complete the march of fifteen or 
sixteen miles and arrive at the camping place a full 
three hours before the train. With a mixed command, 
the ambulance is kept in rear of all, and will arrive with 
the infantry two hours before the train. The cavalry 
are' sometimes held back for morning grazing after 
the infantry and train have resumed the march ; in this 
case, the ambulance will remain with the cavalry until 
the infantry are overtaken, when, keeping in rear of the 
entire command, it will arrive with the infantry as be- 
fore. The adjutant indicates the location of the hospi- 
tal, to which the detachment will proceed immediately. 
Each man will unsaddle and secure his horse with hop- 
ples and lariat in the immediate vicinity. In a scorch- 
ing sun, the backs of animals, moist with perspiration, 
must be protected until dry by the unfolded blanket 
secured by the surcingle. The ambulance is now un- 
loaded and sent to the place where the train will be 
parked when it arrives. All this will take but a few 
minutes ; and the ambulance mules will soon be relieved 
of their harness and grazing at ease. With helpless sick 
men, or in stormy weather, the ambulance may be left 
at the hospital until other provision can be made. The 
reason for not constantly leaving the ambulance near the 
hospital is that his wagon is the teamster's only shelter, 
and it is better that he should lodge near his mules. In 
threatening or stormy weather, or where artificial shade 
is required, the shelter tents may now be pitched. 
The topography of the site of the future hospital will 
now receive careful attention. The location for each 
tent will be marked, briars, weeds, and rubbish removed, 
trenches dug for the sink and the kitchen fire, fuel 
and water obtained, and the cook's fire made ready 
for the match. The location of the tents is a matter of 
some importance. The general location of the hospital 
has been fixed by the commanding officer, but the am- 
bulance officer has discretion as to details. High and dry 
ground will always be selected. A tempting greensward 
at a lower level is always a dangerous experiment; the 
place is smooth and green and level, because storm wa- 
ters concentrate there from every shower. Should our 
command have been preceded by another, it may be com- 
pelled to occupy the old camp ; and there will be a 
temptation to utilize the labor of our predecessors. But 
man is a mischief-breeding animal, and the old camp- 
ground has its dangers. It will be more prudent to 
clear away fresh brambles and pitch our tents to the 
front or rear, to the right or left. The tents will afford 
sufficient shade-and it is better to avoid that of trees, 
for the natural shade is grateful to numerous insects who 
may resent our intrusion ; for, if well apart, the tent and 
the tree will afford shade, and neither lightning nor high 
winds need cause anxiety. We will avoid ant-hills, for 
a ruthless war will result to our disadvantage. 
We will have a constant order in the arrangement of 
our tents and a settled place for everything, so that the 
men may learn to go into camp almost without orders. 
The kitchen should be somewhat in rear and on the lee- 
ward flank, that neither sparks nor smoke may be car- 
ried toward the other tents. If the camp be surrounded 
by dry grass or weeds, they must be immediately cleared 
by a belt wide enough to give protection from the spread- 
ing fire of some injudicious neighbor ; our own kitchen 
fire must be surrounded by a belt of fresh earth. The 
sink must be decorously screened by bushes or a common 
tent. 
The water-supply must be examined. If from a spring, 
a reservoir will be prepared-with gravelled bottom if 
possible-large enough to allow the water to be dipped 
474 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Hospital Steward. 
Hospital Steward,. 
with a camp kettle without roiling. If water is to be 
obtained from a brook, an approach must be made so 
that the water may be dipped from the main current, 
and not from a foul eddy. If from a lake, the water 
may have a brackish taste from saline ingredients ; if so, 
a pit may be dug on the beach that the fluid may per- 
colate through the soil before being used. This will 
improve the matter, but the best will be bad enough. 
The surroundings will be examined carefully, that we 
may not be drinking the seepage from decaying animal 
matter. If the troops begin to use the slope above your 
water-supply as a decorous retiring place to answer the 
calls of nature, the steward will report the matter at 
once to the surgeon, that the matter may be stopped be- 
fore a passing shower can bring down the soluble ex- 
creta. Other organizations must prepare sinks, as the 
hospital has done, and be compelled to use them. The 
perspiration is now dry on the backs of the animals, and 
the blankets can be removed, folded, and placed with the 
other equipments. The animals can be watered and 
moved to fresh circles of grass. 
The experience of a few days will enable all these 
things to be accomplished speedily, and the men will 
have a considerable rest before the arrival of the wagon. 
When this comes, remove only those articles that will be 
needed. The whole force proceeds to pitch the tents 
and store the property and equipments within. The 
cook then unpacks his kitchen, lights his fire, and pro- 
ceeds to prepare dinner. The other men will now dig a 
small trench around the tents, banking the earth so that 
no overflow can reach the interior. These trenches will 
be of little use without a suitable outlet, a problem in 
hydraulics so simple as to be sometimes overlooked. 
The care of animals in camp is, as yet, a new problem 
for the hospital corps. Without experience, or definite 
instructions, the subject can only be discussed in a gen- 
eral way. As a first principle, each man must water, 
feed, and groom his own horse. This will promote a tie 
of comradeship between man and beast that will insure 
a better-cared-for, more serviceable animal. Then, the 
established hours for stable duties must coincide with 
those of the rest of the camp, for the trumpet calls will 
then be a reminder to prevent neglect, and will fix 
boundaries beyond which punishment will not be 
deemed unjust. The question of guards is more ob- 
scure ; no troop commander' will accept the responsibility 
for nine additional animals, and the mingling of these 
animals with a troop herd will be justly deemed a 
nuisance. These animals must be sent sufficiently far 
from camp to secure good grazing, and our four privates 
cannot furnish a herd guard. The most, feasible solu- 
tion of the difficulty seems to be, to put the horses on 
the same footing as the ambulance mules with the quar- 
termaster's train. Two or three lariats twisted together 
and stretched between the wheels of wagons and ambu- 
lance will make an improvised picket rope of sufficient 
length and strength. The end of the ambulance tongue 
is not a proper place to tie up animals. From overlook- 
ing this plain fact, the writer once found himself in 
the sands of Southwestern Texas, sixty miles from the 
nearest post, with the only wagon tongue snapped off at 
the hounds. 
Notwithstanding the midday lunch, the men will be 
ready for their dinner as soon as the cook has it pre- 
pared ; and, in the uncertainties of field service, a de- 
layed meal maybe a lost one. It is impracticable on the 
march to serve three daily meals as in the post; and this 
combined dinner and supper, being the heaviest meal of 
the day, should be served, preferably, two or three hours 
before sunset. Early hours are observed in camp, and 
ample time for digestion before retiring should be given. 
The cook, also, will have ample time, by daylight, to 
put things in readiness for any unexpected order to 
move. 
Tent ropes vary greatly in length with different de- 
grees of atmospheric moisture ; if dry when the tents 
are pitched, a shower in the night will so shorten them 
as to loosen or pull out the pins, when a sudden gust of 
wind may bring down the tents. The men must be in- 
structed to promptly adjust them, as a delay may cause 
a very unpleasant disaster. 
The steward's tent and that of the medical officer 
should be distinguished by planting a hospital guidon 
in front of each, for there may be sick calls in the 
night and the messengers-who will carry lanterns- 
need not arouse the other staff officers and the entire 
hospital. 
With everything in order, the later afternoon and 
evening may be spent in idle revery ; in watching the- 
lengthening shadows, the twilight deepening into night. 
The chirping of insects, the murmur of the brook, the 
rustle of the leaves in the growing stillness, become 
audible music, a droning lullaby, inviting to repose. 
This is the dolce far niente of camp life. At an early 
hour our little world is wrapped in unbroken slumber, 
the occasional challenge of the sentinel only rousing to a 
dreamy consciousness that all is well. 
Permanent Camp.-The bivouac for a night may 
sometimes become a resting-place for weeksand months. 
Sometimes the canvas is gradually replaced by more sub- 
stantial structures, and the bivouac has passed through 
all the stages of development to a military post. When 
it is known beforehand that the position is to be occu- 
pied for a considerable period, additional provisions for 
this more permanent camp can be begun before we dis- 
mount at the end of our march. The location will be 
selected with more care with reference to the convenience- 
of the command, the surface drainage, accessibility to- 
•water, and possible meteorological conditions. Sedi- 
mentary deposit on one side of a bunch of grass, flood- 
wood or rubbish piled against a tree, a general inclina- 
tion in one direction of the undergrowth, especially of 
dead brushwood, are each sufficient to tell you at a 
glance that the apparently driest of deserts is subject to 
overflow. That lightning will not strike twice in the- 
same place is a very unreliable proverb. What has hap- 
pened once is likely to happen again. Like causes have- 
like results, even with the uncertain -weather. Year after 
year a hail-storm will ruin the flowers at one end of the 
garrison and spare the rest. A belt of fallen timber- 
marks the path of a hurricane ; our tents will be safer to- 
the right or the left. Bowlders, or cobblestones, spread 
out at the foot of the hill, mark the limit of a descending 
avalanche ; it will sno-w again ; there are more stones- 
above. The perpendicular face of the terrace has not 
crumbled before the slow processes of rain and frost ; it 
has been cut away by a rushing torrent; more floods 
will come ; more land will fall. 
Where prevailing winds are dry the grass is greener on 
the lee side of the hill. We may profit by the same 
shelter. The cool, refreshing breeze from the mouth of 
a canon tells us that is not a good place for a winter 
camp. Ravines are natural outlets for storm waters ; we 
will avoid the lowest depression. Neither will the ex- 
posed divide be selected. Beware of a spot where un- 
usual vegetation indicates moisture ; it is the probable 
outlet of cold springs that no system of drainage will 
render habitable. In itself, a strong turf is of little im- 
portance, for it will soon be worn away, but if the grass- 
is scattered and wiry, or is replaced by reeds or rushes, 
we will avoid the place ; too cold for healthy grass, it 
cannot be made a sanitary dwelling-place. 
As our stay will be protracted, more room will be re- 
quired, and therefore the increased space may as well be 
cleared at once. A clear passage must be left between the 
tents for convenience, and that an accidental fire may not 
endanger all. The sink will be of greater depth and 
farther away. The tents should face away from pre- 
vailing winds, generally toward the east, or between the 
east and south. Square tents should present a fly to the 
hot afternoon sun. Shade trees in our dooryard will 
give the place a cheerful, homelike appearance, and will 
be so utilized when practicable. 
There is a monotony in life in a permanent camp that 
is sure to grow irksome; everybody will long for the 
novelties of the daily march. This is aggravated by ab- 
solute idleness, and work must be economized so as to- 
provide the men with a few' hours of occupation each 
475 Hospital Steward. 
Hospital Steward. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
morning for as long a time as possible. After the 
essentials are provided, diligence is no longer a virtue. 
It is unwise to do to-day what can be put off till to- 
morrow, for the time will come when even drills will 
cease to be a diversion. If carefully planned, a few 
hours' work each morning after the general police will 
provide many comforts and luxuries. 
The kitchen needs, first of all, a place to store rations 
where they will be secure, out of the way, and preserved 
in better condition than they can be in a tent. A pit of 
suitable size can be dug with a passageway into the tent 
if practicable. It will be covered first with logs or poles, 
then with brush, preferably with the leaves on, and then 
with such a thickness of earth as will render impercepti- 
ble all changes in the external temperature. We must be 
careful to provide ample surface drainage ; and if there is 
danger from ground water, we will carry a narrow 
trench, somewhat deeper than the cellar, to a proper 
outlet. If cobblestones are at hand, this drain can be 
partly filled with them, the sod cut from the top laid on 
the stones, and the remaining ditch filled with earth. 
Poles laid longitudinally so as to leave interstices, may 
take the place of the stones. If necessary, this storeroom 
can be made above the ground level ; but more labor and 
material will be required, and the same uniformity of 
temperature will be attained with difficulty. 
An oven is a very useful addition to the kitchen. Men 
grow tired of baking-powder bread, and good baker's 
bread will be deemed a luxury. If an oven be provided, 
with a cool cellar where stock yeast can be preserved, 
your cook will rival the post baker in the quality of his 
bread ; meat can be roasted and beans baked. With brick 
or stones, lime and sand, but moderate skill is required 
to construct an oven ; but we can do without any of 
these. I have seen good bread baked in a hole in the 
face of a bank, where the soil was but moderately cohe- 
sive, with a perpendicular shaft sunk for a flue. On a 
level prairie, a foundation can be raised, or an excavation 
made for a hearth on which to pull out the coals. An 
empty barrel will serve as a form around which the clay 
can be packed ; a length of stovepipe will give draught, 
or a chimney can be built of sticks and mud. The wall 
must be thick to retain sufficient heat. A piece of sheet 
iron, or an old oil-can, will do for a-door; in the ab- 
sence of these, stones can be piled in the opening and 
banked with earth when the oven is used. The first fire 
will burn out the barrel, but the clay will be hardened 
and make a very durable oven. 
The kitchen fire admits of various improvements. 
Strips of sheet iron with holes for the kettles may be laid 
over a trench. This, with a couple of pieces of Sibley pipe 
or a rude chimney at one end, and a short piece of iron 
at the other to regulate the draught, will answer nearly 
all the purposes of a stove. The supply of sheet iron, or 
tin from old oil cans, is the only limit to the length of 
this trench, which may be extended across the interior of 
a tent, which will be sufficiently warmed thereby in the 
coldest weather. This system of heating may sometimes 
be conveniently applied to other tents, care being taken 
to bury the iron cover where it passes under the canvas. 
Poles, supported by crotches, can be put up in conven- 
ient places, where various articles can be hung when not 
in use. This preserves the articles in better condition 
and gives an unobstructed ground space. For lighter 
articles rope or wire answers the same purpose. 
Tent-pins can be replaced by posts firmly planted close 
to the tents, so as to minimize the hygroscopic variation 
of the ropes, lessen obstruction between the tents, and 
give greater security. The tent-pins will be repacked for 
use when the march is resumed. 
In hot weather, arbors can be built over the tents by 
weaving green bushes into a substantial framework of 
poles. It is better to make the arbor large enough to 
shade the tent without lateral walls, as the latter are in 
the way, and when the leaves get dry increase the danger 
from fire. With this protection from the sun, the square 
tents no longer need the flies, which can be used as awn- 
ings to increase the dry ground space. 
When there is a scarcity of canvas, and at the approach 
of cold weather, improvised shelters will be constructed. 
In choosing an architectural design for these, it is well 
to study the methods of the native population. Their 
experience is longer than ours, and they have arrived at 
their present practice after many errors, into which we 
may fall if we depart from their plans. 
On the prairies the scarcity of timber and the preva- 
lence of cold winds render the dug-out a favorite dwell- 
ing. But when man burrows in the earth, extra care 
must be taken to secure dryness of soil, ventilation, and 
sunlight. Life in a dark cavern will in a short time 
make men look like jail-birds. 
Sods used like brick, make an exceptionally warm 
dwelling, but involve the expenditure of more labor. 
With an earth-covered roof a sod building can be made 
frost-proof and replace the cellar where the nature of the 
soil forbids an excavation. 
The log hut, chinked and plastered with mud, also 
makes a warm dwelling, but windows are difficult to de- 
vise, and sufficient ventilation and light will not be pro- 
vided without a careful supervision. 
In milder climates poles planted in the ground, with 
the interstices plastered with mud, will form the walls, 
and the combined shelter tents of four men will make the 
roof of a very serviceable hut. 
The tent is a very expensive habitation, and when the 
camp is to be of considerable duration, the canvas will 
be replaced by the more economical frame structures, 
and the conditions of a post hospital will be approxi- 
mated. The camp hospital is the germ that by develop- 
ment becomes the post hospital; it is the atom that by 
multiplication produces the field hospital. A ward to 
shelter patients from the elements, a kitchen where their 
food can be prepared, a dispensary where medicines can 
be compounded, an operating-room where wounds can 
be dressed without disturbing other patients, a store- 
room for property not in use, a dormitory for attend- 
ants, a place for the dead, and an office where the records 
can be kept, are the essential elements present in all, and 
the administration is essentially the same. The ward of 
the post hospital, with its perfect ventilation, its cleanli- 
ness, and its abundant sunlight, is the type, the model 
toward which we aim. The variations in management 
are but efforts to obviate the imperfection of our means. 
The hospital tent, covering a ground space of 210 feet, 
and containing a cubic air-space of 1,620 feet, is intended 
to accommodate six patients. The canvas is practically 
as impervious as the walls and ceiling of the permanent 
ward ; some air may percolate through it, but the close 
meshes act as a filter to detain impurities, and the air that 
passes through from without can no longer be deemed 
pure. With a floor space and air space hardly sufficient 
for two patients divided among six, it is evident that the 
openings for ingress of fresh air and egress of foul air 
demand more constant attention. In summer, the side 
walls are raised, the end walls rolled back, and the 
patients are practically in the open air ; but in winter, 
with the sod-cloth sealed down, with the flaps carefully 
closed, with a stove consuming oxygen rapidly, to main- 
tain sufficient warmth and keep the air fit for respiration 
in a hospital tent containing six patients, becomes a very 
difficult problem. For convenience of administration, 
the tents are sometimes joined, end to end ; but, although 
the ventilation of each is kept independent of the others, 
it is unwise to subject more than two tents to a common 
fate, as the chances for error increase with the number, 
and the law of diffusion tends to produce a common at- 
mosphere in all. 
In the field, the soldier carries his personal effects in 
his knapsack, and prefers to bring them with him to hos- 
pital. As the allowance of transportation limits the 
amount of hospital bedding, he may as well use his own 
blanket, leaving the few hospital blankets for emer- 
gencies, or supplementary provision. If the case be in- 
fectious, the blanket and clothing have been contaminated 
before admission, and are better kept away from the com- 
pany baggage. They can also be disinfected before the 
owner is returned to duty. 
Bedsacks stuffed with hay or straw are better than 
476 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Hospital steward. 
Hospital Steward, 
mattresses for field use. When soiled, the bedsack can 
be washed and refilled ; to rejuvenate a hair mattress is 
beyond our resources. 
Laundresses and matrons are unknown in the field; 
every soldier washes his own clothes ; and the laundry 
work of the hospital-as well as the clothing of helpless 
sick men-is a legitimate part of the hospital work to be 
done by members of the hospital corps. If the articles 
are pounded in a barrel of hot soapsuds, secured to a rope 
and allowed to float in a running stream for two hours, 
and then hung up by the corners to drip and dry without 
wringing, the matron and her sad-iron will not be missed. 
Battle.-Behind the line of battle, the first dressing 
station, the ambulance station, and the field hospital will 
each fall under the supervision of a hospital steward, and 
a previous consideration of the elements of the problem 
will facilitate the solution. Great battles are generally 
foreseen, and the location of the field hospital fixed by 
the medical director; but often the movements of the 
enemy are unknown, and an unexpected struggle re- 
quires immediate action. The medical officer may be 
searching for a wounded artery, and the selection of suit- 
able locations, and other preliminary arrangements will 
devolve upon the steward, who must be prepared to act 
intelligently and promptly. To afford the speediest aid 
with the least labor, and to keep out of the way, are the 
chief factors governing our choice of positions. If we 
obstruct the road with the ambulances and delay the ad- 
vance of artillery, ammunition, or reserves, we may give 
the enemy great advantage and ourselves more work. 
The Field Hospital.-This must be sufficiently far 
in rear to insure the wounded from anxiety or further 
danger ; but, with this object attained, as near as possible 
to the fighting line, for bearers and ambulances may have 
many round trips to the front, and an extra quarter of a 
mile will soon amount to a day's journey. From one and 
one-half to three miles is generally the proper distance 
from the line of battle. Previous knowledge of the ter- 
rain is of great advantage, but if we know what we are 
looking for, much topography can be learned at a single 
glance. Water, firm ground, easy access from the main 
road, and protection from the missiles of the enemy are 
the main requirements. A farm-house or other buildings 
that may supplement the tentage in case of need, will be 
a convenience. These things are generally found to- 
gether. A belt of timber or a range of hills may allow 
of a near approach to the scene of operations ; an open 
country, or an unstable front, may render a greater dis- 
tance necessary. It is well to be a short distance away 
from the main road, that it may remain unobstructed by 
waiting ambulances. Then, reserves must use the road 
in passing to the front, and they will not be cheered by 
a close inspection of the unpleasant results of war ; or, 
these marching columns may be observed by the enemy, 
who may experiment with long-range artillery to our dis- 
comfort. Strategic positions, clusters of trees, stone 
walls, and other defensive points will also be avoided, 
for an ebbing tide of battle may pass that way, and mili- 
tary necessity will ignore our field hospital now anchored 
there by a multitude of wounded men. 
The location being chosen, gates will be thrown open, 
fences and other obstructions removed, ditch crossings 
bridged, tilled, or graded, so as to give easy access to the 
front and rear of the proposed hospital. There should 
be a continuous road for ambulances to pass in and out 
without backing, turning, or passing one another. Then 
startled mules can have free headway, and there can be 
no annoying blockades or distressing accidents. 
The operating-room may be a tent-fly stretched as an 
awning, with a small tent to give further protection to in- 
struments and dressings. These should be to windward 
of the roads that the dust of passing ambulances may not 
cause trouble. They should also be screened from ob- 
servation, as patients awaiting treatment will not be 
cheered, and those already cared for will be made sick and 
faint by a view of the operating-table. 
The kitchen should be between the operating room and 
the wards, as it must furnish supplies to each. Boiling 
water and water boiled and allowed to cool in covered 
dishes must be constantly on hand in large quantities, for 
no well or spring will furnish water of sufficient purity 
for surgical purposes. There must also be a constant 
supply of hot tea, hot coffee, and hot beef-soup for 
patients as they are brought in. Hungry men will not 
do good work ; and meals at all hours must be served to 
drivers, bearers, and other attendants. The field hospital 
kitchen is a busy place on the day of battle. 
There should be two wards-one to receive the wounded 
from the field, and one to receive them after they have 
been cared for by the surgeon. The ward for patients 
awaiting treatment may, in fair weather, be in the open 
air with such natural or artificial shade as may be re- 
quired ; in stormy weather, tents must be pitched or a 
convenient building utilized. With a scarcity of canvas, 
it is better to use the buildings as a receiving-ward and 
reserve the tents for the more lasting occupation by 
patients from the operating-room ; for the sanitary condi- 
tion of the tents is under control, and the pathological 
history of the best of farm-houses is a subject for sus- 
picion. 
As the wounded are received from the field, each man 
will be provided with a card-if he has not been already 
provided with one-on which is entered his name, rank, 
company, regiment, hour and day of admission, and any 
other required data that can now be obtained. This 
card goes with the man to the operating-room, where is 
added the diagnosis and treatment, and then to the per- 
manent ward, where entries are made in the register of 
patients, list of wounded, etc., and the hospital number 
is added to the card. 
As the field hospital is but a temporary halting-place, 
liable to advance or retreat at short notice, a final disposi- 
tion of the cases must be made at every opportunity, and, 
without specific instructions from the surgeon, every case 
is awaiting transfer to the division hospital at the base of 
supplies ; and the transfer slip may be prepared at once, 
that transportation need only wait for the entry of date, 
destination, and surgeon's signature. An entry in the 
register of the final disposition, as death, transfer to di- 
vision, or general, hospital, etc., with the date, completes 
each ease so far as the field hospital is concerned. 
The receiving-ward may lack the skilled attendance of 
a surgeon, and the hospital steward must exercise his 
skill and judgment in therapeutics and minor surgery. 
Shock must be combated by artificial heat, hot coffee, 
beef-tea, ammonia, or other stimulants. Pain must be 
mitigated by morphia, by the mouth or hypodermically ; 
in severe cases by anaesthetics. Hemorrhage must be 
watched for and promptly checked until the surgeon 
finds time for its permanent arrest. The order in which 
patients are sent to the operating-room must be deter- 
mined. Hemorrhagic cases must go first; cases in shock 
or collapse must be given time to rally ; cases requiring 
an anaesthetic may alternate with milder ones, to give 
time for the administration. The anaesthetic will be 
given in the ward, as a view of the operating-table may 
unnerve the patient and aggravate the unpleasant effects 
of the drug. 
In the permanent ward, as the cases are received from 
the operating-room, we aim to place them as we would 
have them should our hospital become permanent indeed, 
for wounded men must not be moved about needlessly. 
Prisoners requiring a guard will be placed together. 
Severe cases, not admitting of further transportation, 
will be consolidated, not alone for convenience of nurs- 
ing, but because they will be disheartened at seeing other 
cases selected from the same tent to go to the rear ; then, 
should you be compelled to abandon the location, fewer 
men and fewer tents will need be left behind. Here 
each man's record must be verified and completed. Every- 
thing must be kept well closed up, ready to move at a 
moment's notice. This constant state of preparation for 
all contingencies is the proper remedy for the uncertain- 
ties of the situation, and will prevent that hurry which 
soon passes through confusion to panic. For t,he wounded, 
the battle is over ; and all rumors from the front must be 
rigorously excluded from the ward, as provocative of ex- 
citement and worry. 
477 Hospital Steward. 
House Plumbing. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
In a few hours after the battle the last of the wounded 
will have been brought in, cared for, and sent away to 
a permanent hospital ; instruments will be cleaned, dried, 
and restored to the cases ; dressings and other property 
repacked ; surplus tentage returned to the distributing 
centre ; supernumerary ambulances sent to rejoin the 
central train ; and the field hospital is again a camp hos- 
pital, ready to take its place behind the marching column 
at the trumpet call. 
The Ambulance Station.-As soon as the field 
hospital is located, a steward will go forward with the 
ambulances and bearers toward the fighting line. The 
hospital is marked by a flag ; guidons must be planted 
along the roads leading to it. Study by the way all 
lanes and cross roads, to determine the shortest and best 
routes for the return of the ambulances. Remove ob- 
structions, repair bridges, fill dangerous ruts, and grade 
bad crossings, as you go along, Choose a route not likely 
to be obstructed by troops or trains, screened from the 
enemy by hills or timber. Note the relation of promi- 
nent landmarks to the field hospital, and the roads leading 
to it, that short and definite directions may be given from 
afar. 
The service of the ambulance mules is very important; 
and their safety must be considered in locating the ambu- 
lance station. The limit of safety is generally fixed at 
about a thousand yards from the line of battle ; but the 
nearer the approach, the greater will be the effective 
capacity of the bearers, the more rapidly can the wounded 
be removed from the field. A wood, a hill, a railway 
cut, or a ravine, may justify a much nearer approach to 
the scene of action. These things must be determined 
in a single topographical glance. The spot chosen must 
be a little off the main road, which must not be ob- 
structed ; must afford space for ambulances to pass in 
and out without collision, and without short turns, for 
drivers must have a free headway to bring startled mules 
under control. Uneven ground must be avoided or 
remedied ; the question is not only of broken vehicles, 
but of increased suffering for wounded men. A hos- 
pital flag must plainly advertise our business to friend 
and foe, and guidons, so planted as to be visible from 
the entire field, will help wounded men to find the am- 
bulance station. Shelter here will rarely be required ; 
but should there be delay in the ambulance service, 
shelter tents or blankets can be hung as awnings to give 
protection from sun or rain. A lire may be started and 
preparation made to serve hot soup, tea, and coffee. A 
supply of good water near at hand is an advantage, but 
is not essential, as every ambulance keg will come filled 
from the field hospital. 
A medical officer may be on duty at the ambulance 
station, or all the duties may devolve upon the steward. 
The name, rank, company, regiment, and probable diag- 
nosis of each case brought by the bearers, or coming in 
alone, must be entered in a suitably ruled book, and on a 
card to be attached to the patient. The temporary dress- 
ings applied on the field must be inspected and readjusted 
or others substituted, as may be required. Cases in dan- 
ger from hemorrhage must receive particular attention 
and be emphasized by a strip of red cloth. Shock must 
be palliated by hot drinks, ammonia, or other stimulants, 
care being exercised to avoid excess, always remember- 
ing that whiskey is not a panacea, and that stimulants 
increase the liability to hemorrhage. ■ Pain may be miti- 
gated by narcotics, the dose to be fixed by the Pharma- 
copoeia, and not by the emphasis of the patient's groans. 
Narcotics will only be given for present pain, and not in 
anticipation. Many cases will be able to walk to the 
field hospital, and severe cases have the first claim upon 
the ambulances. With a broken arm supported in a 
sling and bound to the trunk, or with a properly band- 
aged flesh-wound, with a hospital ticket to show the pro- 
vost guard, no man will care to linger in a spot affording 
so little luxury or safety, and small parties may be started 
on foot for the field hospital. Two privates of the hos- 
pital corps will furnish sufficient assistance at the ambu- 
lance station ; if there be more, they may be held as a 
reserve, to go to the front with the litters as required. 
(SUPPLEMENT.) 
The First Dressing Station.-The purpose of a 
hospital corps is to take the unfortunate where they fall 
on the battlefield, and transport them speedily and safely 
to the quietude and security of a hospital, far in rear, 
where they can be put under the most favorable con- 
ditions for speedy recovery. As the proverb says, a 
good beginning is half done, and the first dressing sta- 
tion is the place of beginning. Here, amid the din, the 
turmoil, and the excitement of battle, the attention of the 
hospital corps must be concentrated upon its own work. 
With the speed of systematic order, without disorderly 
haste, each case must have the benefit of cool judgment 
and skill from the very beginning. This can only be at- 
tained by a careful previous training of the men. A 
glance will tell that a man is dead, but it must be an 
educated glance, and without a previous caution the 
men will waste valuable time and leave men to perish 
from lack of attention, while they are bringing corpses 
to the dressing station. They must learn to recognize 
the presence and know the meaning of jetting arterial 
blood ; a few minutes may make the difference between 
life and death ; and it is clearly useless to start for the 
dressing station if their charge will be dead when they 
get there. They rhust learn to slit the clothing with the 
knife, and, having exposed the wound, to check the ebb- 
ing life-blood by direct pressure or by the tourniquet. 
They must have in mind the evil potentialities of the 
sharp fragments of a splintered bone, and learn to confine 
them within limits by such splint material as they have 
at hand, to secure immobility of the injured limb by 
binding it to its uninjured mate or to the trunk. They 
can protect open wounds from further harm by a fold of 
antiseptic gauze secured by a bandage. The aim of the 
first dressing station is to fit men for the journey of two 
or three miles to the field hospital. With intelligent 
bearers, under the supervision of acting hospital stew- 
ards, this work will be so thoroughly done where the 
man falls that the duty at intermediate points will be of 
inspection and verification only. Patients still able to 
walk, will come direct to the dressing station and receive 
attention there. Before beginning the thousand-yard 
journey to the ambulance station, as a rule, every case 
should be inspected and receive a hospital ticket as evi- 
dence that this has been done ; otherwise uninjured men 
might straggle to the rear. No matter how slight the in- 
jury, no wounded man will be returned to the ranks. 
The sight of his own blood unnerves a man ; he may be 
a good soldier to-morrow, he is useless in the line to-day. 
At the ambulance station or the field hospital he can re- 
place a hospital corps private, who can be sent forward 
for duty with the litters. After every battle there is a 
list with the uncertain record f' missing ; " and anxious 
friends turn to the records of the medical department, 
which should begin at the first dressing station. 
After a continuous peace of twenty-seven years, it is 
useless to try to follow the duties of the hospital steward 
through all the intricacies of field service in war. The 
survivors from our last great struggle are old men now ; 
and the everyday problems, the little perplexities and 
vexations of that great period have passed from their 
memories ; like the discordant note in distant music, these 
things have been left behind. The elements already dis- 
cussed are raised above the humdrum of life : these 
seemingly petty details assume a vital importance when 
we consider that, from this starting-point the younger 
generation must go forward to meet the great problems 
of the future. We live not for to-day, but patiently 
strive to perfect our methods in expectation of the mo- 
ment when Father Time shall change the slide in his 
dissolving views, when these minor pictures shall fade 
away, and we shall stand face to face with the grander 
panorama of a Nation in Arms. The magnitude of the 
picture will not appal us; for in it we will recognize-as 
old friends-familiar elements, combined in familiar 
atoms, multiplied many fold, but ever the same. The 
steward's work will be simplified ; for in this increase of 
work there must be a division of labor. If he keep the 
records, it will be without interruption from kitchen or 
ward ; if in charge of the kitchen, he can give it his en- 
478 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Hospital Steward. 
House Plumbing. 
tire attention ; the perfection of his methods will stand 
out in bold relief ; he will be glad that he learned to avoid 
errors on a smaller scale, for what he learned to save as 
pennies will be dollars in the larger transactions; his 
tables, laden with delicacies, will tell the story of long 
and careful preparation. In immediate charge of the 
sick, in a large general hospital, in church or school- 
house, on cars or steamboats, or in tents on the hillside, 
the ward of the old post hospital with its annexes wijl 
forever remain the unit of measure, the model and the 
type. Each oscillation of the kaleidoscope will produce 
a" pleasing combination, for the beauty of each picture 
will be derived from the perfection of the same familiar 
fragments. 
The advent of war will bring higher duties ; for the 
increased work there will be a multitude of willing but 
untrained hands ; with a perfect knowledge of details, 
with long experience in the study of men, the hospital 
steward will stand forth as a teacher, with a far-reaching 
influence for good. 
Art is long, and time is fleeting, and no man can hope 
to say, in one short work, the hundredth part of what 
might well be said on any subject. The chief object of 
book or treatise is to make men think ; and, if this little 
work is laid down, not only with a knowledge of what 
has been said, but with a consciousness of dozens of other 
things that might have been said in the same connection, 
if it incites to meditation, to more thorough preparation, 
it is a success-its highest aim has been accomplished. 
George IF. Adair. 
HOUSE PLUMBING, GENERAL PRINCIPLES OF. 
During the last six years considerable progress has 
been made in the practice of plumbing toward the ideal 
outlined in the Handbook in 1886. Greater simplicity 
in piping, and more science in the construction of the 
fixtures, are the most marked features of this progress. 
Several cities and towns have modified their plumbing 
ordinances by striking out the requirement for special 
trap ventilation called " back venting," and architects, 
builders, and plumbers generally are becoming more 
convinced of the uselessness and danger of 
such a requirement. 
The importance of constructing all fixt- 
ures on the principle of the "flush tank" 
is becoming widely recognized, and we 
rarely find to-day in first-class plumbing 
work fixtures with the diminutive outlets 
almost universal ten years ago. The waste 
pipes are now thoroughly scoured at each 
discharge of the wide-mouthed fixtures 
now in use, and ample ventilation is 
effected throughout the entire drainage 
system by the discharges, as well as by the 
thorough ventilation of all the main stacks 
of piping at both top and bottom. Me- 
chanical seals for trapping are fast disap- 
pearing, and are now rarely seen in good 
work. People have become convinced that 
balls and valves in traps increase the com- 
plication, retard the outflow, and add abso- 
lutely nothing to the security of the seal. 
A sound water seal has been shown to 
afford perfect safety, and, moreover, no 
other kind of seal is practicable in water- 
closet traps. Hence the simple antisi- 
phonic " water seal trap is becoming exclu- 
sively used for all kinds of fixtures. 
The sanitary rule of setting all fixtures "open" has 
become fashionable. Traps and waste pipes are neatly 
and solidly set, and handsomely polished or nickel- 
plated. They are becoming each year more frankly rec- 
ognized by architects as legitimate subjects for artistic 
treatment. Scientifically constructed and beautifully 
decorated fixtures, set with highly finished open piping, 
are among the "show" features of a well-appointed 
mansion to-day. It is the rule now to admit light and 
air everywhere under the fixtures, where ten years ago it 
was the exception. 
The quick flushing sink for kitchens and pantries de- 
scribed in the Handbook has been greatly improved 
within the last few years, and is now entirely automatic 
in its action. It affords, perhaps, the best illustration of 
what can be done by plumbing fixtures toward scouring 
out the waste pipes by powerful water flushing. 
Figs. 310 and 311 represent the perfected sink in sec- 
tion and in perspective view. The sink is discharged by 
means of a self-acting siphon, and a vertical strainer is 
interposed between the flush-pot and its siphon. The 
short arm of the siphon is trapped with a seal-retaining 
Fig. 310. 
Fig. 311. 
trap just behind the vertical strainer. This strainer 
slides up and down in a groove to give access to the trap 
when desired, but closes again automatically by its own 
weight as soon as released. It has been assumed as an 
indispensable condition in the design of the apparatus, 
that absolutely nothing should be dependent upon the 
intelligence or care of the servant, and that by no possi- 
bility could the waste passages become clogged, either 
by accident or by design. 
Clean-out openings are provided at the trap and weir- 
chamber, and give access to every part of the waste sys- 
479 House Plumbing, 
Hydrogen Peroxide. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
tem. No bones and solid refuse can be scraped into the 
discharge outlet and dropped into the waste pipe, be- 
cause this pipe ascends instead of descends at the outlet, 
and should the top be clogged it will simply cause the 
water to cease to How out until the obstruction is re- 
moved, which can easily be done by simply raising 
the lower strainer and lifting out the obstruction by 
hand. 
The operation of this apparatus is as follows : The 
sink is used in the ordinary manner until the flush-pot 
fills to the height of the siphon overflow. When this 
point has been reached the next discharge of a quart or 
two of water suddenly emptied from the washing-pan or 
drawn from the faucet, charges the siphon and causes the 
entire contents of the flush-pot to rush out through the 
waste passages, filling them " full bore " and scouring 
them from end to end. The solid matter and large 
lumps of grease will be left on the bottom of the flush- 
pot, and must be removed by the servant in the proper 
manner, inasmuch as they cannot possibly be removed in 
any other manner. 
The simple standpipe overflow basin and bath-tub, and 
the siphon "jet'' water-closet described in the Hand- 
book as lately introduced improvements in plumbing, 
have now come into very general and constantly increas- 
ing use, and in one form or another are recommended by 
every dealer in plumbing fixtures as embodying the cor- 
rect principles of construction. 
J. Pickering Putnam. 
HYDRACETIN (Acetyl-phenyl-hydrazine). A chemical 
compound of hydrazine, H2NNH3, in which two hydro- 
gen atoms are replaced by phenyl and acetyl groups. Its 
formula is C6H5 HNN1I CH3CO. It may be prepared 
by mixing one part of anhydrous acetic acid with two 
parts of phenyl hydrazine ; the mass becomes hot, and on 
cooling deposits crystals of hydracetin. Pyrodin of com- 
merce is hydracetin mixed with three parts of sugar. It 
was introduced by Dr. Dreschfleld, of Manchester, Eng- 
land, in 1888. Hydracetin is a white crystalline powder, 
without taste or odor. Soluble in water, 1 part in 50, 
more so in hot water; very soluble in alcohol. Dose, 
one-sixth to one-half grain. 
It possesses powerful antipyretic properties, and was 
recommended for typhoid fever, rheumatic fever, and 
phthisis. The temperature begins to fall in half an hour, 
and the lowest point is reached in two hours. The effect 
is not of long duration, and the fever begins to rise again 
in a few hours. In acute rheumatic fever it appears to 
have had the best effects, the painful joints being also 
relieved. It also possesses analgesic properties, and has 
been used to relieve the pains of locomotor ataxia, 
neuralgia, and muscular rheumatism, with marked suc- 
cess. 
Its employment, however, is negatived by its toxic ac- 
tion. It is a very decided blood - poison, exerting a 
destructive action on the corpuscles, and haemoglobinuria 
is produced. It gives rise to depression, coldness of ex- 
tremities, sweating, and weakened pulse and respiration. 
It is generally conceded that it must be used with care, 
not more than two grains being given during the day, 
and it should not be continued for more than three days 
in succession. Guttman, who early reported its value as 
an antipyretic, and carefully studied its action, advises 
one and one-half grain a day in divided doses. If the 
antipyretic action is wanted, the second dose should be 
given an hour after the first ; if for rheumatism or neu- 
ralgja, one dose should be given in the morning, the 
other in the evening. 
Hydracetin is also employed as a local remedy for pso- 
riasis, its value in this disease depending upon its reduc- 
ing power. It is employed as an ointment of pyrodin in 
the strength of one part in ten. Il has failed to meet 
with approval, as it is not equal to pyrogallol and chry- 
sarobin, and if applied externally may produce toxic 
symptoms. A case is reported where a ten per cent, 
ointment, applied to a third of the surface of the body, 
produced jaundice, haemoglobinuria, and the usual poi- 
sonous symptoms within ten days. Beaumont Small. 
(SUPPLEMENT.) 
HYDRASTIS CANADENSIS (Golden Seal). Although 
not at all a new remedy, its haemostatic properties 
have received a great deal of attention during the past 
few years, particularly in Europe. Attention was di- 
rected to it in Germany in 1883, by Dr. Schatz, at a 
meeting of the Association of Physicians and Natural- 
ists. He described it as an American remedy of decided 
value, and reported strongly in its favor for the treat- 
ment of chronic hyperaemia, and chronic inflammation 
of the internal genital organs attended by losses of 
blood. Since this introduction it has been extensively 
employed with very general satisfaction. In menor- 
rhagia and metrorrhagia without organic disease, as well 
as in hemorrhages associated with metritis, endome- 
tritis, and other structural changes, it is said to check 
the flow more rapidly than any'other remedy. In the 
hemorrhages occurring at the menonopause, and the ex- 
cessive menstruation of young girls in which the tissues 
are relaxed and congested, it has proved itself particu- 
larly useful. It also relieves all conditions of conges- 
tion of the pelvic organs, ovarian pain, dysmenorrha'a, 
and other distressing symptoms arising from this cause. 
Its action when the flow is due to myomata appears un- 
certain, some observers claiming for it decided curative 
powers, while others have failed to secure any benefit. 
It has been used in obstetric practice without producing 
any ill effects. Bossi, of Genoa,1 gives the result of sixty- 
four cases in which he employed the fluid extract in such 
cases. He gave from one hundred to two hundred minims 
daily, in divided doses, and found that it had " a constant, 
curative, and prophylactic haemostatic action on the 
uterus during pregnancy, labor, and the puerperium, 
without any ecbolic effect or modification of the uterine 
contractions." He found it more beneficial than ergot 
in the flooding of labor and in post-partum hemor- 
rhages, and he trusted to it as a prophylactic for hemor- 
rhages at all periods. Notwithstanding this very de- 
cided statement regarding its ecbolic properties, it should 
be administered with great caution during pregnancy. 
Cases are reported * in which it has exerted a very pow- 
erful action on the uterine muscular tissue and induced 
abortion. Dr. Falk4 in his experiments with hydras- 
tinine was not able to arrive at any conclusion, but 
thought it probable that it did possess an ecbolic action. 
The haemostatic properties of Hydrastis are due to a 
constricting action on the arterioles, and this effect seems 
particularly directed to the vessels of the uterine mucous 
membrane. Numerous Experiments have been made to 
determine the physiological action of the drug, and 
among the more recent is a very thorough study of the 
alkaloid made by Dr. Cerna,3 of Philadelphia. The 
following are some of his more important conclusions : 
Hydrastine is poisonous to animals, the minimum lethal 
dose in dogs being 0.50 gramme for every kilogramme of 
the body weight; it kills by failure of respiration. In 
small doses it appears to have a stimulating effect on the 
muscular tissue; toxic quantities, however, destroy the 
irritability of the muscular tissue ; on the nervous system 
it resembles strychnine in its action, increasing reflex 
activity by stimulating the spinal cord ; in larger quanti- 
ties it produces convulsions, and lastly paralysis ; on the 
circulation, its effect is to diminish the number and in- 
crease the volume of the cardiac beats, by an action upon 
the heart-muscle and the intra-cardiac ganglia ; in minute, 
medium, and poisonous doses it invariably causes a fall 
in the blood-pressure ; in lethal doses this continues until 
death occurs, while in smaller and medium doses the 
pressure gradually rises again, but never above the nor- 
mal point. This lowering is due to a direct action on the 
heart, and through a paralyzing influence exercised on 
the vaso-motor system, acting through the central ner- 
vous ganglia. 
Although the active principles obtained from the plant 
have been extensively employed, the tincture and fluid 
extract still sustain their reputation and are preferred by 
many. Twenty or thirty minims of the tincture, or 
twenty minims of the fluid extract, repeated four or five 
times a day, will generally secure all the virtues of the 
plant. 
480 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
House Plumbing. 
Hydrogen Peroxide, 
Two alkaloids have long been known, hydrastine and 
beberine, and a third termed xantho-puccin has recently 
been described, but it has not been definitely separated, 
and its identity remains a matter of dispute. 
Hydrastine possesses all the haemostatic properties of 
the plant. Its salt, the hydrochlorate, is usually em- 
ployed. It is a crystalline white or faintly-yellow salt, 
soluble in water and having an extremely bitter taste. It 
is employed in doses of from half a grain to five grains, 
in the same conditions and with the same objects in view 
as when the preparations of the crude drug are given. 
The alkaloid beberine is not present in large quantities, 
and is generally obtained from beberis vulgaris, in which 
plant it is present in large quantities. It is devoid of 
any haemostatic properties, and is employed as a tonic 
and alterative. It is a bitter orange-yellow crystalline 
powder. Hydrastin is an eclectic remedy consisting 
chiefly of beberine and extractive matter, it is used for 
many of the purposes for which the alkaloid is employed, 
and as a cholagogue, stomachic, and tonic. It is a bright- 
yellow powder. 
The latest product, and what is looked upon as the final 
active principle, is hydrastinine. It is a product of the 
oxidation of hydrastine which breaks up into hydrasti- 
nine and opianic acid. Hydrastinine hydrochloras, the 
salt employed, is a pale-yellow crystalline powder, hygro- 
scopic and soluble in its own weight of water. The dose 
is very much less than that of hydrastine, being from half 
a grain to one and a half grain. This substance is said 
to possess all the medicinal properties of the plant, and 
is used in all the disorders for which the latter has proved 
beneficial. The reports of its use are very satisfactory. 
It is said to act very rapidly, producing its effect almost 
immediately when administered by subcutaneous injec- 
tion, while the preparation of the root requires several 
days' administration before any decisive effect is produced. 
Dr. Falk4 has used it in all forms of uterine hemorrhage 
with very great success ; in menorrhagia he obtained the 
best results by commencing the treatment six or eight 
days before the expected flow. He gives during this time 
a daily hypodermic injection of three-quarters of a grain 
of the hydrochlorate of hydrastinine, and when the flowr 
has begun he doubles the dose. He uses a ten per cent, 
solution in distilled water. No advantage or disadvan- 
tage arises from larger doses. Other reports6 are equally 
favorable : twenty-six out of forty-eight cases of hemor- 
rhage were checked within twenty-four or thirty-six hours, 
and of twenty-seven cases it exerted a decidedly beneficial 
action in twenty-four. It was administered iu capsules 
or pearls, each containing three-fifths of a grain, three or 
four being given daily. No unfavorable symptoms fol- 
lowed its use. 
Its vaso-constrictive action has suggested the use of 
hydrastinine in epilepsy.6 Experiment on animals with 
two-thirds of a grain per kilogramme, distinctly dimin- 
ished the excitability of the cerebral cortex, and moder- 
ated or prevented artificially induced epilepsy. These 
observations led to its use in six cases of epilepsy, in 
doses of from one-quarter of a grain to one or two grains 
per day. In four of the cases the attacks decreased, both 
in frequency and intensity ; in the other two not much 
benefit was noticed. 
In addition to the haemostatic properties, hydrastis also 
exerts a beneficial effect on the mucous membrane of the 
digestive tract. It has been used with success in atonic 
dyspepsia, and habitual constipation due to torpid liver; 
and in the debility arising from the drain of the bleed- 
ings it acts as a tonic, resembling quinine in its action. 
Its local action is also important, its alterative and 
astringent properties having long been utilized. It is 
used as a lotion or injection in leucorrhoea, purulent 
vaginal discharges, erosions of the uterus, and gonorrhoea. 
Its local application has also been beneficial in pharyn- 
gitis. Beaumont Small. 
1 British Medical Journal. November, 1891. 
2 The Lancet. May. 1886. 
3 The Therapeutic Gazette, May, 1891. 
4 British Medical Journal, May, 1890. 
6 Merck's Bulletin. March, 1892. 
* Ibid., October, 1892. 
(SUPPLEMENT.) 
HYDROFLUORIC ACID. The employment of inhala- 
tions of this gas has been suggested by Dr. Dujardin- 
Beaumetz as a means of treating tuberculosis of the lungs. 
Knowing its very powerful antiseptic and bactericidal 
properties, and it having been demonstrated that a 1 to 
3,000 solution was destructive to the tubercle bacilli, he 
instituted a series of experiments, and found that animals 
could live without inconvenience in an atmosphere con- 
taining one part of hydrofluoric acid to 1,555 of air. In- 
quiry among the employees of glass-works also showed 
that the vapors in no way acted injuriously on the work- 
men, and those who were afflicted with pulmonary affec- 
tion were benefited by employment in the works. For 
the purpose of applying this treatment the patient is 
placed in an air-tight compartment in which the atmos- 
phere has been impregnated, with the gas. One grain of 
the pure acid may be vaporized in a room of the capacity 
of twenty-two cubic metres, which gives the proportion 
of 1 to 25,000 ; or, the room may be filled with air that 
has been forced through a solution containing fifty per 
cent, of the gas. The patient is placed in the room for 
one hour daily, the period being gradually prolonged. 
The results of this treatment are varied : in some in- 
stances very favorable results were obtained, in others it 
proved irritating and increased the pulmonary trouble. 
Experience has shown that asthmatic and emphysema- 
tous patients, and those subject to haemoptysis should not 
be subjected to the treatment. 
Inhalations have also been applied to other zymotic 
diseases. In diphtheria it has been used, the air of the 
room being impregnated with the gas obtained by vapor- 
izing the acid, or by the action of sulphuric acid on fluor- 
spar. 
In whooping-cough it is reported to have a very de- 
cided effect. One tablespoonful of the acid is put in about 
one quart of water in an inhaler, and used every second 
day. Four or five inhalations are said to check the 
paroxysms, and the cough that remains may be treated 
as an ordinary catarrhal affection. 
The ordinary acid of commerce is impure and requires 
to be redistilled for medicinal purposes. It is an aqueous 
solution of about thirty per cent, of the gas, from which 
copious white suffocating fumes are evolved. It requires 
to be kept in leaden or gutta-percha vessels, on account of 
its corroding action on glass. 
The salts of hydrofluoric acid have been utilized for 
their antiseptic properties, the fluoride of sodium being 
the most suitable. It is quite unirritating, and is recom- 
mended for use where bichloride of mercury cannot be 
employed. Experiments have shown that a 1 to 350 so- 
lution prevents the growth of the yeast fungus, and pa- 
thogenic and non-pathogenic microbes. Solutions of the 
strength of 1 to 3,000 may be used for ordinary antiseptic 
purposes. Beaumont Small. 
HYDROGEN PEROXIDE. There has been an extra- 
ordinary revival of this compound during the past few 
years. No new method of utilizing its many virtues has 
been discovered, nothing new has been added to its me- 
dicinal properties, and yet, after an interval of more than 
thirty years, its value is suddenly recognized by the pro- 
fession and it becomes " the necessary peroxide of hy- 
drogen." It is difficult to trace the cause of this sudden 
prominence, but in all probability we have to thank the 
enterprise of the manufacturers for bringing it to the 
notice of the physician and the surgeon. 
Discovered in 1818 by Baron Thenard, it remained 
almost unknown until Dr. B. W. Richardson instituted 
a series of experiments, to consider the possibility of 
utilizing it in the treatment of disease, and communicated 
the result of his work to the Medical Society of London 
in 1860 and 1862. These papers formed a very exhaustive 
treatise and introduced the subject in almost as thorough 
a manner as we know it at the present day, although the 
presence of germs and the role they play in disease was 
not known at that time. The following is Dr. Richard- 
son's resume of his papers. In the paper of 1860 he ad- 
vanced that, (a) the peroxide quickens oxidation, increases 
secretion, arterializes blood, and hastens the decomposi 
481 Hydrogen Peroxide. 
Hydrogen Peroxide. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
tion of decomposing animal tissue ; (b) in combination 
with blood it restores the power of muscles just dead to 
contract, and yet calms muscular irritability ; (c) that it 
promises valuable aid in a large number of cases of dis- 
ease ; (d) that in instances of poisoning by narcotics and 
the alkaloids it might with advantage be introduced in 
the blood by transfusion or injection ; (c) that in tetanus 
it affords a most rational treatment, since tetanic rigidity 
is lost by its presence in muscle ; (/) that in typhus, in 
which death takes place from what I designated as as- 
phyxia commencing in the blood, it might be employed 
with good effect as an oxygenator ; (</) that it ought to 
prove useful both as an internal and an external remedy 
in the treatment of cancer. In the paper of 1862 the fol- 
lowing were his conclusions : (a) that in diabetes the 
peroxide reduces the specifio gravity of the urine, while 
it rather increases the quantity ; (b) that in chronic and 
subacute rheumatism it affords relief ; (c) that in valvular 
disease of the heart with pulmonary congestion it gives re- 
lief to the dyspnoea ; (d) that in mesenteric disease and in 
jaundice it causes an improvement in the digestion; (e) that 
in pertussis its effect for good is very remarkable, since it 
cuts short the paroxysms of cough, and seems decidedly to 
shorten the period of the disease ; (/) that in chronic 
bronchitis it lessens the dyspnoea and renders the expec- 
torated matter less tenacious; (y) that in chronic laryn- 
gitis it gives pain on being swallowed, and does not 
appear to be useful ; (Ji) that in anaemia it does not of 
itself render a service, but favors the good effect of iron ; 
(0 that in the first stage of phthisis it causes improvement 
in the digestion, and in the later stages gives unquestion- 
able, and even wonderful, relief to breathlessness and op- 
pression, acting, in fact, like an opiate without producing 
narcotism, and assisting oxidation ; (J) that it produces a 
modified salivation, and might be a good substitute for 
mercury and the iodides in the treatment of syphilis. 
In these papers, although noticing the disinfectant 
properties, the author did not emphasize their importance, 
but in an address to the British Medical Association, in 
1865, the local employment of the remedy and its disin- 
fectant property were particularly dwelt upon. On this 
occasion he introduced its use as a spray, and recom- 
mended it as a disinfectant for sick-rooms in which 
patients were suffering from infectious disease, for fetid 
and ulcerated surfaces, and for the treatment of diph- 
theria, syphilitic ulcerations of the throat, and gangrene. 
Until quite recently there appears to have been but lit- 
tle advantage taken of these important communications. 
From time to time an occasional paper would appear, 
and with the advance of knowledge in the field of bac- 
teriology its germicidal properties were demonstrated, 
but the applications of these properties to the treatment 
of disease were wholly disregarded. The revival of its 
use may be said to date from a paper by Dr. E. R. 
Squibb, of Brooklyn, published in Gaillard's Medical 
Journal for March, 1889, in which he pointed out its 
valuable properties and advocated its use in diphtheria. 
There had been occasional communications before this, 
but they had not attracted the attention of the medical 
authorities, or influenced the profession to any extent. 
Numerous papers and reports of cases treated with the 
peroxide followed, but it was not established as a remedy 
in surgical practice until Dr. R. T. Morris, at the meeting 
of the American Medical Association, in 1890, described 
its usefulness wherever there was formation of pus. 
Very little is known of the chemical constitution of 
hydrogen dioxide. It has the formula H2O2, and is de- 
scribed as water combined with an additional atom of 
oxygen, but what this combination is has not been deter- 
mined. Richardson considered it identical with ozone, 
and this view is very generally accepted ; it responds to 
the same tests, and it has been found that water saturated 
with as many volumes of oxygen in no way resembles the 
solution of the peroxide, and the action of the two is very 
different. In using the peroxide it is possible to secure 
either the ozonic action or the action of simple oxygen ; 
if the solution or spray is used ozone is the active ingre- 
dient, but if the peroxide is decomposed the gas that is 
evolved is no longer ozonic but simple oxygen gas. 
The therapeutic value of the peroxide depends upon 
its instability, and the decomposition that takes place 
when it conies in contact with certain substances. It is 
compatible with the mineral acids, alcohol, alcoholic 
solutions of the alkaloids, alcohol combined with ether, 
amyl nitrite, glycerine, tannin, and is not decomposed by 
healthy living tissue, or if decomposed by other sub- 
stances, exerts on it no injurious influence ; but in the 
presence of every form of germ life, decaying organic 
matter, pus, or abnormal secretion, it is instantly decom- 
posed and the liberated " ozonic " oxygen attacks and de- 
stroys such substances. Its action is perfectly simple 
and uninjurious, it cleanses the part of all impurities, 
and acts as a mild stimulant to granulation tissue ; it 
does not cause pain, except in a slight degree when ap- 
plied to the delicate mucous membranes of the nose, con- 
junctiva and urethra. 
Possessed of this bactericidal action and the property 
of destroying albuminoid discharges and necrosed tis- 
sue, its value in many surgical diseases is readily under- 
stood. Applied to ulcers, abscesses, or any secreting sur- 
face, it destroys all foreign matter and leaves a clean 
healthy surface ready for immediate repair. A daily ap- 
plication of the fifteen-volume solution, and dressing with 
borated lint or any simple dressing, will secure a healthy 
and rapidly healing surface. In abscess cavities the same 
treatment may be adopted after evacuation, and Morris 
states that it is possible to open an abscess of the breast, 
sterilize it, and destroy the pus, and have perfect recov- 
ery, under one dressing. Where there is a sinus or where 
the abscess is deep and burrowing, it is better to in- 
ject slowly and gradually, allowing the first portion to 
cease effervescing before a further injection is made. In 
some instances, where the sinus is not deep, it may be 
desirable to inject freely, the distention that follows al- 
lowing the fluid to permeate more thoroughly into the 
numerous recesses that may be present. For sloughing 
and gangrenous conditions of cancerous disease it is in- 
valuable to the surgeon and to the patient. It rapidly 
disinfects the part and removes the offensive odor, and 
its haemostatic properties check any dangerous hemor- 
rhage that may follow the removal of sloughing tissue. 
For inflamed mucous surfaces, • where pus is freely 
secreted, it may be used with much advantage, partic- 
ularly if the discharges are foul and offensive. In con- 
junctivitis, ozaena, ear troubles, cystitis, vaginitis, and 
gonorrhoea, the parts are to be first washed and a solu- 
tion of fifteen volumes diluted with eight or ten parts of 
distilled water applied freely. In these cases it will 
sometimes be found necessary to use cocaine to allay any 
sensitiveness. In washing out the cavity of the bladder 
a double catheter should be used to allow the liberated 
oxygen to escape. 
It has lately been used in the treatment of empyema. 
Cases are reported in which the pleural cavity was 
washed with the peroxide, followed by a borated solu- 
tion. The advantage derived from the peroxide in all 
cases was very decided, recovery being rapid and unac- 
companied by any unfavorable symptom. In poisonous 
snake-bites and the bites of rabid animals, it is recom- 
mended as an antidote, and has been used with good 
effect to counteract the painful effects of rhus poison- 
ing. 
Its powerful local action makes it a very valuable ap- 
plication in diphtheria, and this is one of the most im- 
portant uses of this compound. It proves very efficient 
in destroying and removing the diphtheritic membrane 
and counteracting the ptomaines that may be formed. 
The frequency and strength of the application to a 
great extent depends on the character of the disease. 
Two or three applications may be sufficient, but if the 
membrane is extensive and interferes with respiration, 
the solution can be used every hour with benefit. Spray- 
ing or gargling should always be adopted. The fifteen- 
volume solution is used in its full strength if the case is 
urgent, but the solution diluted with three or four parts 
of water will generally be sufficiently strong. Reports 
point to its very great service, and it is rapidly becoming 
the one topical application that is supplanting all others. 
482 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Hydrogen Peroxide. 
Hydrogen Peroxide. 
In all forms of diphtheritic inflammation it is equally 
efficient, as either in the nose or in the larynx the spray 
readily reaches the site of the disease. In addition to its 
beneficial local action, the inhalation of the liberated 
oxygen undoubtedly is of benefit, particularly in the 
severe cases in which the oxidation of the blood has been 
interfered with, and the patient is in a condition of 
cyanosis. 
The internal administration of the peroxide is as impor- 
tant as its topical use. In giving it we are giving oxygen, 
and, as in its local application, it is the supply of free 
oxygen upon which its beneficial action depends. With- 
in the intestinal tract, as well as on the surface of the 
body, its disinfectant and bactericidal properties are 
taken advantage of. In thrush, aphthous states of the 
mucous membrane of the mouth, and all such unhealthy 
conditions, it acts quickly and beneficially. In chronic 
gastritis, gastric ulceration, and all catarrhal disorders 
accompanied by fermentation and flatulent indigestion, 
its use checks the abnormal fermentation and restores 
the disturbed function. Under its influence the general 
acidity of the gastric juice and the proportion of free 
hydrochloric acid are increased, and the digestive power 
markedly improved. In the forms of dyspepsia accom- 
panied by hyperacidity the administration of the perox- 
ide causes an aggravation of all the symptoms. One 
drachm of the fifteen-volume solution, diluted, three 
times a day before meals, has proved a sufficient dose. 
For disturbances of the lower bowel and rectum it may 
be administered as an enema. Richardson used one 
ounce to a pint of water and injected it through an 
O'Beirne tube. In typhoid fever it has been used in this 
way and administered by the mouth. One ounce may 
be diluted with one pint of water and taken during the 
day as a beverage. Richardson used it with favorable 
results, and Dr. H. F. Wiggin, in the New York Medical 
Record, November 28, 1891, reports a case in which he 
believed that the peroxide proved of great value. In ad- 
dition to the above conditions, in which it exerts a local 
disinfectant action, its power of oxidizing the blood opens 
up a train of diseases in which it may prove of very 
decided service. Whether administered by the mouth 
or inhaled into the lungs, it affords rapid relief in asthma, 
emphysema, chronic bronchitis, phthisis, heart disease, 
and in acute pneumonia. Also in poisoning by hydro- 
cyanic acid and the numerous new aniline compounds 
it should prove of benefit. In pulmonary phthisis it not 
only relieves dyspnoea and shortness of breath by im- 
proving the blood, but also counteracts the night-sweats 
and fever by neutralizing the ptomaines. It is also sup- 
posed to act favorably by destroying the bacilli and the 
purulent infiltrated tissue. In the first stages it possesses 
a decided remedial action, and Richardson states that it 
is, of all medicines, the most valuable. This observer 
also suggested that it might be administered by sub- 
pulmonary injection, throwing the solution directly into 
the lung tissue. He considers that no harm should fol- 
low this method, and the oxygen would rapidly diffuse 
and destroy the tuberculous exudation. In whooping- 
cough it is said to act almost as a specific, given internally 
and inhaled. Dose : from ten to eighty minims, three 
times a day, diluted. Its beneficial action here is due not 
only to its antiseptic properties, but also to its power 
of relaxing muscular spasms. Its action is the same in 
asthma and angina pectoris, and other spasmodic affec- 
tions. This action described by Richardson leads him to 
suggest its use in hydrophobia and tetanus. He proposes 
to inject groups of muscles with the ten-volume solution, 
using amyl nitrite in combination if necessary. 
The property of promoting oxidation in the system has 
led to its use in diabetes, with beneficial results. The 
sugar is rapidly diminished, but the amount of urine is 
increased, this latter effect being characteristic of the 
peroxide, which increases all the glandular secretions. 
To overcome this excessive secretion the following com- 
bination is used by Dr. Richardson : Codeine, 3 grains ; 
alcohol, 2 drachms ; peroxide of hydrogen (10 vols.), 2 
fluid ounces ; distilled water to make 12 fluid ounces ; a 
tablespoonful to be taken three times a day in a wine- 
(SUPPLEMENT.) 
glassful of water. Many other observers have obtained 
the same satisfactory results in this disease. 
On account of its stimulating effect on the excreting 
glands, it is highly extolled by Richardson in the treat- 
ment of syphilitic disease, especially in the secondary 
and tertiary stages. For indolent ulcers, skin lesions, 
and tertiary deposits its internal administration is very 
beneficial, particularly if the cachexia is marked. He 
recommends that it be given in two- to four-drachm doses, 
three times a day, with infusion of cinchona. The only 
unfavorable action is a mild form of salivation, which is 
readily overcome by stopping the medicine. It also in- 
creases the action of mercury when given at the same 
time, much smaller doses of the mercurial salt proving 
effective. 
The evolution of the oxygen and the great expan- 
sion that accompanies this physical change, furnish 
what may be termed its mechanical use. This may 
be taken advantage of in invagination of the bowel, 
and may also prove serviceable when sounding the blad- 
der for stone, a small quantity causing a sufficient disten- 
tion for the purpose. It is also recommended to inject it 
into a part in which suppuration is suspected. If pus is 
present the usual reaction occurs and distention follows, 
into which an incision may be made with facility. 
The freedom from toxic action and its unirritating 
qualities render it a very simple remedy to use. One to 
two drachms of the fifteen-volume solution, three or four 
times a day, can be administered, without the fear of any 
unfavorable symptoms, and will generally prove suffi- 
cient to secure all its peculiar effects. It should be freely 
diluted with water free from any organic matter, and 
mixed as required. For enemata and for hypodermic 
injection the solution should always be neutralized with 
soda. 
For sick-rooms its disinfectant and deodorizing proper- 
ties are best secured by diffusing it as a spray, and hard 
rubber or glass appliances only should be used. For 
spraying the throat the solution may be medicated with 
tannin, quinine, morphine, or any of the alkaloids solu- 
ble in alcohol. 
The subcutaneous injection is indicated only when an 
immediate and rapid supply of oxygen to the tissues 
is wished for, as in asphyxia from drowning, hanging, 
or in chloroform poisoning, or poisoning from any nar- 
cotic.. In extreme cases of chloroform poisoning Dr. 
Richardson suggests that deep subpulmonary injections 
might be made, throwing the peroxide directly into the 
pulmonary tissue of each lung. The solutions should be 
diluted and free from any acid, and of the temperature of 
the body. No ill effects should follow, as the oxygen is 
rapidly absorbed, and the small amount of water that re- 
mains is harmless. 
For inhalation the oxygen is very readily eliminated 
from the solution, by the aid of permanganate of potash, 
which also supplies its share of oxygen. A ten per cent, 
solution of the permanganate added to the peroxide at 
once decomposes the solution thoroughly. This reaction 
may be produced in an inhaler and the gas at once uti- 
lized, or- it may be preserved in balloons and used as re- 
quired. 
The peroxide of commerce is a two or three per cent, 
solution of true peroxide of hydrogen. Pure anhydrous 
peroxide of hydrogen is known only as a chemical curi- 
osity, and is described as a colorless, transparent, inodor- 
ous liquid, specific gravity 1.45, extremely unstable. 
When decomposed it yields four hundred and seventy- 
five times its own bulk of oxygen, leaving behind a little 
less than one volume of water. The solutions of com- 
merce are designated by the numbers of volumes of the 
gas that they supply, being five-, ten-, or fifteen-volume 
solutions, according as they contain a little over one, two, 
or three per cent, of peroxide of hydrogen. To be exact, 
a one per cent, solution should supply 4.75 per cent, of 
oxygen, and a fifteen-volume solution should contain a 
little more than three per cent, of the peroxide. The 
pure peroxide is of course undesirable, not only is it not 
manageable, but it is altogether too strong for any prac- 
tical use. 
483 Hydrogen Peroxide. 
Hydroxylamine. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
The preparation is still the same as that proposed by 
its discoverer. It may be formed from the peroxides 
of any of the alkaline earths, but barium is the most 
suitable. The barium oxide is formed by exposing ba- 
ryta, heated to redness, to a current of oxygen gas ; the 
resulting salt is then acted upon by hydrochloric acid 
which releases the oxygen, and this combines with the 
water to form the peroxide of hydrogen. Fourteen parts 
of hydrochloric acid are diluted with nine hundred and 
sixty parts of distilled water, and to this thirteen parts of 
powdered barium dioxide are added. This gives about 
a one per cent, solution of the hydrogen dioxide. The 
barium chloride, which is still in solution, is removed by 
treating w'ith dilute sulphuric acid, and the chlorine, 
which remains as hydrochloric acid, is precipitated by 
sulphate of silver and baryta water. The presence of a 
small amount of hydrochloric acid is useful in maintain- 
ing the stability of the solution, and it is generally pres- 
ent in a slight degree ; the amount, however, should be 
very small. Richardson preferred the addition of dilute 
phosphoric acid, but the acid produced during its manu- 
facture is the one usually present. 
The instability of the peroxide renders the article of 
commerce of a very indefinite strength. Numerous anal- 
yses show that the solutions are far below their nominal 
strength. Of nine specimens examined by Dr. S. S. 
Wallian,1 only two were found to be of the proper 
strength, and one sample of a ten-volume solution con- 
tained one and a half volume only. Dr. H. E. Smith 2 
analyzed fifty samples, and found that the highest volume- 
tric strength was only 8.86 ; eight per cent, of the samples 
did not contain any hydrogen peroxide whatever, and 
thirty-six per cent. wrere decidedly deficient in strength. 
Dr. E. R. Squibb3 examined nine samples of the five 
leading manufacturers' products, and found that only 
one reached two-thirds of the proper strength, and two 
samples were less than one-half the stated strength. 
These results speak for themselves, and when it is re- 
membered that many of the articles that are supplied to 
the physician have been in the chemist's shop for a pro- 
longed period, with very little care to preserve their prop- 
erties, there is little wonder that the results obtained from 
its use are not as favorable as expected. 
It is desirable to keep the bottle away from the light 
and in a cool place, but the decomposition that goes on 
within the bottle is due to organic matter and other im- 
purities in the solution. A good preparation should re- 
main fairly stable, even when of a high strength. Squibb 
states that, even when exposed to a summer temperature, 
it should grow stronger rather than weaker, as the water 
should evaporate more rapidly than the peroxide decom- 
poses. A solution of peroxide should be bright and 
clear and free from any deposit or cloudiness, this arising 
from the oxidized matter thrown down by the decom- 
position of the peroxide. To prevent this decomposition, 
free acids are added, but if impurities are present the 
loss of oxygen still continues. 
The strength of the solution may be tested with a stand- 
ard solution of permanganate of potash. Dissolve 2.832 
grammes of potassium permanganate in distilled water 
sufficient to make 500 c.c. of the solution. Ten c.c. of 
hydrogen peroxide is then diluted with water to make 
100 c.c., and ten c.c. of this is to be tested. A few drops 
of sulphuric acid are added to acidify the solution, and 
into it the permanganate solution is to be added, drop by 
drop, until it begins to color the solution. The number 
of c.c. used indicates the number of volumes of oxygen 
present. Another method of testing is to decompose the 
solution and collect and measure the oxygen evolved. 
Ozonic Ether.-At the British Medical Association, in 
1865, Dr. Richardson introduced this combination of 
ether and peroxide of hydrogen. He produced it by 
agitating a thirty-volume solution of the peroxide with 
anhydrous ether and adding five per cent, of alcohol. 
It is soluble in water, is more stable than the solution of 
peroxide, and may be administered in all the conditions 
in which the latter is used. The dose is from half to two 
drachms. As a spray for topical use and to disinfect the 
atmosphere it is particularly serviceable. In whooping. 
(SUPPLEMENT.) 
cough it is very highly praised, as almost a specific 
remedy ; it is used as a spray and the following mix- 
ture given : Ozonic ether, three drachms ; syrup of Tolu, 
six drachms ; glycerine, four drachms ; distilled water, 
to make six ounces ; one-half to two tablespoonfuls for a 
dose. The ethereal compound also permits of its union 
with fatty bases for inunction. This is employed in scar- 
let fever as a disinfecting application, the use of which 
prevents any poisonous matter from being disseminated, 
and at the same time is a soothing and emollient applica- 
tion. Richardson also recommends the use of ozonic 
ether for the production of anaesthesia, the presence of 
the oxygen preventing any dangers that might arise from 
partial asphyxia. 
Under the name pyrozone, there is supplied an ethereal 
solution of different degrees of strength. In one it is 
stated that there is as much as one hundred and twenty 
volumes of oxygen. 
Glycozone is another preparation of peroxide of hydro- 
gen, in which glycerine is acted upon by the peroxide 
under pressure ; it is said to supply fifteen volumes of 
oxygen. The advantage claimed for it is that it is more 
stable, acts more slowly, and proves more efficient as a 
dressing for wounds and other surgical purposes. 
Beaumont Small. 
1 New York Medical Journal, November 26, 1892. 
2 Ibid., August 6, 1892. 
3 Ibid., August 6, 1892. 
HYDROPS ARTICULORUM INTERMITTENS. An 
extremely rare and obscure disease, characterized by 
periodically returning attacks of swelling of one or more 
of the larger joints, unaccompanied by fever or any of 
the usual signs of inflammation. 
• But thirty-three cases have so far been reported, and 
of these but three in this country, the two observed by 
Fridenberg and the one of my own. 
There is a remarkable uniformity as regards the symp- 
toms in all the cases, they forming a clinical picture so 
characteristic and typical as to leave no doubt of the 
diagnosis in any well-developed case. 
The patient notices a slight swelling in one of the 
larger joints, usually the knee, and perhaps has his atten- 
tion drawn to it by a feeling of tension, or of discomfort, 
uneasiness, insecurity, or wabbling in the affected part. 
This rapidly increases, so that usually, in from twenty- 
four to thirty-six hours the joint is so swollen as to seri- 
ously interfere with, if not to entirely inhibit, the nor- 
mal functions. In a short time, usually a day or two, the 
swelling begins to subside, and in from twenty-four to 
thirty-six hours more it is entirely gone, leaving the 
joint to all appearance in as perfect and healthy a con- 
dition as before. After an interval of perfect freedom 
the swelling again appears and the same phenomena are 
repeated, and so on for an indefinite period of time. 
There are no premonitory signs or symptoms indica- 
tive of the disturbance ; the patient may be, and usually 
is, in his customary good or bad health, as the case may 
be. During the attacks there are in most cases no signs 
of constitutional disturbance; the normal functions of 
the body remain undisturbed. In two cases, those of 
Bruns and Pletzer, there was a slight rise in the temper- 
ature during the initial attacks, but not afterward, while 
Perrin reports a case in which each attack was preceded 
by light chills, followed by slight fever ending in perspira- 
tion. Simultaneously with this there was a contraction of 
all the flexors of the upper extremity, also a painful prick- 
ling in all the joints of the same limb. A few hours 
later the swelling began, and with it the above phenom- 
ena gradually disappeared. 
In most cases there is no acute pain whatever ; in some, 
however, especially when the hip-joints are affected, the 
pain is quite acute. In these exceptional cases the diag- 
nosis might be difficult at times, as the swelling would 
be more apt to be overlooked than when the knee was 
affected. The subjective sensation is more that of ten- 
sion, insecurity, and wabbling, than that of pain. Ex- 
amination during the attack shows the swelling to be an 
484 REFERENCE HANDBOOK OF TIIE MEDICAL SCIENCES. 
Hydrogen Peroxide 
Hydroxy la mi ne. 
effusion into the joint. When the knee is affected there 
is the characteristic bulging at the sides of the patella, 
which, together with the fluctuation and the ■well-marked 
' floating of the patella, renders the determination of the 
cause of the enlargement easy. There is no increase in 
surface temperature, except in one or two instances 
(Bylicki, Fridenberg), and no flushing or redness of the 
skin. 
The attacks occur with such regularity that in many 
cases the patients can tell, not only the day, but even the 
hour when the seizure will begin. As a rule the interval 
of freedom varies in different cases from eight to four- 
teen days ; thus in thirty out of thirty-nine recorded 
observations the intervals fell within these limits. The 
attacks themselves last in the majority of cases from 
three to five days. Out of twenty-seven observations 
twenty did not exceed these limits. The longest interval 
reported was three months, and the duration of the 
longest individual attack ten days. 
As to age, it may be said to be a disease of middle life, 
most of the cases occurring in patients from twenty to 
fifty years of age. 
Females are about twice as often affected as males. 
One or both knees are almost invariably involved at some 
period of the disease. In three of the cases it is not 
stated which joints were involved ; in one other the 
elbows alone were affected. In all the others the knees 
were implicated. 
Sometimes there is an alternation in the joints affected, 
one attack being of the knee, the next of the hip, and the 
third returning again to the knee, and so on. In two 
of the cases almost all of the joints in the body were in- 
volved, even those of the spine and fingers. 
A marked peculiarity of the malady is the strong ten- 
dency which it shows to spontaneous cessation of the 
attacks for periods varying from a month to many years, 
after which it recommences -without any assignable 
cause. 
The disease runs a very chronic course, several of the 
cases lasting from twenty to twenty-five years. Preg- 
nancy in almost all cases puts a stop to the attacks while 
it lasts. During only one out of nine recorded pregnan- 
cies was the patient afflicted. In several the attacks 
ceased at once at the beginning, and only one reappeared 
again a few weeks post partum. In no case is there any 
marked relation to the catamenia reported, though in a 
few cases the attacks first began at or about the time 
when menstruation became established. 
As to the nature of the affection, there is nothing defi- 
nitely known. That it is due to vaso motor disturbance 
is admitted by everyone who has been fortunate enough 
to have observed a case ; but whether this disturbance is 
due to micro-organisms, or is a mere neurosis, is at pres- 
ent undetermined. The evidence is but circumstantial 
in support of either theory. While it is true that several 
of the cases have occurred in patients subject to various 
nervous troubles, yet there are many more in persons 
having absolutely no hereditary tendencies in that direc- 
tion. Subjective symptoms, as a rule, are more prom- 
inent than objective in neurotic diseases, while here we 
find the objective far more in the foreground. 
Pain, as a rule, is only due to the distention of the 
joint, and there is none of that hypenesthesia so charac- 
teristic of hysterical joints. The argument that galvan- 
ization of the medulla has cured one or two patients is 
not of much force, as both the patients were taking 
arsenic at the same time, and one of them had had a 
period of freedom from attacks for four years, at an 
earlier stage of the disease, following the administration 
of Fowler's solution. It is a noteworthy fact that almost 
every case reported cured or improved had taken either 
quinine or arsenic, or both combined. 
Several of the cases had suffered from malarial poison- 
ing at some previous period, and two others at least were 
from a malarial region. In two cases the spleen is re- 
ported as enlarged, and in one of them the swelling sub- 
sided simultaneously with the improvement of the pa- 
tient under the use of quinine and arsenic. 
It would take us beyond the scope of this article to 
(SUPPLEMENT.) 
enter into the subject of periodicity in disease. There is 
no satisfactory explanation of it except in those cases 
dependent on micro-organisms, yet there is scarcely a 
disease which does not present more or less well-marked 
traces of it at times. Innumerable instances might be 
cited, but as there is a separate article on this subject in 
a preceding volume, to avoid repetition we may refer 
to it for a discussion of the various theories advanced and 
for illustrative cases. 
In typical cases there is no difficulty in the diagnosis, 
except that from its very rarity it is apt to be overlooked. 
Probably most of the cases are called rheumatism at one 
time or another, yet a very slight examination would 
show the swelling to be due to an effusion within the 
joints, and not extra-capsular. 
As regards prognosis, the chronicity and liability to 
remissions and relapses has been already mentioned. In 
one case the disease finally ran into chronic dropsy of 
the joint. In one there was some crackling in the joint, 
and in two a slight thickening of the capsule, noted. In 
all others, even after many years' duration, there were no 
signs of chronic changes in the joints. 
As would naturally be expected in so obscure an 
affection, the most diverse methods of treatment have 
been employed. The natural tendency of the disease to 
spontaneous remissions makes the proper estimation of 
any given method very difficult. However, quinine and 
arsenic enter into almost all reported cures. In my own 
case, whereas under 1he old rheumatic treatment the at- 
tacks always ran on through a period of several months, 
since she has tried arsenic and quinine she has found that 
she can always stop their recurrence after one, or, at most, 
two attacks. The tendency to relapse remains. 
Of seventeen cases reported cured, relieved, or im- 
proved, injections of ergotin, electricity, cauterization 
and fixation, sulphur baths, and injections of carbolic 
acid, have each one successful result. In all the others 
quinine and arsenic were the chief remedies employed, so 
that in any given case these should have the first trial. 
After these electricity would probably be more service- 
able than any of the other proposed remedies. 
Literature. 
Moore, C. H.: Trans, lied. Chir. Society, London, 1867, p. 21. 
Canonne, M.: These de Paris, 1867. 
Loewenthal : Berliner klin. Wochenschrift, 1871. No. 48. 
Bruns, Paul: Berliner klin. Wochenschrift, 1872, No. 1. 
Grandidler: Berliner klin. Wochenschrift, 1872, No. 22. 
Roser : Centralb. f. Chir., 1874, No. 25. 
Bylicki : Centralb. f. Chir., 1874, No. 38. 
Hueter : Klinik d. Gelenkkrankheiten, 1877, p. 188. 
Jousser : Art Medical de Paris, 1877, p. 85. 
Bejou: These de Paris, 1877. 
Panas : Bull, de la Soc. Chir. de Paris, March 27, 1878, and June 19, 
1878. 
Panas : Progres Medical, 1878, p. 242. 
Verneuil : Bull, de la Soc. Chir. de Paris, March 27. 1878. 
Le Dentu : Bull, de la Soc. Chir. de Paris, March 27, 1878. 
Perrin : L'Union MAdicale, 1878, No. 61. 
Seeligmtiller : Deutsch Med. Wochenschrift, 1880, Nos. 5 and 6. 
Pletzer: Deutsch Med. Wochenschrift, 1880, No. 37. 
Kolbe : Deutsch Med. Wochenschrift, 1881, No. 4. 
Pierson : Deutsch Med. Wochenschrift, 1881, No. 7. 
Fiedler : Deutsch Med. Wochenschrift, 1881, No. 3. 
Kapper : Allgemeine Wiener Med. Zeitung, 1885. No. 31. 
Bosenbach: Centralb. f. Nervenheilkunde. 1886, No. 21. 
Nicolaysen : Norsk Magazin fur Laegevil., 1887, No. 2. 
Eschricht : Dissertation Kiel.. 1888. 
Fridenberg: N. Y. Med. Becord, 1888, vol. 33, p. 657. 
Brincken : Berlin, klin. Wochenschrift, 1889, p. 714. 
William Barnes. 
HYDROXYLAMINE. This compound base exists in 
the free state only in solution. It is ammonia in which 
one hydrogen atom is replaced by the hydroxyl group. 
The formula is NIL OH. Hydrorylamine hydrochloride, 
Nil, OH HC1, forms in colorless crystals resembling 
chloride of ammonium ; it is hygroscopic and very solu- 
ble in water, alcohol, and glycerine. It possesses active 
reducing powers, in consequence of which it has been 
suggested as a substitute for chrysarobin and other re- 
ducing bodies in the treatment of skin diseases. It has 
been used with success in psoriasis, parasitic affections, 
•and in lupus. It is a powerful poison to all forms of 
vegetable and animal life, but while proving effective 
485 Hydroxyl ami lie. 
Hyoseiiie. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
in destroying the disease for which it is used, it is liable 
to produce toxic symptoms by its absorption and in- 
fluence on the haemoglobin of the blood. The salt 
should be kept in well-closed bottles in the dark, and 
when used, a solution of one part in a thousand may be 
prepared. The diseased part, previously washed with 
soap, is to be painted from three to five times a day. 
Beaumont Small. 
HYERES AND COSTEBELLE. In addition to the in- 
formation already given with reference to Hyeres (see 
Vol. III. of the Handbook); the following particulars 
may be of interest to physicians. The writer's residence 
at Hyeres was too brief to permit personal verification of 
all that is claimed for this Provencal winter station. But 
the testimony of Drs. Biden and Cormack, the resident 
English practitioners, agrees in all principal points. 
There is certainly no question that the winter at Hyeres 
is very mild, and were it not for the mistral, and com- 
parative dulness of the town, Hyeres would doubtless 
be quite as popular as Cannes and Nice. Formerly it 
(SUPPLEMENT.) 
those beyond middle life it is difficult to conceive a more 
suitable environment than Costebelle offers. The cli- 
mate of Hyeres is less exciting than that of Cannes and 
Nice " (Dr. Sawtell). " The chief attractions of Ilyeres 
are its climate and the beauty of its environs, which ren 
der it an agreeable place of winter abode, even for per- 
sons in health who do not require the animated move- 
ment and recreative resources presented by large towns, 
and who are in tolerable walking condition. The walks 
and rides, both on the plain and through the cork-tree 
woods, by which the hills are for the most part covered, 
present considerable variety, while from the more ele- 
vated positions charming prospects may be enjoyed " 
(Dr. Edwin Lee). The barometer is high and steady, 
But on the Riviera, as elsewhere, every winter varies in 
the rainfall and in the degree of cold ; and, therefore, it 
may happen that the traveller's experience will not agree 
with stereotyped meteorological tables. 
Dr. Cormack says {The Climatologist, January 15, 
1892) that : " Hyeres is admirably suited to cases of 
phthisis. Should the disease be in its first period when 
Fig. 312.-View of Hyeres Looking North. 
was much more so. The table given on the next page 
is reproduced from the writer's description of Hyeres in 
the Medical Record, January 16, 1892, and is due to the 
courtesy of Dr. Biden, who specially prepared it. 
Synopsis of Meteorological Observations Taken 
at Hyeres.-The shade thermometers are placed in a 
Stevenson's screen. The screen stands in the open, com- 
pletely exposed all round, quite away from buildings and 
walls. If of an inch of rain is measured in the 
twenty-four hours it is considered a day on which rain 
has fallen. 
In regard to indications and contra-indications, the 
following opinions will suffice : " The winter climate 
of Hyeres and Costebelle is suitable especially for con- 
sumption, chronic bronchitis, asthma, heart disease, and 
rheumatism ; also Bright's disease, gout, incipient paraly- 
sis, and the feeble constitution of delicate children. In 
consumption, obviously, the disease is most amenable in 
its early stages. Nevertheless, remarkable instances have 
occurred of relief in advanced cases of a type quite un- 
suitable to Alpine climates. The occurrence of hemor- 
rhage is not a contra-indication to residence here. For 
the patient arrives, a complete cure may take place. The 
same result may be obtained with cases which have ar- 
rived at their second period, although the chances are 
less, but in any case a considerable improvement may be 
expected. When the disease has passed into the third 
period, or is too far advanced for any reasonable hopes of 
recovery to be entertained, life is prolonged for a time. 
" All chest complaints and bronchial affections im- 
prove under this genial climate. Liver complaints, 
affections of the kidneys, Bright's disease, diabetes, etc., 
are all favorably influenced by the warm and equable 
temperature. 
"Gouty and rheumatic cases get on very well here, 
and generally are much relieved after a winter or two's 
residence. This is only what would naturally be ex- 
pected when one bears in mind of what capital impor- 
tance a dry and warm climate is to such cases, and the 
great benefit they derive from out-door exercise, for 
which Hyeres offers special facilities, for there is hardly 
a day upon which an invalid is unable to get out for at 
least an hour or two, unless the nature of his complaint 
keeps him confined to his bed. 
486 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Hydroxyl amine. 
Hyoscine. 
" Cases of anaemia and asthma also do remarkably well 
for the same reasons. 
" The invalid's day is comprised between the hours of 
10 a.m. and 4 P.M. for the warmest months, and 11 a.m. 
to 3 p.m. when the days are colder. Naturally, special 
cases have to follow special rules; but no invalids, in 
any case, should go out until the sun is well risen, nor 
after sunset, as both before and after sunset the tempera- 
ture is many degrees below what it marks in the middle 
of the day ; it is specially dangerous for delicate per- 
sons and those having weak chests to go out after sunset, 
for there is invariably a very rapid fall in the thermom- 
eter at this time. A most useful precaution for all pa- 
tients is to be provided with a shawl when passing from 
the sun into the shade, as the difference of the two tem- 
peratures is very considerable. There are certain times, 
during the mistral, for instance, when invalids do well 
to keep within doors ; more particularly is this the case 
for those of weak constitution or nervous temperament." 
Finally, Drs. Biden and Cormack agreed in assuring 
the writer that Hydres is a healthy town. There is very 
little typhoid, no diphtheria or other zymotic diseases, 
and the foreign colony has nothing to fear, and has had 
nothing to regret at this delightful winter resort. Anae- 
mia and American neurasthenia should do particularly 
well there. About the only contra-indication for a win- 
ter's residence at Hyeres is furnished by recent neuroses, 
with a tendency to mania. 
(SUPPLEMENT.) 
move been made to provide accommodations for the in- 
creasing number of visitors. 
In addition to the two older hotels (selected for the 
Queen of England's residence in the spring of 1892), 
Costebelle has a third and quite modern hotel, called the 
Albion, which is in every respect a first-class family resi- 
dence. 
At the Albion good sanitary arrangements were found 
by the writer, and the other Costebelle hotels have been 
recently overhauled and made nearly perfect in this re- 
spect. Edmund C. Wendt. 
HYOSCINE. This alkaloid is present in other plants 
beside hyoscyamus niger, having been obtained from 
duboisia my oporoides and scopala carniolica. It is sup- 
posed to be identical with scopolamine, which is isomeric 
with cocaine and not with hyoscyamine ; it is also identi- 
cal with duboisine. Hyoscine, C17H23NO3, is a non-crys- 
tallizable body, but all its salts form in large, white 
prismatic crystals, freely soluble in water, insoluble in 
alcohol and ether. The salts also resemble each other 
in therapeutic as well as physical properties. The hy- 
drobromate, hydrochlorate, sulphate, and hydriodate are 
prepared. 
As a mydriatic it is rapid, energetic, and brief, but its 
action is readily maintained. During the administration 
of the drug its effect on the pupil is an early symptom. 
Dilatation is said to be more marked with a £ to | per 
cent, solution than with a one per cent, solution of atro- 
pine ; it has to be used with caution on account of the 
readiness with which the system is affected. 
Its sedative and hypnotic action has brought it into 
prominence, during the past few years, as a remedy in 
cerebral excitement and in the treatment of nervous dis- 
eases. In small doses it produces a stimulating action on 
the nervous centres, but in larger doses it is a powerful 
sedative. When given until its physiological action is 
produced, itcauses the pupils to dilate, and checks the 
secretion of the salivary glands and the action of the 
skin. On the heart it depresses the inhibitory nerves, 
and causes a weak and accelerated action of the pulse. 
Some observers have noted in the early stages a slowing 
of the pulse and an increase in the blood-pressure. It 
diminishes the irritability of the brain and nerve-centres, 
lessens to a slight extent the perception of pain, but does 
not affect tactile sensibility. Its toxic action is shown by 
the dilated pupil, rapid pulse, relaxed arteries, and red- 
ness of the surface, dry, hot skin, rapid breathing, and 
coma and convulsions. 
Hyoscine has largely supplanted morphine in the treat- 
ment of acute mania and delirium tremens, in restless- 
ness, and violence in all forms of mental disorders, and in 
hysteria and epilepsy. Its sedative action is very rapidly 
produced, and in the majority of cases a calm and refresh- 
ing sleep ensues. When pain is the cause of insomnia, 
it is not of much service. Its action is purely calmative 
and sedative on the brain, and it should not be adminis- 
tered as a powerful or decided hypnotic ; in insomnia it is 
only applicable in cases in which it arises from central 
or nervous excitement. In mania, and when there is 
much excitement, it should be given in full doses of 
grain by the mouth or T|F to grain hypodermically ; 
a small dose is generally sufficient. When the symp- 
toms are less acute, smaller doses should be given. 
Hyoscine has also proved itself very efficient in the treat- 
ment of chronic mania and all nervous affections accom- 
panied by mental restlessness ; also in nervous diseases 
characterized by debility and tremors, as in paralysis ag- 
itans, disseminated sclerosis, and chronic alcoholism. In 
these cases the stimulating action of small doses is taken 
advantage of, and of a grain daily or twice a day is 
a sufficient dose. Its antispasmodic action is also se- 
cured with the same small dose, and it may be used, and 
with benefit, in chorea, asthma, and other spasmodic 
troubles of a nervous origin. When cardiac disease is 
present the use of hyoscine should be avoided or given 
with great caution, on account of its depressing action on 
the heart and circulation. 
The early physiological effects of the drug are mani- 
r 
Nov... 
Dec ... 
Jan ... 
Feb ... 
March. 
April.. 
58.7 
Max. 
61.4 
55.5 
55.8 
56.5 
59.8 
63.3 
Mean shade tempera- 
ture. Thermometers 
rw 
Min 
45.8 
40.5 
39.3 
40.6 
42.3 
47.2 
registering and cor- 
recting. 
S 
53.6 
48.0 
47.5 
48.5 
51.0 
55.0 
Mean daily shade tem- 
perature. 
107.0 
Mean. 
106.5 
9S.7 
101.2 
105.7 
112.1 
117.6 
Solar radiation (black 
bulb in vacuo). 
73.5 
76.0 
73.0 
76.0 
75.0 
71.0 
71.0 
Relative humidity, daily 
mean. (Per cent.) 
s 
to to m ie hs 
O h- - 
Days of sunshine per 
month. 
oo 
16 
15 
18 
13 
12 
9 
Days calm. 
w 
11 
9 
11 
15 
16 
Light to fresh. 
Day 
wi 
tO 
to 
>U 03 CO ce Ur 
Strong to a gale. 
■s of 
nd, 
co 
-lO'O. OCM 
Days on which rain has 
fallen. 
17.04 
In. 
3.52 
2.86 
3 08 
2.21 
2.26 
3.11 
Rainfall. 
The water-supply of Hyeres and Costebelle is moder- 
ately good. The water is very hard, however, and does 
not agree with everybody. The drainage is quite im- 
perfect, and the cesspools, which are in common use, may 
become sources of danger. 
In the writer's report, already alluded to, Costebelle 
is thus referred to : From the railway station of Hyeres 
it is but one mile of slightly up-hill wooded road to 
Costebelle. From the town proper it is two miles in a 
southerly direction. From Marseilles to Genoa, i.e., 
along the entire Western Riviera, or " le littoral," as 
the French call it, there are ever-changing and enchant- 
ing views. But in all this favored strip of land, so abun- 
dantly blessed with blue skies and health-giving sun- 
shine, I have found no prettier views than those which 
are enjoyed from the Costebelle hill-sides. 
Situated on the southern slope of an eminence appro- 
priately named Mont des Oiseaux, which effectually pro- 
tects it from that much-dreaded wind called " mistral," 
surrounded by forests of aged pines, oaks, and olive- 
trees, that richly clothe in different shades of green the 
adjoining hills on the north, east, and west, and with a 
southerly view over undulating woodlands, stretching 
out into a picturesque plain that ends abruptly at the 
Mediterranean Sea a mile below, Costebelle has been 
happily chosen as a site for a few first-class hotels. 
The late Duke of Grafton some years ago found it to 
be a site without parallel along the whole coast. He 
built a princely villa and made a road through the pines 
to serve it. But only within the last ten years has any 
487 Hyoscine. 
Hypnotics. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
fested far in advance of dangerous symptoms, but in 
some cases very severe toxic symptoms have been pro- 
duced by doses of -fa and -/j grain. Pilocarpine and 
morphine are physiological antidotes. The former 
has proved very serviceable and may be administered 
freely, as much as two grains having been required in a 
case of delirium tremens in which a comatose condition 
followed frequent doses of hyoscine. 
Beaumont Small. 
HYOSCYAMINE. This alkaloid, formerly obtained 
solely from hyoscyamus niger, is now known to be the al- 
kaloid present in many other plants of the order solana- 
ceae, notably atropa belladonna, datura, stramonium, and 
scopola carniolica. It has recently been obtained from the 
common lettuce plant, lactuca satira.1 Professor Laden- 
burg demonstrated that atropine, daturine, and duboisine 
are identical with hyoscyamine, both in chemical consti- 
tution and physiological action. Any difference is to be 
found in the molecular arrangement of the constituents, 
and not in any fundamental change. The terms "atro- 
pine " and "hyoscyamine" have been applied to the 
heavy and light mydriatic alkaloids obtained from the 
belladonna and henbane plants, the former being the 
heavy and the latter the light alkaloid. It is now known 
that both the heavy and light alkaloids may be obtained 
from either plant, according to the process of manufac- 
ture. The light may be converted into the heavy by 
melting under reduced pressure, or by the addition of 
caustic soda to its alcoholic solution.2 
Hyoscyamine, C17H23NO3, occurs in light, silky, snow- 
white crystals, without odor, soluble in one hundred 
and twenty parts of water, freely soluble in alcohol, and 
in acidulated water. There is also an uncrystallized or 
amorphous hyoscyamine, of a dark-brown extract-like 
mass, with a strong disagreeable odor. This appears to 
be a mixture of the various alkaloids and extractive mat- 
ters. A sulphate, hydrochlorate, hydrobromate, and hy- 
driodate of hyoscyamine are prepared ; they are alike in 
degree of strength and character, forming white, fine 
crystals very soluble in water. A sulphate and hydro- 
bromate prepared from the amorphous alkaloid are amor- 
phous, deliquescent salts, and less active and certain in 
their effects. 
The therapeutic properties of hyoscyamine resemble 
those of hyoscine, but since the introduction of the latter 
alkaloid it has fallen into disfavor. It was found to be 
less certain in its action, and its use was frequently ac- 
companied by unpleasant symptoms. It is employed 
as an hypnotic, nerve sedative, and antispasmodic, in 
mania, restlessness, delirium, insomnia, and all condi- 
tions accompanied by mental excitement, also in asthma, 
chorea, epilepsy, etc. 
The dose is somewhat larger than that of hyoscine, tJk 
to of a grain, which in some cases requires to be 
increased to | grain to obtain the desired action. The 
presence of the amorphous salts in the market is the 
source of much of the uncertainty of its action, and the 
cause of many of the toxic symptoms. The dose of 
these salts is much larger, being from J to 1 grain. 
Its mydriatic action is rapid and powerful, but not so 
manageable as atropine. Cases3 are reported in which 
it produced spasms of the ciliary muscle and intense pain 
and distress ; the solution used was J grain to the drachm, 
and relief was obtained by placing in the eye a stronger 
solution of the same alkaloid. Its toxic action is the 
same as that of hyoscine, viz., dryness of the throat and 
mouth, and of the skin, accelerated pulse, dilated vessels, 
and excitement followed by convulsions and coma. 
Beaumont Small. 
1 The Lancet, December 26, 1891. 
2 Extra Pharmacopoeia. 1892. 
3 Therapeutic Gazette, March, 1892. 
HYPNAL. It is well known that a mixture of an- 
tipyrine and chloral results in the production of an oily 
fluid, which in time again crystallizes. Dr. Bardet 
(Repertoire de Pharmacie, April 10, 1890) made known 
the fact that when combined in certain proportions the 
compound possessed the therapeutic properties of its 
component parts ; to this product he gave the name of 
hypnal. It may be prepared by mixing a solution of 47 
grammes of chloral hydrate in 50 c.c. of distilled water, 
with a solution of 53 grammes of antipyrine in 50 c.c. of 
distilled water, pouring into a separating funnel, and 
drawing off, after an hour, the oily-looking fluid from 
the aqueous layer. At the end of twenty-four hours the 
liquid will have solidified to a mass of rhombic crys- 
tals.* The salt is colorless, odorless, soluble in five or 
six parts of water, being less soluble than either chloral 
hydrate or antipyrine. 
Bardet found it very useful as an hypnotic and anal- 
gesic. He employed it in twenty-two cases, and found it 
to produce sleep as readily as chloral hydrate, and where 
pain was present marked relief was at once secured. He 
also found it act very beneficially in producing sleep 
when the cause was a spasmodic cough. It has not the 
bitter taste nor the disagreeable effect on the stomach of 
its constituents, and secures its desired effect in compar- 
atively small doses. No ill effects have followed its use, 
but in some instances where it has failed to produce sleep 
it has given rise to increased restlessness. It is easily 
taken by children on account of its freedom from taste. 
The dose is from seven to fifteen grains for adults. It 
may also be given hypodermically in the same quanti- 
ties. As an enema it will also produce its effect in doses 
of thirty grains. Beaumont Small. 
H YPN ONE (Acetophenone). Chemically this com- 
pound is methyl-phenyl-ketone, CeH5CO CH3. It has 
long been known, but its therapeutic properties were 
studied and demonstrated by Dr. Dujardin-Beaumetz 
and Dr. Bardet, in 1885, at which time it was given the 
shorter name of hypnone. They considered it a very 
valuable hypnotic, even superior to chloral and par- 
aldehyde, particularly in the insomnia due to alcohol- 
ism. Dose, two to four drops. It is a colorless liquid, 
sp. gr. 1.032. At 57.2° F. it solidifies into a mass which 
persists to a temperature of 60° F. It is volatile and its 
odor is very penetrating, recalling that of the oil of bit- 
ter almonds. It is not soluble in water nor in glycerine, 
but is soluble in alcohol, ether, and oil of sweet almonds. 
It has a sharp, almost caustic taste, and requires to be 
given well diluted or with the oil of sweet almonds, in 
capsules. 
Further employment of this drug has not supported 
the views of its discoverers. Its action has proved un- 
certain, and it is not of any service when the sleepless- 
ness is due to pain. It is only indicated in primary and 
nervous insomnia, when other soporifics have failed. A 
further objection to its use is its disturbing effects on the 
digestive organs and its ill effects on the blood. The 
following conclusions are formulated by Kamensky: 
(1) Hypnone enfeebles sensibility and diminishes the re- 
flexes ; (2) moderate or large doses produce a slight sleep 
resembling natural sleep when the drug is introduced 
directly into the blood ; (3) it increases the heart-beat, 
probably by stimulating the accelerator centre of the 
heart ; (4) in moderate quantities it increases respiration, 
but large doses paralyze it ; (5) it depresses arterial press- 
ure by paralysis of the vaso-motor centre and enfeeble- 
ment of the heart's energy ; (6) moderate and large doses 
diminish the excitability of the cerebrum, while all 
quantities increase the excitability of the spinal cord ; 
(7) it reduces the oxyhaemoglobin of the blood ; (8) it 
diminishes temperature by increasing heat dissipation. 
Beaumont Small. 
HYPNOTICS. Numerous chemical products have 
lately been found to produce sleep, and have been tried 
as hypnotics in cases of insomnia. Most of them proved 
uncertain and disagreeable in action ; a few, however, 
especially chloralamide, sulphonal, and amylene hydrate, 
have been found to act with much certainty, and without 
* It may also be formed by shaking together concentrated solutions in 
the above proportions, the crystals being deposited, if the chloral be in 
excess, the crystals form in prismatic needles. 
488 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Hyoscine. 
Hypnotics. 
markedly affecting the functions of circulation and res- 
piration. In some respects they seem to be superior to 
the old, well-known hypnotics, and hence will probably 
come into general use, and occupy a prominent place 
among the standard remedies for insomnia. 
Chlor al amide, or Chloral-formamide.-Chloral- 
amide was introduced in 1889, by Professor Von Mering, 
as a substitute for chloral in cases of insomnia in which 
the influence of chloral on the organs of circulation should 
be avoided. He supposed that the formamide, contained 
in chloralamide, would effectually prevent the depressing 
action of chloral. 
Chloralamide is prepared by mixing molecular weights 
of chloral and formamide, that is, 147 parts of anhydrous 
chloral and 45 parts of formamide. The liquids combine 
and form a crystalline solid, as represented by the follow- 
ing equation : 
C Cl3 COII + TICONIL = C Cls CH (Oil) IICONII 
chloral formamide chloral-formamide 
Chloralamide is in the form of white, lustrous crystals, 
having a bitter taste, but no odor. It is slowly soluble 
in 20 parts of water, and in 14 part of alcohol. It de- 
composes in hot water having a higher temperature 
than 60° C. ; so also in alkaline solutions, but not in di- 
lute acids. 
Physiological Action.-Chloralamide does not irri- 
tate the mucous membrane of the stomach, and is not 
affected by the gastric juice. After absorption it is slowly 
decomposed by the alkaline blood into chloral hydrate 
and formate of ammonium. The latter is produced as 
follows : HCONH, + HaO = NH4CHO2. Consequent- 
ly, the action of chloralamide is that of chloral hydrate, 
modified by the rate of its decomposition in the blood, 
and possibly by the presence of the formate of ammo- 
nium. 
The experiments made upon animals have yielded 
somewhat discordant results, not as to the influence of 
chloralamide on the brain, but as to its action on the or- 
gans of circulation and respiration. Von Mering,1 Kny, 
and others noticed no fall of blood-pressure in rabbits 
under the influence of hypnotic doses of chloralamide ; 
Laanggaard,2 on the contrary, observed decided lowering 
of blood-pressure, although this effect supervened more 
slowly than after chloral hydrate. 
Upon man chloralamide acts like chloral, except that 
it produces sleep less rapidly and less certainly. As a 
rule, after doses of 2.0 to 3.0 (thirty to forty-five grains) 
sleep ensues in half an hour, and continues from five to 
eight hours. During the sleep, the functions of circula- 
tion and respiration are performed as vigorously as in 
normal sleep. After awakening the patient presents no 
disagreeable after-effects. 
Numerous deviations, however, from this ordinary ac- 
tion have been observed, depending chiefly upon the 
causes of the insomnia. Thus, in cases of intense excite- 
ment of the brain, of severe pain, of harassing cough, 
and of high fever, doses of 2.0 to 3.0 have failed to pro- 
duce sleep, and sometimes even 4.0 (sixty grains) have 
been ineffectual. Often, even when the causes of insom- 
nia were not intense, sleep did not supervene before an 
hour, sometimes two hours, and in rare instances even 
three hours. In some cases of heart disease,3 especially 
in v.alvular disease with imperfect compensation, a very 
decided depression of the circulation has been observed. 
So, too, in typhoid fever a very unfavorable effect upon 
the pulse was noticed after 2.0 (thirty grains) given in 
divided doses. 
Generally, after-effects do not occur, or they are very 
trivial, consisting of headache, slight giddiness, a feeling 
of fatigue, and skin eruptions. 
From the above it is evident that chloralamide closely 
resembles chloral in action, but that it induces sleep more 
slowly and less certainly, and that it is less apt to depress 
the circulation. The differences seem to be due to slow 
and gradual liberation of chloral in the blood, although 
it is not improbable that the presence of the formate of 
ammonium may somewhat modify the action of the 
chloral on the organs of circulation. The variations in 
the rapidity of action doubtless result from differences 
in the rate of decomposition in the blood of different 
persons. 
Therapeutic Uses.-Chloralamide is a suitable hyp- 
notic in insomnia not caused by intense excitement of the 
brain, very severe pain, or extreme dyspnoea. When 
severe pain causes insomnia, chloralamide alone is not 
very efficient, but it acts well if given together with a 
moderate quantity of morphine. In the insomnia associ- 
ated with mild nervous excitement, with neurasthenia, 
and with somatic diseases in general, moderate doses, 
from twenty to thirty grains, are usually effectual. Such 
moderate doses having frequently failed in cases of in- 
tense mental excitement and severe pain, larger doses, 
as much as one drachm, have been recommended ; but 
it should be recollected that such large doses may cause 
dangerous depression. Even moderate doses should not 
be given in cases of heart disease, if the heart's action be 
very feeble, or if symptoms of inadequate compensation 
be present. In no case should the dose be larger than the 
corresponding dose of chloral hydrate. Chloralamide 
contains 77 per cent., and chloral hydrate 89 per cent., of 
anhydrous chloral. 
Chloralamide may be prescribed as follows : (1) R. 
Chloralamid., 9ij.-3j. ; Aq. dest., § ijss. ; Acid, hy- 
drochi. dil., gtt. v. ; Syr. rubi idaei, f ss. M. S.: One 
half to be taken before retiring. (2) $. Chloralamid., 
3 j. ; Spir. frumenti, Syr. rubi idaei, aagss. M. S.: 
One tablespoonful shortly before retiring. 
Sulphonal.-The properties of this hypnotic have 
been described in this Handbook, Vol. VIII., p. 499, 
and need not be repeated here. 
Sulphonal has been extensively used in the last four 
years. The results obtained by clinicians, who have had 
ample opportunities for observing its effects, may be 
summed up as follows : 
1. In doses of 1.0 to 2.0 (fifteen to thirty grains) sul- 
phonal is a very reliable hypnotic in simple nervous in- 
somnia ; but in such doses it often fails in the insomnia 
caused by cough, pain, and dyspnoea. Large doses,4 
however, will generally produce satisfactory sleep ; but 
their action is often followed by disagreeable effects, and 
in heart disease by serious depression of the circulation. 
2. Sulphonal continues to act in the same dose for a 
long time. In some cases it has been found that, after 
one dose had acted well, sleep would take place spon- 
taneously on the subsequent night. It has frequently 
been observed that a moderate dose, 1.3 (twenty grains), 
would on the first night act only for a short time, but, 
when repeated on the following night, cause prolonged, 
refreshing sleep. Cases 6 have been reported in which 
moderate doses had been taken for months, at first 
nightly, and afterward several times a week, with a sat- 
isfactory result, and without any apparent injury. 
3. Some observers have noticed cumulative effects ; 
moderate doses, repeated once in twenty-four hours for 
some weeks without ill effects, suddenly produced very 
grave phenomena, such as vomiting, prostration, and 
ataxia. Doses of 1.0 to 2.0 (fifteen to thirty grains) 
given repeatedly for several days, have in a few instances 
caused weakness, staggering, grinding of the teeth, diffi- 
cult articulation, and severe giddiness. In one case 20.0 
(three hundred grains) taken within a week, caused se- 
vere vertigo, great restlessness, confusion of mind, loss 
of memory, and clonic spasms.6 
4. The prolonged use has in some instances been fol- 
lowed by serious disease of the kidneys, and changes of 
the blood.1 The urine had a dark-red color, and con- 
tained much coloring matter, albumin, and tube-casts. 
Some of the patients died from heart-failure. The doses 
were moderate, usually from 1.0 to 2.0 daily. 
Amylene Hydrate,-C6IL2O.-Dimethyl-ethyl-car- 
binol (ClDaCoHsCOH. Amylene hydrate is a limpid, 
volatile, neutral liquid, having a peculiar, spicy odor, 
and a pungent taste. It is soluble in eight parts of 
water, and readily mixes with alcohol, ether, chloroform, 
glycerine, and fixed oils. It boils at 99° to 103° C. Its 
sp. gr. is 0.815 to 0.820. 
Physiological Action.-Professor Von Mering8 investi- 
gated the action of amylene hydrate in experiments upon 
489 Hypnotics. 
Idiopathic Anaemia. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
animals. In rabbits, doses of two to three grammes in 
ten to twenty minutes produced sound sleep, which con- 
tinued from six to eighteen hours. In dogs, proportion- 
ate doses were followed in half an hour by sleep, which 
lasted from ten to eighteen hours. During the sleep no 
notable change took place either in respiration or in cir- 
culation. No lowering of blood-pressure was found when 
the narcosis was so deep that all the reflexes had disap- 
peared. Moderate doses acted chiefly upon the cere- 
brum ; but large and toxic doses affected also the spinal 
cord and the medulla oblongata ; first the reflexes ceased, 
then the breathing stopped, and finally the heart stood 
still. 
In man moderate doses cause prolonged refreshing 
sleep, without affecting the heart, the respiratory ap- 
paratus, or the alimentary canal. Poisonous doses pro- 
duce symptoms resembling those of alcoholic intoxi- 
cation-deep, long-continued sleep, with complete sus- 
pension of motility, sensibility, and reflex action ; dila- 
tation of the pupils ; slow, irregular, superficial breath- 
ing ; slow, small pulse, and lowered temperature. No 
cases of death from amylene hydrate have been re- 
ported. 
Therapeutic Uses.-Having observed the genial action 
of amylene hydrate upon animals. Von Mering tried it 
clinically in cases of insomnia. To 60 patients affected 
with sleeplessness he gave 350 doses. After doses of 
3.0 to 5.0 (forty-five to seventy-five minims), sleep en- 
sued within half an hour, and continued from six to 
twelve hours. Only four times was the hypnotic action 
unsatisfactory. No disagreeable incidental effects oc- 
curred, and only one patient complained on the following 
morning of slight headache. When the sleeplessness 
was due to pain, amylene hydrate did not act well ; but 
the simultaneous administration of a small quantity of 
morphine rendered the action satisfactory. No devia- 
tion from the normal condition took place in the func- 
tions of respiration and circulation, and in several cases 
of heart disease with insomnia, quiet sleep resulted with- 
out any disagreeable effects. Von Mering supposed that 
2.0 of amylene hydrate act as strongly as 1.0 of chloral 
hydrate, and 3.0 of paraldehyde. 
A very thorough trial of amylene hydrate was made at 
Professor Jolly's psychiatric clinic in Strasburg.9 To 
80 patients 1,050 doses were given. Small doses, 1.6 to 
2.6, were at first used in all cases; if a satisfactory re- 
sult was not obtained, the dose was increased until the 
maximum, 4.8 to 5.0, was reached. Generally sleep 
ensued in from five to twenty minutes ; in excited and 
restless patients, in twenty to thirty minutes ; and in the 
maniacal, in one-half to one hour. During the sleep the 
pulse and breathing were normal in all cases. The sleep 
was less sound and protracted after small than after large 
doses, and the patients were awakened by the slightest 
touch, as when the pulse was counted ; but this rarely 
occurred after large doses. No injurious incidental ef- 
fects were observed. The digestive tract was never 
disordered, and only two or three times did nausea 
or vomiting occur. The appetite was not diminished, 
and the action of the bowels not disturbed. In very 
rare instances patients complained on the following 
morning of slight headache or throbbing in the head ; 
but in those cases the general condition was disturbed 
by the primary psychical disease. Free perspiration at 
the beginning of the hypnotic action occurred in a few 
patients. 
Amylene hydrate has been used to a considerable ex- 
tent as a hypnotic in hospitals and insane asylums. The 
reports from these institutions have in general fully 
corroborated the observations of Von Mering, and of 
Jolly, of Strasburg. 
The dose of amylene hydrate is 2.0 to 4.0 (thirty to 
sixty minims), preferably in aqueous solution, with ex- 
tract of glycyrrhiza, syrup of orange, or syrup of rasp- 
berry as corrigents. The maximum dose of the Ph. G. is 
pro dosi 4.0, and pro die 8.0. 
It may be prescribed as follows: (1) !}• Amyleni 
hydrat., 3 jss. ; Aq. dest. § ij. ; Extr. glycyrrh., 3 ij. 
M. S. : One-half to be taken at bedtime. (2) IJ. Amyleni 
(SUPPLEMENT.) 
hydrat., 3 jss. ; Aq. dest. 3 jss. ; Syrup, rubiidsei., | ss. 
M. S. : One-half to be taken at bedtime. 
Samuel Nickles. 
REFEBENCES. 
1 Chloralamid, ein nenes Schlafmittel, von Dr. Eugen Kny, Therap. 
Monatsch., 1889, p. 345. 
3 Ueber einige nene Schlafmittel, von Dr. A. Laanggaard, Ther. 
Monatsch., 1889, p. 461. 
3 Zur klinischen Wuerdigung des Chloralamids, von Dr. A. Robinson, 
Deutsch, med. Wochenschrift, 1889, No. 49. 
4 Beitrag zur Sulfonalwirkung, von Dr. Joachim, Ther. Monatsch., 
1889. p. 226. 
6 Ueber Sulfonal, von Dr. M. Steiner, Therap. Monatsch.. 1889, p. 
459. 
8 Ein Fall von Sulfonalintoxication, von Dr. Joachim Battenberg, 
Therap. Monatsch., 1891. p. 648. 
7 Ueber das chemische Verlialten des Harns nach Sulfonalintoxication, 
Therap. Monatsch.. 1892. p. 39. 
8 Das Amylenhydrat, ein nenes Schlafmittel und dessen Anwendung in 
der Medicin, Therap. Monatsch., 1887. p. 249. 
9 Ueber die Verwendbarkeit des Amylenhydrat als Schlafmittel, ins 
besondere bei Geisteskranken, Therap. Monatsch., 1887, p. 329. 
HYSTERIONICA BAYLAHUEN, H. B. A perennial 
plant belonging to the order of Compositae-Synantherese, 
and closely allied to Grindelia robusta. It is indigenous 
to Chili and is remarkable for the resinous exudation 
with which all its parts are covered. It contains a brown, 
odorous, acrid resin, and an essential oil. No alka- 
loids have yet been separated. It has a local reputa- 
tion as an anti-diarrhoeic remedy, and has been used 
with success in chronic dysentery and the diarrhoea of 
phthisis. The action of this plant has been studied by G. 
Bailie (Bull. Gen. de Therap., February, 1889). He found 
it very serviceable in all the diarrhoeas of wasting dis- 
eases, particularly in phthisis. He recommends that an 
aqueous solution be prepared, 1 part to 150 of water, as 
the alcoholic preparation is not of any value in these 
troubles. Dr. H. Gilbert (Therap. Gazette, January, 
1891) has used the fluid extract'in various forms of 
chronic diarrhoea, and always found it serviceable. He 
employed the fluid extract in doses of ten minims every 
six hours, and continued its use for a prolonged period. 
No bad effect followed its use in any of his cases. 
He used the tincture in lung diseases, and found that it 
lessened the secretion and cough, and did not irritate the 
stomach. The large quantity of aromatic resin which it 
contains has led to its use in bladder troubles and dis- 
eases of the urinary passages. It lessened the pain of 
micturition in cystitis and rendered the urine clearer and 
purer. Beaumont Small. 
ICHTHYOL. This compound is obtained by the dis- 
tillation of a bituminous mineral deposit of Tyrol, which 
contains an abundance of the fossil remains of fish and 
other marine animals. During the dry distillation there 
passes over, between 100° C. and 225 C., a crude vol- 
atile oil. This is treated at 100° C. with an excess of 
concentrated sulphuric acid, which forms ichthyo-sul- 
phonic acid, and this is precipitated by the addition of 
concentrated brine. The product contains a certain pro- 
portion of the unchanged oil, which cannot be removed 
without producing decomposition of the whole com- 
pound. 
Ichthyo-sulphonic acid forms salts with ammonium, 
sodium, lithium, zinc, and mercury, but the ammonium 
salt is the one preferred and generally understood by 
the title of ichthyol. Ammonium ichthyol sulphonate, 
CssHaeSgOe (NH4)2, is a clear, thick, brownish liquid 
with a smoky bituminous odor and taste. It is soluble 
in water, in a mixture of alcohol and ether, in glycerine, 
oils, and fats. Experiments on animals show that it does 
not possess any toxic properties, and but one instance is 
recorded where very distressing symptoms followed the 
application of one part ichthyol to two parts of glycerine, 
to the curetted surface of the uterus. The patient com- 
plained of the taste of the drug, tachycardia and general 
depression came on, and the patient remained prostrated 
for twelve hours. The symptoms were supposed to be 
due to absorption of the ichthyo-sulphonic acid through 
the abraded surface of the uterus. 
The therapeutic value of ichthyol depends upon three 
490 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Hypnotics. 
Idiopathic Anaemia. 
factors : its reducing property, its antiseptic action, and 
a contractile effect which it exerts on the vascular system. 
It was introduced by Dr. Unna, of Hamburg, in 1883, as a 
remedy for the treatment of various forms of skin disease. 
Its use has since been greatly extended, and it is very 
generally used, both externally and internally, in a great 
variety of diseases. Unna described it as the remedy par 
excellence against acne, the pustular as well as the papu- 
lar form. He advises fifteen drops internally twice a 
day, and a ten per cent, lotion to be painted on at night ; 
each day the part was to be bathed with hot water and 
ichthyol soap. In rosacea it was equally beneficial, but 
in eczema, or in either of the above skin affections ap- 
proaching eczema, it had to be used cautiously and more 
mild applications employed. He also recommended it in 
lichen, urticaria, intertrigo, erythema, furunculus, burns, 
and innumerable other forms of skin disease. In ecze- 
mas he found benefit from the internal use of ichthyol 
and mild soothing applications. Subsequent experience 
has confirmed the value of this remedy in nearly all 
forms of skin diseases, including eczema and all forms of 
eczematous inflammations. Externally it is employed as 
a lotion of the strength of ten or twelve per cent., or as an 
ointment with lanoline or other base. Dr. Unna has re- 
cently advised the preparation of varnishes, which he 
considers the most suitable way of applying the remedy : 
Ichthyol, 40 parts ; starch, 40 parts ; solution of albu- 
min, 1 to 1| part ; water, to 100 parts. The starch is 
first moistened with the water, the ichthyol is then added, 
and lastly the albumin. For surgical purposes he uses : 
Ichthyol, 25 parts ; carbolic acid, 2.5 parts ; starch, 50 
parts; water, 22.5 parts ; the ichthypl and carbolic are 
dissolved in the water, warmed, and when cool the starch 
is added. These varnishes may be applied and remain 
on the parts until the next application, and are easily re- 
moved by water. 
A more important addition to the therapeutic value of 
ichthyol has been its employment in erysipelas. Klein 
found that in dilute solutions it arrested the develop- 
ment of the bacilli of erysipelas, and when used in the 
treatment it shortened the attack by one-half. The 
parts should be carefully washed and an ointment of 
equal parts of vaseline and ichthyol applied ; where the 
surface affected was extensive a weaker application was 
used-ichthyol, lanoline, and water in equal parts. The 
applications should be thoroughly rubbed in two or 
three times a day, and continued for five or six days, 
when the redness and inflammation will be found thor- 
oughly removed. In using the application the clothes 
and bedding should be protected. 
This drug has not been employed to any extent in 
general surgery, although it has been recommended as a 
dressing for wounds, abscesses, and ulcers, in which it 
undoubtedly possesses a beneficial action. Unna advises 
the use of the pure, undiluted ichthyol for such purposes. 
In gynaecological disorders it is much used, and reports 
of its success are numerous. In chronic forms of para- 
metritis and perimetritis, with exudations and adhesions, 
inflammatory conditions of the ovaries and tubes, cervical 
erosions, vaginal catarrh, it causes a lessening of the con- 
gested condition, and promotes absorption of the inflam- 
matory products. In no instance has it produced any un- 
favorable symptoms, and as a wash and tampon it may 
be used without danger. It may be used with glycerine, 
one to twenty, as a tampon, with lanoline in equal parts, 
or a ten per cent, solution in water may be used as a 
wash. It is also given internally, which assists the ac- 
tion of the typical application in promoting absorption. 
On account of its success in gynaecological practice, it 
has been employed in inflamed conditions of the pros- 
tate, a ten per cent, solution being injected into the 
anus three or four times a day. It appeared to have a 
very favorable action on the inflamed gland, and in 
forty cases in which it was used, no abscess occurred in 
any case. 
It was advised as a remedy in rheumatism, particularly 
in the form due to gonorrhoeal infection, but experience 
has not proved it a success. An ointment is rubbed in 
the affected joints, and five to twenty minims are taken 
(SUPPLEMENT.) 
internally each day. At the meeting of the Fourth In- 
ternational Congress, Dr. Unna read a paper pointing 
out the value of ichthyol in the treatment of leprosy. 
He presented the following conclusions: (1) Lepra tu- 
berosa, even of universal extension and more than one 
year's standing, can be cured ; (2) the cure can be ef- 
fected in a comparatively short time by the energetic in- 
ternal and external employment of the reducing reme- 
dies ; (3) among them may be specially recommended 
ichthyol, chrysarobin, pyrogallol, and resorcin. Of these 
ichthyol is the only one that can be administered inter- 
nally, without danger, for any length of time, and con- 
sequently is a remedy of great importance. The appli- 
cation advised is an ointment of ten parts ichthyol, seven 
parts lard, and oil, three parts. Internally, fifteen to 
twenty-four minims may be taken daily. 
In addition to the diseases enumerated, it may be ad- 
ministered internally in all conditions in which'there is 
hypersemia and capillary dilatation. It in no way dis- 
agrees with the patient, although at first it may give rise 
to disagreeable eructations of gas ; this, however, does 
not persist. It does not cause any irritation of the mu- 
cous membrane, but has been found beneficial in all forms 
of chronic gastric and intestinal troubles. The dose for 
a child of two years of age is about two minims daily ; 
for adults, from five to twenty minims daily. It is usually 
administered in pills or in capsules. 
Beaumont Small. 
IDIOPATHIC AN7EMIA.-Much study has been given 
to idiopathic anaemia since the publication of the Refer- 
ence Handbook. Its clinical characteristics, particu- 
larly those of the blood, have been more sharply defined, 
but there is still a lack of entire agreement as to its patho- 
geny. The most important papers which have appeared 
in recent years are those of Hunter, Russell, and Macken- 
zie. 
The blood changes in idiopathic anaemia are, with few 
exceptions, such as may occur in any grave chronic 
anaemia, but in the former they are more varied and 
reach a more intense degree. A very important charac- 
teristic is the amount of haemoglobin present ; the whole 
amount is diminished, but, as compared with the greatly 
diminished number of red blood-corpuscles present, the 
haemoglobin is relatively increased. Again, there is 
great variation in the size of the red blood-corpuscles, 
the average size probably being larger than normal. 
The number of nucleated red blood-corpuscles varies, 
and as they are found in other anaemic conditions their 
presence alone is not significant ; but the occurrence of a 
considerable number of nucleated cells of large size 
(gigantoblasts) is regarded by Ehrlich and his followers 
as almost diagnostic of idiopathic anaemia. 
The leucocytes of idiopathic anaemia are diminished 
in number, the proportion of small mononuclear cells 
(lymphocytes) being increased, and that of multinuclear 
cells diminished. 
Minute examination of the blood requires that cover- 
glass preparations should be made, and the blood 
stained. For this method we are indebted largely to 
Ehrlich. The cover-glasses should be perfectly clean, 
and to avoid soiling or moisture it is advisable to use 
forceps. A satisfactory solution for staining is the fol- 
lowing, suggested by Dr. W. S. Thayer :1 
Sat. aqueous sol. of orange G 2 
Sat. aqueous sol. of methyl green.... 6.25 
To be added, drop by drop, while shaking the solu- 
tion : 
Water 15 
Alcohol 10 
Glycerine 5 
The cover-glass preparations of the blood are first 
fixed by immersion in equal parts of alcohol and ether, 
or, what is better, by heating them at a temperature of 
212° F. or a little higher ; but they should not be kept 
at that temperature more than an hour. They are then 
stained in the solution mentioned for from two to five 
491 Idiopathic Anaemia, 
lull uenza. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
minutes, washed in water, dried, and mounted in oil 
or balsam. " The red cells are stained orange or 
buff, the nuclei of the colorless corpuscles green, the 
neutrophilic granules violet or lilac, the eosinophilic 
granules a deep red. The nuclei of the nucleated red 
blood-cells are stained an intensely deep green, almost 
black." 
As regards the pathology of idiopathic anaemia, 
Hunter's investigations seem to show conclusively that 
haemolysis is at least the largest factor in idiopathic 
anaemia. He, by the way, looks upon pernicious anaemia 
as a special disease, and as a distinct variety of idiopathic 
anaemia. 
Hunter found the most constant anatomical change to 
be a large excess of iron in the liver. He concludes that: 
"In pernicious anaemia the seat of disintegration is 
chiefly the portal circulation, more especially that por- 
tion of it contained within the spleen and the liver, and 
the destruction is effected by the action of certain poi- 
sonous agents, probably of a cadaveric nature, absorbed 
from the intestinal tract.'' 
Griffith and Burr2 reach essentially the same results as 
Hunter. 
W. Russell believes that the blood is defective before 
it reaches the liver, and that this explains the increased 
liver haemolysis. 
As regards treatment, it is important to keep the stom- 
ach and bowels in a healthy condition. Washing out 
the stomach is a rational procedure, and is reported to 
have cured one case (Meyer). 
The bowel should also be kept free from putrefactive 
changes by laxatives and antiseptic agents. Dr. G. A. 
Gibson,3 adopting Hunter's suggestion, employed /3-naph- 
thol in two-grain doses three times a day in a case of per- 
nicious anaemia. Apparent cure resulted. The jB-naph- 
thol is best given with salicylate of bismuth, to prevent 
intestinal disturbance. Hunter prefers farinaceous and 
fatty foods to meats. Of internal remedies, arsenic is 
unquestionably the best. It should be given in as large 
'doses as can be borne ; some patients have been able to 
take as high as twenty to thirty minims of Fowler's solu- 
tion at a dose. Inhalations of oxygen have also proved 
helpful. J. II. Musser. 
i Boston Medical and Surgical Journal, February 16 and 23, 1893. 
2 Medical News, Philadelphia, 1891, lix., 445-450. 
3 Edinburgh Medical Journal, October, 1892. 
ILFRACOMBE. A popular sea-side resort and cli- 
matic station in North Devonshire, England. Ilfracombe 
is situated near the mouth of the British Channel, and is 
surrounded by peculiar picturesque heights called 
" tors.'' The climate is bracing, but not mild and equa- 
ble. It is less rainy, however, than at Torquay. The 
sanitation of the place is good. The rate of mortality is 
only about seventeen per thousand per annum. Accord- 
ing to Black (" Watering Places of England "), Ilfracombe 
is "a good-sized seaport town, formed principally by one 
main street, about a mile long, running parallel with the 
sea-shore, and a harbor (formed by an inlet of the Bris- 
tol Channel), which is almost encircled by picturesque 
verdurous heights or tors. It is remarkable for a pecu- 
liar form of coast, rarely to be met with elsewhere in 
England. Beginning with the harbor of Ilfracombe it- 
self, the land and sea together combine in making con- 
stant alternations of high, craggy, furze-crowned tors, 
in some cases almost overhanging the sea below, which 
precipitately break and give place to little bays or inlets, 
separating and varying what would otherwise be a con- 
tinuous line of cliffs-thus allowing glimpses of the in- 
land foliage beyond." 
The bathing facilities are good, but there are no sands 
fit to stroll on. One of the features of the beach is a 
peculiar vaulted passage leading to two coves, one for 
ladies, the other for gentleman bathers. Interesting ex- 
cursions abound in this section of Devon. The height of 
the season is from July to October. Ilfracombe is about 
six and a half hours by rail from London. 
Edmund C. Wendt. 
(SUPPLEMENT.) 
IMMUNITY, ARTIFICIAL. As will be seen from the 
article " Artificial Immunity" (p. 51), in Ehrlich's experi- 
ments upon the transmission of immunity, this observer 
found that immunity in the father has no influence upon 
the offspring : the offspring of a highly immune father 
are just as susceptible as those of a highly suscepti- 
ble father. Immunity can only be transmitted by the 
mother, and this takes place in two ways : by intra- 
uterine transfer of immunity from the mother to the 
fretus, and by extra-uterine transfer with the mother's 
milk. Moreover, the milk of an immunized animal will 
not only give immunity to the offspring of the animal 
herself, but can also be used by feeding or by subcuta- 
neous injection to render other animals immune. Now, 
since the article above referred to was cast, and conse- 
quently after it was too late to make any additions, there 
have appeared two publications : one on the transmission 
of immunity by the male, and the other upon the varia- 
bility in the immunizing power of the milk of an immu- 
nized animal. The first of these articles' goes to prove 
that in hydrophobia a male dog does transmit immunity 
to his offspring ; this is in striking contrast to Ehrlich's 
results. It was shown that in rabies highly protected 
male dogs in two out of three cases transmitted a high 
degree of immunity to a part of a litter (two out of five in 
one case, and two out of four in the other). In the third 
case, where there were four puppies, there was no evi- 
dence of transmission at all. In those cases where im- 
munity was transmitted the puppies resisted the inocu- 
lation of the spinal cord from a case of "street-rabies" 
under the dura mater. Animals died of hydrophobia in 
the check experiments. The three remaining puppies of' 
the first experiment, and all four of the third, died of hy- 
drophobia on subdural application of spinal cord from a 
case of street hydrophobia. The two puppies which died 
in the second experiment took the disease from inocula- 
tions under the dura with the " virus fixe," a more power- 
ful virus than that of the street. The fathers of each of 
the litters of puppies were different, but all three were 
highly rabies-proof. The mothers were all normal, i.e., 
not rabies-proof. 
The small number of these observations and the con- 
flicting results necessitate substantiation before the trans- 
mission of immunity from rabies by the male can be 
accepted as proven. 
The other publication 2 referred to above gives the re- 
sults of further tests of the power of the milk from the 
goat, which was given immunity from tetanus during 
and after gestation (mentioned under " Artificial Immu- 
nity " on p. 51). It shows that the power of the milk is 
subject to considerable fluctuation, depending upon the 
length of time that may have elapsed between the inocu- 
lation of the goat and the making of the tests. Some 
time after the goat had been inoculated it was found that 
its milk had 4,000 degrees immunizing power. The goat 
was then inoculated with 75 c.c. of a virulent tetanus 
culture, and showed no symptoms ; but tw'enty-four hours 
after this inoculation the milk showed that its immuniz- 
ing power had fallen to 1,000, and further tests showed 
that it remained at 1,000 for a day and then gradually 
rose, attaining a value of over 8,000 in eighteen days. It 
then gradually fell to below 4,000 in seventeen days, 
where it remained stationary. 
The explanation given of this behavior is that at first 
some of the antitoxin contained in the milk had to be 
used to counteract the poison contained in the virulent 
culture injected into the animal, and this was followed 
by an over-production of antitoxin. In other words, it 
is an analogous process to the over-production of leuco- 
cytes following extensive destruction of these. Other 
processes of a similar nature are often met with in bio- 
logical investigation. 
In testing the value of the milk or blood-serum of a 
goat made immune from tetanus, it is seen from the above 
that the test must be made at least four or five weeks 
after the last inoculation, otherwise the result will not be 
uniform. 
The antitoxin contained in the milk was obtained in 
a concentrated state by precipitation with ammonium 
492 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, 
(SUPPLEMENT.) 
Idiopathic Anaemia. 
Influenza. 
sulphate, dialysing in running water, and drying in vacuo 
at 35° C. There resulted a yellowish-white powder pos- 
sessing powerful antitoxic properties. 
Meade Bolton. 
1 Tizzoni und Centanni: Die Vererbung der Immunitat gegen Rabies 
von dem Vater auf das Kind, Centralbl. f. Bakt., etc., Bd. xiii., No. 3. 
a Brieger und Ehrlich : Beitrage zur Kenntniss der Milch-immunisir- 
ter Thieve, Zeitschr. f. Hygiene, etc., Bd. xiii., No. 2. 
INFLUENZA. Influenza is an acute, self-limited, in- 
fectious fever, occurring in widely distributed epidemics, 
and characterized by catarrhal inflammation of the re- 
spiratory and gastro-intestinal mucosa, by profound ner- 
vous disturbances, and by extreme debility. 
Synonyms.- Febris Catarrhalis ; Epidemic Catarrhal 
Fever ; La Grippe ; Grip ; Tac ; Horion ; La Dando ; 
Ziep ; Epidemischer Husten ; Epidemischer Schnupfen ; 
Schafhusten ; Blitz Catarrh ; Mbdefleber ; Mal Russe ; 
Snufsjuka (Swedish); Qual-Tong (Chinese). 
Many other synonyms, grave and humorous, might be 
listed which have been suggested by the peculiarities of 
various epidemics, the national characteristics of the 
people affected, or some fancied resemblance of the symp- 
toms, but influenza, la grippe, or the Anglicised grip, have 
practically superseded all other names, in medical as well 
as lay circles. 
Influenza is of Italian origin, and was probably first 
employed by the Italian savants to indicate the supposed 
occult influence of the stars over the course of the disease. 
Wolff states that it was first used by an Italian author, 
Gagliardi: " Parere sopra 1'Influenza catarrale, che pre- 
sentamente regna in Roma e stato ecclesiastico, Roma, 
1733." 
Other authorities, however, trace its origin to the Eng- 
lish writers Pringle and Huxham, the latter of whom, 
in describing the epidemic of 1742-43, writes : " Quae per 
totam Europam hoc vere sub nomine influenza grassata 
est." 
The derivation of la grippe is likewise in doubt. 
Most authors refer its origin, and probably correctly, to 
the French, agripper-to seize, but others derive it from 
the Polish, chrypka, or grypka-hoarse. It came into 
general use in France during the epidemic of 1732 
(Marigne : Description et traitement d'une affection 
catarrhale epidemique observee en 1732, vulgairement 
appellee la Grippe, 1776). 
Historical Sketch.-Since the appearance of the 
fourth volume (1887) of this Reference Handbook, 
containing the brief article on Influenza, a series of epi- 
demics has swept over the world, which, for rapidity of 
movement, extent of distribution, and numbers affected, 
rival any previous visitations of the disease. This series, 
which began in the fall of 1889, and which can hardly 
yet be spoken of as an event of the past, was the first 
general epidemic of la grippe since 1847-48, and really 
introduced the present generation of practitioners to a 
disease known to them only in history, and thus becomes 
one of the notable medical events of the latter half of the 
century. 
Recurring at a time when the study of the infectious 
diseases was being pushed so zealously along bacterio- 
logical lines, and engaging in its study the ablest clinicians 
of every nation, it was confidently predicted that the 
mysterious problem of its nature and etiology would be 
speedily solved. While this prediction has not been ful- 
filled, our knowledge of epidemic influenza has been 
materially increased and necessitates a restatement here. 
In this necessarily brief historical sketch we shall not 
attempt a complete chronological account of the epi- 
demics of all ages but shall only allude to those which, 
from special incidents, mark an era in the progress of our 
knowledge, and endeavor to trace somewhat in detail the 
course of the recent epidemics of 1889-92. 
Medical historians have interpreted the vague utter- 
ances of Hippocrates and Livy, referring to a disease 
which assumed epidemic proportions in 412 b.c., as the 
first written allusion to influenza. 
Mention is made of an epidemic which prevailed ex- 
tensively in the latter part of the sixth century, in which 
the prominent symptoms were headache, debility, cough, 
and an irresistible desire to yawn. Sneezing was usually 
the first symptom of the prevailing distemper, and the 
custom of calling down " God's blessing " upon one who 
was heard to sneeze is said to have originated at this time. 
It is very probable, as maintained by many authors, 
that not a few of the general epidemics described in the 
earlier medical chronicles under various names (catarrhal 
fever, Italian fever, etc.), were epidemics of true in- 
fluenza. 
Parkes traces the disease back to the ninth century. In 
827 and 876 epidemics in which cough was the most prom- 
inent symptom, and which also extended to domestic 
animals and birds, originated in Italy and spread rapidly 
over all Europe. The epidemic of 876 is said to have 
sadly discomfited the victorious army of Charlemagne on 
its return march from Italy. 
But one epidemic, and that limited to Germany and 
France, is known to have occurred in the tenth century, 
after which the world apparently enjoyed immunity for 
about two hundred years. 
Whatever may have been the nature of these early epi- 
demics, our positive knowledge of influenza, according 
to Wilson, dates from the great visitation of 1510, which 
covered the whole of Europe and the British Islands, and 
was so general that " not a single family and scarce a per- 
son escaped it." 
The epidemic of 1557, which appeared suddenly in 
Eastern Asia and spread rapidly to the West, was the first 
influenza epidemic which is known to have crossed the 
Atlantic to America. This pandemic was very severe in 
certain localities and was attended with a high mortality. 
Five thousand are said to have died in Delft alone within 
a short period. 
During the past four hundred years there have been 
about seventy epidemics of grippe, one-half of which, 
from their widespread prevalence, deserve to be called 
pandemics. 
The present century has experienced thirteen visita- 
tions ; the last important one previous to 1889 was that of 
1847, in which were stricken more than one-quarter of 
the population of London and Geneva, and fully one-half 
that of Paris. 
The course of the later epidemics has been quite uni- 
formly from east to west. It is, of course, only the 
general trend of the epidemic that can be followed, since 
every locality invaded becomes at once a new centre from 
which arms of infection reach out in every direction. 
With few exceptions, the later pandemics of influenza 
originated in Eastern Asia, where the disease may almost 
be said to be endemic. From this nidus they travelled 
westward across Russia, thence over Continental Europe 
and the British Isles, over the ocean to America, Aus- 
tralia, East Indies, until, like Puck's girdle, they circled 
the globe. 
The epidemic of 1889-90 followed closely the beaten 
path. The first cases, of which we have knowledge, oc- 
curred in Bokhara, Central Asia, in May, 1889. The dis- 
ease became quite prevalent in July, and following the 
lines of the new railways slowly invaded other portions 
of the Russian Empire. 
The epidemic can be easily traced through Western 
Siberia and the post-towns and stations in Russia in its 
march toward St. Petersburg, which was reached by the 
end of October, and two weeks later it had assumed such 
startling proportions in that city as to attract the atten- 
tion of the civilized world. 
From St. Petersburg the epidemic spread with unpre- 
cedented rapidity, and the cities of Western Russia, Cen- 
tral and Northern Germany, Austria, France, and the 
British Islands became, in turn, the scene of its ravages, 
until by the end of December it had compassed the whole 
of Europe. Scattering cases announced the appearance 
of the disease in New York about the middle of December, 
and a week later it had assumed epidemic proportions. 
From the seaboard it extended in every direction, and 
during January, 1890, was generally diffused over the 
United States, British North America, the Sandwich 
Islands, and Central America (Guatemala.) 
493 Influenza. 
Influenza. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
From its starting-point in Central Asia the epidemic 
also extended in a southeasterly direction. Malta, Cy- 
prus, and Egypt were successively visited in January and 
February. It was reported from India in February, be- 
came epidemic in March, and prevailed extensively in 
Upper and Lower Birmah during April and May. It 
reached Arabia in April, many of the pilgrims arriving 
from India and the Straits having sickened on the voy- 
age. 
In the Southern hemisphere the course was from the 
south northward. Capetown was the seat of its first 
appearance in Africa, it having been carried thither by 
steamers ; thence it extended northward, reaching Mau- 
ritius in August, the Shire Highlands in September, and 
Abyssinia in November, 1890. 
South America was reached in February. Buenos 
Ayres was infected presumably by steamer from Bor- 
deaux ; thence it travelled up both coasts and prevailed 
in Brazil, Chili, and other States during April and May. 
It was notably severe in the province of Pernambuco. 
It was prevalent in Australia and New Zealand from 
March to July. 
In Iceland it occurred in July, and in some remote 
places of China and Kashmir during September and De- 
cember. 
Dr. Parsons, in his exhaustive report to the British 
Medical Association, July, 1891, to which we are largely 
indebted for the facts above related, writes : " Thus as- 
suming the epidemic to have started from Russia in Octo- 
ber, it took about six weeks or two months to spread over 
Europe and reach North America, rather more than two 
months to reach the Cape, three months to reach South 
America, four months to reach India, five months to 
reach New Zealand and Australia, nine months to reach 
Iceland, ten months to reach Mauritius, and nearly a year 
to make some remote places in Africa and Asia." 
During the summer and fall of 1890 influenza was 
" smouldering on," as shown by the numerous local out- 
breaks, usually of short duration, indifferent parts of the 
world. 
The second general epidemic-1891-began in Janu- 
ary, and was but little less extensive, and probably more 
fatal, than the one just sketched. It, too, was pandemic, 
but in the journey around the world the course of its 
predecessor was reversed, and the general trend was 
from west to east. 
The origin of the epidemic is traced to New Orleans, 
where influenza prevailed extensively and fatally in Jan- 
uary, and from which it radiated in every direction. 
During February, March, and April it spread over the 
Northern States and was notably severe in Pittsburg and 
Chicago (March) and the sea-board (April). It was re- 
ported from England in April, from Germany in August, 
from Scandinavia and Denmark in July, from Russia (St. 
Petersburg) in September, from France in October, from 
Italy in December, and thus passed from country to coun- 
try until almost the whole civilized world had been revis- 
ited. This epidemic also ran its course in about one year. 
Nature and Etiology.-It has been customary to 
consider influenza as an epidemic catarrhal fever, but 
recent denouements have materially strengthened the be- 
lief, long entertained by some, that it is really an infec- 
tious nervous fever. 
Many of the symptoms are most readily explicable 
upon a neural basis, while its probable bacterial origin, 
together with the knowledge of the toxaemias that usu- 
ally attend upon bacterial infection, gives support to 
such an explanation. Much testimony has accumulated 
during the recent epidemics to show that the nervous 
symptoms are primary and are followed by secondary 
involvement of the respiratory and digestive organs. In 
a given case the pulmonary, gastro-intestinal, or cerebro- 
spinal symptoms predominate as the nervous apparatus 
of one or the other system bears the brunt of the disease. 
Nervous symptoms are uniformly present and usually 
pronounced, even in the mildest forms of grippe, while, 
on the other hand, in many of the worst cases, catarrh 
of the mucous membranes and inflammation of the re- 
spiratory tract are totally absent. 
(SUPPLEMENT.) 
Again, when catarrh and pneumonia are present, they 
frequently assume " such a peculiar character as to lead 
to the suspicion that they might arise from irritation of, 
or loss of power in, the various nervous mechanisms 
supplying the affected parts, and would therefore have 
to be looked upon more as vaso-motor and trophic neuro- 
ses than as ordinary catarrh and inflammation." 
The histories of the various epidemics prove clearly 
that the disease is not dependent upon climate, soil, sea- 
son, meteorological, or electrical conditions. It affects 
all classes of people, irrespective of nationality, sex, so- 
cial position, or environment, although infants and young 
children seem to possess partial immunity. While no 
season of the year is exempt, late autumn and early win- 
ter are the periods of its greatest frequency. 
The phenomena of influenza are only comprehensible 
upon the theory of a specific infecting virus or germ as 
the exciting cause. Its epidemic occurrence, transmis- 
sion along lines of travel, rapid diffusion, sweeping over 
whole continents in a few weeks, and affecting nearly 
the entire population in a certain district in a few hours 
after its appearance, indicate some powerful morbific 
agent in the atmosphere which acts specifically upon the 
animal economy. 
Some authors still cling to the theory that the morbific 
agent is a miasmatic material, but the most generally ac- 
cepted doctrine, and the one most in accord with our 
knowledge of the etiology of other infectious diseases, is 
that which makes it dependent upon the presence of a 
micro-organism. 
Notwithstanding the diligent search of bacteriologists 
during the past three years, working under the improved 
modern technique, but little is positively known about 
the morphology of the pathogenic bacillus and absolutely 
nothing about the chemical constitution of its special 
toxine. These investigations have uniformly disclosed 
the presence of the pyogenic bacteria and the diplococcus 
pneumoniae, but it is not claimed that they bear a causal 
relation to the disease. 
From time to time the discovery of the grippe microbe 
has been announced. But, like Weichelbaum's lancet- 
shaped diplococcus, Klebs's flagellatum, Jolly's cossack- 
shaped coccus, Kirschner's punctiform microbe, and 
Babes's radiated bacterium, each, in turn, has failed in 
the crucial test and has been relegated to obscurity, along 
with Saulsbury's infusoria and Seifert's micrococci. 
It is again confidently announced that the true in- 
fluenza bacillus has been, at last, successfully and in- 
dependently demonstrated by Staff - Surgeon Richard 
Pfeiffer and Dr. Canon, of the Moabit Hospital, Berlin. 
According to these observers, it is a tiny rodlet of about 
the thickness and half the length of the bacillus of mouse- 
septicaemia. It is the smallest bacillus yet isolated, and 
is only recognizable during the first twenty-four hours 
by means of a lens, so that macroscopically a test-tube 
containing them can scarcely be distinguished from a 
sterile one. The bacilli are, however, readily differ- 
entiated by the peculiarity of their growth, as the colo- 
nies always remain separate and do not, like the colonies 
of all other species of bacteria, join together and form a 
continuous row. They have been found in large numbers 
in the blood, sputum, bronchial, and pleural exudations 
of influenza patients. 
Dr. Kitasato has successfully cultivated the bacillus in 
glycerine-agar to the sixteenth generation. Inoculation 
experiments have been negative in some species of ani- 
mals (guinea-pigs, pigeons, mice), but in others, notably 
monkeys and rabbits, have caused a disease simulating 
grippe in its main features. Letzereich, of Wiesbaden, 
has quite recently published an account of control ex- 
periments in fifty cases of infectious diseases, viz., mea- 
sles, scarlet-fever, diphtheria, pneumonia, and catarrhal 
affections of the respiratory passages, in which in 
neither blood nor sputum was the Pfeiffer-Canon bacillus 
found. 
Corroborative testimony comes from others high in 
authority like Professors Babes and Cornil, and even 
Koch himself is said to have given a partial endorsement 
to the claims made. It is premature, in the face of the dis- 
494 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
lull ueiiza. 
Influenza. 
appointments of the past, to give a positive opinion, but at 
present it looks as if the Pfeiffer-Canon-Kitasato bacillus 
were indeed the true pathogenetic microbe of epidemic 
influenza. Should this be confirmed it will add another 
to the brilliant triumphs of the present decade. 
It is highly probable that the action of the morbific 
principle of grippe is not limited to man. Epizootics, 
very similar in many respects to the epidemics in the 
human race, have often prevailed among domesticated 
and wild animals, especially horses, dogs, and cats. 
The attention of the profession was first called to this 
fact by Huxham in connection with the epidemics of 
1732-33. These epizootics occur independently, but 
more often happen either simultaneously with, or im- 
mediately precede or follow, epidemics of influenza. 
Bartholow favors the view that the epidemic disease in 
animals is the parent of that in man, but is so modified 
by transition that each succeeding epidemic is milder 
and less aggressive. 
The contagiousness of influenza has long been a mooted 
question. The doctrine that contagion is one method of 
its propagation has been strengthened by numerous ob- 
servations made during the recent epidemics and is now 
fully accepted by most clinicians. 
The frequency with which epidemics, both in their 
general and local distributions, follow the regular lines 
of travel, the immunity of isolated households and com- 
munities, and the frequency with which local outbreaks 
have been traced to their sources leave, indeed, little 
room for scepticism. The marvellous rapidity with which 
influenza sometimes spreads in a community once in- 
fected is readily accounted for by its remarkably short 
period of incubation. It is claimed by many that per- 
sonal contact with infected individuals or materials is 
the only method of its propagation. The supporters of 
this doctrine contend that the dissemination of disease- 
germs through the air must have its limitations. That 
they can be carried thousands of miles in air-currents 
without dispersion or destruction, or the assumption, on 
the other hand, of a proliferation in the air itself, does 
violence to our knowledge of the life history of disease- 
germs. There are, however, too many irregularities in 
the behavior of grippe epidemics, not necessary to be 
enumerated here, to permit us to accept personal con- 
tact as the only factor in its propagation. Hirsch has 
pointed out that notwithstanding the modern facilities of 
inter-communication and rapid transit, epidemics do not 
travel more rapidly now than under the old regime. 
The passengers and crews of ships which have sailed 
from non-infected ports, and have held no communica- 
tion with other ships, have been repeatedly attacked in 
mid-ocean. 
The following striking instance is related by Sir 
Thomas Watson: The frigate Stag anchored at Berry 
Head, on the Devonshire coast, all on board well, April 
3, 1833, the very day on which Watson saw his first 
two cases of influenza in London. The breeze was off 
the land, and in half an hour after dropping anchor 
forty men were down with influenza ; six hours later the 
number was increased to sixty, and soon reached one 
hundred and sixty. 
The period of incubation is very variable, both in in- 
dividual cases, and in different epidemics. It may de- 
velop almost immediately after exposure, from which it 
has received one of its popular names, Lightning Ca- 
tarrh, Blitz Catarrh, but, in other instances, there is an 
incubation period, lasting from a few hours to several 
days. 
The attack does not confer immunity from subsequent 
ones, and a few persons even experience a second seiz- 
ure during the same epidemic. An epidemic, as a rule, 
lasts from four to eight weeks in a given locality, al- 
though many run a shorter course and often end as sud- 
denly as they began. The rate of progress not only 
varies greatly in different epidemics, but also in the 
same epidemic as it spreads over different districts. 
There is no causative relation between influenza and 
other epidemic or infectious diseases. The statement 
that prevalent infectious and contagious diseases abate in 
(SUPPLEMENT.) 
frequency and intensity upon the appearance of grippe, 
is not sustained by facts. Neither is there any ground 
for the popular belief that cholera follows in the wake of 
influenza. In some instances, notably in 1831, 1847, and 
1856, the two diseases have been closely associated in 
point of time, but the official report of the French Com- 
mission fully endorses the conclusion of Ghige and Smo- 
lensky that the association was purely accidental. 
Morbid Anatomy.-The anatomical lesions found 
after death give meagre information as to the pathology 
of influenza. A fatal termination is almost invariably 
due to some complication, and the structural changes 
found post mortem are characteristic of the secondary dis- 
ease, and not of influenza. Death rarely occurs in un- 
complicated cases. The lesions peculiar to influenza are 
almost exclusively localized upon the respiratory mucous 
membrane. The mucous lining of the larynx, trachea, 
and bronchial tubes is hyperaemic, swollen, and covered 
with frothy or viscid muco-pus. The catarrh may ex- 
tend to the finer bronchi, but is ordinarily limited to the 
trachea and larger tubes. The bronchial glands are some- 
times enlarged and softened. The gastric and intestinal 
mucous membrane is more or less congested in a consid- 
erable portion of the cases. 
The solitary and agminate glands of the intestine are 
not usually implicated. 
Kernig, of St. Petersburg, found the spleen enlarged 
in all cases which came under his care. 
Symptoms.-The complexus of symptoms of influenza is 
exceedingly varied, and this variability extends not only 
to different epidemics, but also to individual cases of the 
same epidemic. In many cases the attack closely resem- 
bles an ordinary catarrh, with little fever and slight hy- 
persemia of the naso-pharyngeal mucosa ; again, it as- 
sumes the form of an intense infectious fever, with pro- 
found involvement of the nervous centres, while between 
these extremes are found cases of almost every grade of 
severity, and almost every combination of symptoms. 
Many attempts have been made to satisfactorily classify 
the protean forms of the disease. The classification most 
generally followed by recent writers, and which is a mod- 
ification of that long ago proposed by Hufeland, is into : 
1. The nervous form. 
2. The catarrhal or respiratory form. 
3. The gastro-intestinal form. 
It is estimated that in the recent epidemics about fifty- 
five per cent, of the cases belonged to the nervous, thirty 
per cent, to the catarrhal, and fifteen per cent, to the gas- 
tro-intestinal form of the disease. These estimates will 
undoubtedly have to be changed for different localities. 
According to the observation of the writer, nervous 
symptoms predominated in about eighty-five per cent, of 
the cases in the epidemic of 1889-90, while in that of 
1891, the catarrhal and gastric forms were more com- 
mon and severe, but still constituted a small percentage 
of the cases. The division is, however, purely arbitrary, 
and finds its chief value in emphasizing the fact that the 
brunt of the attack may fall upon any one of the three 
great systems. 
Influenza usually begins abruptly, but is occasionally 
preceded by a feeling of indisposition or malaise of from 
a few hours' to several days' duration. A distinct chill, 
or, oftener, a mere chilliness, is at once followed by a rise 
in temperature and the symptoms of a naso-pharyngeal 
catarrh, with cough, sore throat, frontal headache, pains 
in, and general soreness of, the limbs, depression of 
spirits, and sometimes with gastro-intestinal disturb- 
ances. 
The fever is remittent in type, variable in intensity, 
rarely exceeds 104° F. in uncomplicated cases, and sub- 
sides by lysis, rather than by crisis. As a rule, the tem- 
perature reaches its maximum at the beginning or early 
in the attack, and often drops below normal during con- 
valescence. 
A subnormal temperature has also been noted by many 
during the progress of the disease, accompanied, usually, 
by surface coldness, feeble circulation, and other evi- 
dences of depression. The recent epidemics were pe- 
culiar in the large number of cases in which the fever 
495 Influenza. 
Influenza. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
took on a continuous type, and persisted for two or three 
weeks, resembling, in many of its features, a mild ty- 
phoid fever. 
Anomalous cases were also recorded in which the 
whole course of the disease was afebrile, and, according 
to Eichhorst, these were particularly liable to nervous 
explosions. 
The pulse is moderately increased in frequency and 
changeable in rhythm and quality. The tendency to 
cardiac asthenia, so pronounced in grave cases, often be- 
comes a serious menace in those of moderate severity. 
An extraordinary slowing of the pulse is sometimes ob- 
served. The pulse may only register in the forties or 
fifties and naturally excites fears of some cerebral com- 
plication. This abnormal retardation belongs to the natu- 
ral history of the disease, although it is often erroneously 
attributed to remedies, especially if digitalis or other car- 
diac sedatives have been administered. 
Coincidently with the fever, and sometimes preceding 
it, the symptoms of an acute catarrh of the upper air- 
passages are manifested. 
There are frequent paroxysms of sneezing, a feeling of 
stuffiness in the head, the eyes are suffused and watery, 
and coryza with an abundant secretion of mucus speedily 
follows. The mucous membrane of the nose, mouth, 
frontal sinus, pharynx, and larynx is congested. The 
voice becomes hoarse or reduced to a whisper. Cough is 
rarely absent, usually severe, and recurs in paroxysms 
which harass the patient day and night. At first it is 
harsh and brassy and attended with a scanty muco-serous 
expectoration, which, as the disease progresses, becomes 
abundant, muco-purulent, and often blood-streaked. 
Sharp pains in the sides and under the sternum, dysp- 
noea, and suffocative paroxysms are experienced, and, as 
was long ago pointed out by Graves, of Dublin, often 
without any recognizable intra-thoracic lesion. The ca- 
tarrhal process does not, as a rule, extend below the 
larynx or trachea, but if it should invade the lower air- 
passages, the deepening of the symptoms at once an- 
nounces the fact, and the illness assumes a more serious 
aspect. 
depression. When thoroughly under the grippe influ- 
ence, the patient shrinks from mental as he does from 
physical exertion, is vacillating, foreboding, and often 
becomes a veritable " Jacques " in his melancholy. 
While restlessness and wakefulness characterize most 
epidemics, others are equally marked by somnolence. 
Thus the remarkable epidemic of 1712 is known as the 
steeping sickness, from the almost universal presence of 
this symptom. 
The disturbances of the digestive organs are gener- 
ally mild and consist of anorexia, coated tongue, epi- 
gastric tenderness, abdominal pains and constipation. 
Nausea and vomiting sometimes usher in the attack and 
may continue throughout its course. At times, the 
force of the disease is expended in the intestinal tract 
and causes severe colicky pains, tympanites, and obstinate 
diarrhoea. The stools, at first bilious and fetid, soon 
take on a dysenteric character or become large and wa- 
tery, like the discharges of cholera nostras, and are ac- 
companied with vomiting, leg-cramps, and rapid prostra- 
tion. The digestion remains impaired for some time 
after the subsidence of the acute symptoms, and not 
only retards convalescence, but favors a return of the 
gastro-intestinal derangements upon the slightest indis- 
cretion of diet. 
The urine is scanty, high-colored, and contains abun- 
dant urates. Albumin with casts, hyaline and epithelial, 
are present in a limited number of cases not necessarily 
of the gravest type. The integrity of the kidneys is 
rarely permanently impaired. Cystitis is sometimes met 
with, and retention of urine in elderly persons is tolera- 
bly common. 
The presence of an hemorrhagic tendency has been re- 
marked by many observers. 
Epistaxis and menorrhagia are the most, and cerebral 
hemorrhage the least common of the accidents dependent 
upon this tendency. 
Eruptions are occasionally seen, of which herpes, urti- 
caria, and erythema constitute the chief examples. 
The disease attains its height on the second or third 
day and then rapidly declines, covering a period of from 
four to seven days in its full evolution ; but in the graver 
cases, or in those disturbed by complications, recovery 
may be indefinitely delayed. 
Convalescence is often announced by the appearance 
of some critical discharge, such as profuse sweating, a 
copious secretion of bronchial mucus, a free discharge 
of sedimentary urine, or a profuse diarrhoea. 
After complete apyrexia has ensued, there is not infre- 
quently a temporary return of the fever and other 
symptoms not dependent upon the presence of a compli- 
cating disorder. This new outbreak is usually of brief 
duration, and should be considered as an exacerbation, 
rather than a relapse. It is apt to appear on the fifth or 
seventh day of the disease, and is oftenest seen in those 
who have committed some error of diet or have under- 
gone some exposure. True, relapses are, however, not 
uncommon or free from danger. 
Complications and Sequels.-While there has 
been, of late, a tendency to exaggerate the frequency 
and importance of the complications and sequelae of in- 
fluenza, the fact remains that there is scarcely another 
disease so liable to intercurrent disorders or to serious 
after-effects. The more common of these are divisible 
into two groups : First, those which are the direct out- 
growth of the lesions in the mucous membranes and par- 
enchymatous tissues ; and, second, the sensory-motor de- 
rangements, which result from the action of the grippe 
toxine upon the cerebro-spinal centres. Among the 
rarer affections belonging to the first group may be 
mentioned circumscribed ulceration of the vocal cords, 
abscess of the larynx, oedema of the glottis and paralysis 
of the muscles of the throat. 
Otitis media is comparatively common. The inflam- 
mation does not, as a rule, proceed to suppuration, but 
is rebellious to treatment and occasionally ends in mas- 
toiditis. 
Bronchitis and pneumonitis are, by far, the most fre- 
quent and fatal complications of this group. Authors 
Nervous symptoms are uniformly present, but vary 
greatly in intensity. In some epidemics, notably in 
1889-90, they predominated over all other symptoms. Se- 
vere headache, usually frontal, and pain in the eyeballs 
are rarely absent. The head pain comes on suddenly, is 
nearly continuous, dull, and throbbing, with frequently 
recurring paroxysms of atrocious severity. It is exagger- 
ated by pressure or movement, and is often associated 
with hyperaesthesia of the scalp and neck. 
With the headache there is stiffness and soreness over 
the entire body, as if it had been beaten, and a backache 
which in its intensity is suggestive of dengue or small- 
pox. 
The patient either lies perfectly quiet, to prevent the 
suffering which the slightest movement causes, or tosses 
restlessly about in the futile effort to find a position of 
comfort. Sharp neuralgic pains dart along the principal 
nerve-trunks, but show a decided preference for the tri- 
geminal, intercostal, lumbo-abdominal, and sciatic nerves. 
These neuralgias are often intermittent, but do not ex- 
hibit the periodicity of ordinary malarial neuralgias. 
Persistent insomnia or unrefreshing snatches of sleep 
filled with painful dreams add to the patient's distress. 
Delirium of a mild type is usually present, and is often 
marked when the fever is slight. In exceptional cases it 
becomes so furious as to overshadow all other symptoms. 
Coming on late in the disease it often announces the on- 
set of some complication. 
Vertigo, especially on rising, and muscular tremor are 
not uncommon. Convulsions and coma are rare, but 
may develop with the initial fever or at any subsequent 
period. 
The extreme muscular weakness, amounting, at times, 
to a serious depression of the vital powers, is a peculiar 
feature of influenza. The debility is wholly dispropor- 
tionate to the amount of fever, or the severity of the other 
symptoms, and generally reaches far into convalescence. 
The mental condition harmonizes with the physical 
496 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Influenza. 
Infl uenza. 
have endeavored to show that these affections, when asso- 
ciated with influenza, are peculiar in nature and symp- 
tomatology. According to Elliott " the grip-lung has a 
long and very varying condition of passive blood-stasis 
unaccompanied by rales. If resolution occurs within 
three or four days, it is accompanied by large mucous 
rales, and no time is given for the slow appearance of 
bronchial breathing or bronchophony ; but during the 
long-continuance of the blood-stasis an exudation occurs, 
increasing slowly, which will give in time some broncho- 
phony and bronchial breathing, but never so complete as 
in pneumonia. Resolution never occurs in these cases 
with the suddenness that characterizes it in acute pneu- 
monia. The condition passes off as gradually as it is 
formed. The sharp, clear-cut, and sudden phases of the 
pneumonia attack separate it clearly from the obscure, 
irregular and slow phases of the grip-lung." 
Da Costa, in a recent clinical lecture, describes the 
characteristic influenza lung as one " in which intense 
congestion occurs, with patches of collapse and with spots 
of localized consolidation here and there, if consolidation 
happen at all. Yet there are instances in which real 
croupous pneumonia takes place, involving considerable 
portions of the lungs. But these are comparatively rare, 
and true lobar pneumonia is not nearly so characteristic 
of the influenza lung as the other fovm." 
Osler, with whom the writer is in full accord, admits 
that pneumonitis complicating influenza sometimes runs 
an atypical and very obscure course, but these cases are 
exceptional, and all the anomalies mentioned by writers 
as peculiar to influenza are found in any large series of 
cases of pneumonia. 
It is highly important to bear in mind what has been 
previously stated, that lung complications are liable to 
creep on insidiously, and that in the presence of anoma- 
lous symptoms, whether referred to the respiratory tract 
or not, the chest, as a matter of routine, should be care- 
fully interrogated. Pleurisy and empyema are not un- 
common complications. Abscess of the lung has been 
noted. That influenza bears an etiological relation to 
phthisis pulmonalis, especially in the presence of the 
disposition, can no longer be doubted. It is furthermore 
a matter of common observation that consumptives fare 
badly during the prevalence of the epidemic influence. 
Watson and Curtin call attention to the fact that dur- 
ing the recent epidemics many chronic catarrhal cases 
where the lungs were involved resembled closely, and 
were often mistaken for, phthisis. There were present 
night-sweats, cough, diarrhoea, fever, and emaciation, 
while the physical signs also agreed with those of phthi- 
sis in all but dulness on percussion, which was absent. 
These writers in speaking of the relationship between 
phthisis and influenza make the following remarkable 
statements: "The catarrhal condition remains and 
causes a breaking down of lung-tissue. These cases, 
while presenting the physical signs of phthisis and ter- 
minating finally in death, showed during life, on exami- 
nation of sputum, no bacilli. In the fall of 1890, in the 
Philadelphia Hospital, the sputa of fourteen cases of 
phthisis examined (several times and by different meth- 
ods) for bacilli showed them abundant in four, few in 
six, absent in four cases. In the fall of 1891, after most 
of the old cases of phthisis had died, twelve out of 
twenty-eight cases were found free from bacilli, and in- 
variably with histories dating from an influenzal at- 
tack." 
The nervous disturbances which occur during and after 
grippe are equally important. 
Althaus reflects the opinion of neurologists in the 
statement : " That as a powerful etiological factor of 
protean forms of nerve-disease influenza stands facile 
princeps among all infectious fevers. " 
The organic nervous diseases most frequently observed 
may be enumerated in the order of their frequency, as 
neuritis, meningitis, myelitis, and cerebritis. 
Multiple neuritis is less common than the local forms, 
of which latter neuritis of the supra-orbital, intercostal, 
and sciatic nerves are of tenest met. But "isolated neu- 
ritis of almost every cranial nerve has been recorded with 
such resulting conditions as optic atrophy, loss of smell 
and taste, ophthalmoplegias, both internal and external, 
oculo-motor, facial, bulbar and pseudo-bulbar palsies of 
various types, including true pneumogastric paralysis " 
(Mills). 
Lepto-meningitis (pia-arachnoid) and cerebro-spinal 
meningitis are the commonest types of meningeal inflam- 
mations. 
Bristowe has reported two cases of cerebral abscess, 
and has seen others in which the symptoms would jus- 
tify such a diagnosis. 
Convulsions have been repeatedly observed, and, in a 
few instances, the epileptic habit has been permanently 
established. Mills has seen two cases. 
Polio-myelitis anterior is the form of spinal cord dis- 
ease most frequently associated with influenza. Tem- 
porary paralysis of one or more limbs, evidently of spinal 
origin, is occasionally seen. Abolition of the patellar 
reflex has been noted. 
Neuralgic attacks, severe, persistent, and involving any 
of the nerve-trunks are, perhaps, the commonest of the 
post-influenzal neuroses. The rekindling of old and 
fading neuralgias during convalescence is another of the 
curious features of the disease. 
Neurasthenia, both cerebral and spinal, hysteria and 
hystero-epilepsy, with their illimitable repertory of dis- 
ease mimicries, were frequent sequels in the late epidem- 
ics. 
Insanity is not rare. It usually takes the form of 
melancholia, with hypochondriacal or religious delusions 
and decided suicidal impulses. Leledy, Ladame, and 
others believe that influenza may act either as an excit- 
ing or as a predisposing cause, but that there is always an 
antecedent acquired or inherited predisposition. The on- 
set is often sudden and bears no relation to the severity 
of the febrile attack. The insane are less disposed to 
contract grippe than the sane, and its occurrence is 
sometimes attended by a remission in the mental symp- 
toms. Althaus also recognizes as a rare post-grippal 
neurosis a peculiarly rapid-galloping-form of general 
paralysis of the insane, of which he has seen a few ex- 
amples. 
Biermer, Gottschalk, and others remark upon the fre- 
quent occurrence of severe hemorrhagic endometritis. 
In these cases the uterus is enlarged and sensitive, and 
the hemorrhage profuse. It has long been known that 
women sick with influenza were subject to profuse and 
painful menstruation, and, on the other band, that the 
menses were apt to return to those suffering from 
amenorrhcea. Pregnant women are liable to abort un- 
der the same conditions. 
Prognosis.-Uncomplicated cases of influenza re- 
cover. The prognosis is modified somewhat by the 
character of the prevailing epidemic and the physical 
condition of those affected. The extremes of life and 
those debilitated by disease or vicious habits bear influ- 
enza badly. Infants are fortunately less likely than 
adults to contract the disease. The mortality is largely 
due to complications or to its development in those suf- 
fering from advanced pulmonary, cardiac, or renal affec- 
tions. 
Diagnosis.-Influenza is not likely to be mistaken in 
its epidemic form. The numbers affected, the fever, the 
catarrhal phenomena, the prominence of the nervous 
symptoms, and the rapid course will readily establish 
the diagnosis. Influenza bears a striking resemblance to 
non-specific catarrh caused by atmospheric changes, but 
it is only in those isolated cases which herald the ap- 
proach of an epidemic that this similarity could mis- 
lead . 
The only difficulty in diagnosis attaches to those cases 
occurring during the prevalence of an epidemic of grippe 
in which coryza is absent and the symptoms are those of 
a general fever. Some of these cases bear a striking re- 
semblance to typhoid fever. The continued fever, de- 
lirium, epistaxis, diarrhoea, and prostration are common 
to both, but the temperature charts and progress of the 
diseases are very dissimilar. 
In other cases the suddenness and violence of the on- 
497 Influenza. 
Insanity. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
set, the variety and intensity of the nervous symptoms, 
and the irregular febrile movement are very like epi- 
demic cerebro-spinal fever. 
Dengue and the nervous type of influenza have many 
symptoms in common, but the former is preeminently a 
disease of tropical climates. In our own country it is con- 
fined to the Gulf States and rarely extends beyond the 
thirty-second parallel. Only once (1780) has it reached as 
far north as Philadelphia. It was at that time described 
by Dr. Rush under the name of bilious remitting fever. 
Treatment.-Influenza is a self-limited disease of 
short duration. There is no specific and the treatment is 
largely symptomatic. In view of the many severe com- 
plications and sequehe which may arise, every case should 
be regarded as serious enough to necessitate confinement, 
at least within doors, until the fever has disappeared. 
The experience of the late epidemics demonstrated that 
those who remained in bed from the beginning of the 
illness not only appreciably shortened the attack but 
made a pleasanter convalescence. 
Rest in bed, a mild calomel purge or saline draught, cool- 
ing drinks, an occasional Dover's powder to quiet cough, 
and the employment of such general hygienic and die- 
tetic measures as are indicated in acute infectious diseases 
will meet every indication in simple, uncomplicated cases. 
In the futile search for a specific all of the leading reme- 
dies, new and old, received an extensive trial in the recent 
epidemics. The coal-tar derivatives-acetanilid, antipy- 
rin, and phenacetin-were all extensively used, but phe- 
nacetin, from its greater safety and the absence of un- 
pleasant after-effects, deservedly enjoyed the greatest 
popularity. Given early in the attack, it rarely failed to 
relieve the headache, lower the temperature, and lessen 
the muscular soreness and tired feeling. The writer ob- 
tained excellent results from its combination with quinine 
or salol and caffeine. 
Salicin is an eligible remedy. It acts as a mild tonic, 
reduces temperature, excites perspiration, and relieves the 
gastro-intestinal irritation. Its taste is objectionable. 
Quinia in medium-sized doses may be advantageously 
given throughout the sickness but is especially indicated 
in the later stages and in delayed convalescence. When 
the head pain and muscular soreness are prominent the 
salicylate of cinchonidia is preferable to quinia, and is 
supposed to possess decided prophylactic powers. The 
insomnia, as a rule, readily yields to the bromides or 
chloralamid. The singularly depressing effects of grippe 
on the mental and physical powers strongly contraindi- 
cate the use of lowering measures and remedies. Stimu- 
lants, preferably some form of ammonia or alcohol, 
should be resorted to on the first evidence of failing 
strength. In the presence of great thoracic distress or 
heart-failure a timely use of the heart tonics, of which 
digitalis and caffeine are the best representatives, may 
avert the threatened danger. Strychnine alone, or in 
combination with tonics, is the most reliable drug with 
which to tone up the feeble heart so often left by grippe. 
Gastro-intestinal irritation is best met with salicin, bis- 
muth, resorcin, and the salicylates. 
Local applications to the inflamed mucosa add greatly 
to the patient's comfort and favorably influence the 
course of the disease. In the writer's experience nothing 
gives such grateful relief as the occasional spraying of 
the throat and nose with a weak solution (one to two per 
cent.) of cocaine and menthol in benzoinol. A gargle of 
boracic acid or salicylate of soda in glycerine and water 
soothes the irritation of the mouth and throat. Dobell's 
solution in the form of spray, or the inhalation of 
steam, pure or medicated, with eucalyptus, creasote, or 
terebene, is of signal benefit in allaying the laryngeal 
and bronchial irritation. Troublesome cough is readily 
controlled by the old-fashioned Brown's mixture, or by 
small doses of codeine in syrup of wild cherry. 
In the graver types of influenza, or when the course is 
anomalous, care must be taken not to overlook compli- 
cations, which often, especially those of intra-thoracic 
origin, steal on insidiously. These must be managed 
according to the principles of treatment laid down on 
other pages of this Handbook. 
Delayed convalescence will call for a prolonged course 
of tonics, and, in many cases, for a temporary change of 
climate. 
Little has been attempted in the way of prophylaxis. 
It has, however, been lately proposed, on account of its 
probable contagiousness, to isolate those suffering from 
the disease and to close the schools and places of pub- 
lic resort during an epidemic. 
But the volatile nature of the pathogenous material and 
the remarkable rapidity with which influenza spreads- 
its whole career from inoculation to full development 
being only a matter of hours-will doubtless render abor- 
tive all attempts at quarantine. 
It has been abundantly proven that during the preva- 
lence of the epidemic influence those who are over- 
fatigued or much exposed in the open air, especially at 
night, are more susceptible to the disease. The lesson to 
be drawn from this fact is obvious and should be heeded 
by the aged and debilitated. 
Considerable testimony has been recently collected to 
show that vaccination with animal lymph furnishes im- 
munity against influenza. Dr. Goldschmidt, of the 
Island of Madeira, was the first to call attention to this 
fact. The island suffered from a double invasion of 
small-pox and grippe, and in investigating the relationship 
between the two diseases he ascertained that out of 112 
persons successfully revaccinated not one contracted in- 
fluenza ; and of 98 in whom revaccination was attempted 
but failed, only 15 showed any symptoms of the disease. 
In an isolated villa there were 27 inhabitants, of whom 12 
had been recently vaccinated. These all escaped, but 
the 15 who had not been vaccinated were affected. Alt- 
haus, who strongly advocates the protective power of 
vaccination, refers to illustrations which came to his 
knowledge, in which small clusters of recently vacci- 
nated persons remained untouched, although surrounded 
by and freely mingling with grippe-stricken people. The 
well-known immunity of children is likewise attributed 
to the protective influence of vaccination. It is stated 
that in the German army, where revaccination is sys- 
tematically enforced, influenza was less prevalent and less 
fatal than in civil life. While influenza affected forty- 
two per cent, of the population of Berlin, and about 
sixty-four per cent, of that of Paris, its prevalence in the 
German Army amounted to only a little more than eleven 
per cent. A number of garrisons were entirely spared 
while the inhabitants of the adjacent towns suffered se- 
verely, and it is further stated that no garrison was ever 
affected with influenza when the civil population es- 
caped. When an outbreak did occur in a military post 
it was found that those affected were almost exclusively 
soldiers who had not been recently revaccinated. And, 
finally, statistics show that the average duration of the 
disease is shorter, complications less frequent, and the 
death-rate lower in military than in civil life. Further 
developments in the prophylaxis of influenza will be 
awaited with interest. 
Bibliography. 
Parsons: The Influenza Epidemics of 1889-90 and 1891, British Medi- 
cal Journal, 1891. 
Wilson : Influenza, Pepper's System of Medicine. 
Parkes : Influenza, Reynolds's System of Medicine. 
Althaus : The Pathology and Prevention of Influenza. 1892. 
Wolff : Die Influenza Epidemic. Bei lin, 1892. 
Ruhemann: Die Influenza in dem Winter 1889-90. 
DaCosta : Pulmonary Complications of Influenza, International Clin- 
ics, 1892. 
Thornbury : Influenza and the Latest Bacteriological Researches, Med- 
ical Record, 1892. 
Mills: The Nervous and Mental Phenomena and Sequela; of Influenza, 
Medical News, 1892. 
Ingals : The Epidemics of Influenza of 1890 and 1891 in Chicago, Jour- 
nal of American Medical Association, 1891. 
Hirsch : Handbuch der Historisch-Geographischen Pathologie. 
Osler : Practice of Medicine. 1892. 
Watson : Practice of Physic. 
Prudden : Bacteriological Studies in Influenza and Its Complicating 
Pneumonia. Medical Record, 1890. 
Jacobi: General History of the Epidemic of Influenza, Medical Rec- 
ord, 1890. 
The Influenza Bacillus, Editorial, Medical News, 1892. 
Leledy : La Grippe et 1'Alienation Mentale. 1891. 
498 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Influenza. 
Insanity. 
Kraepelin : Ueber Psychosen nach Influenza, Deutsche med. Wochen- 
schrift, 1890. 
Althaus: Post-Grippal Psychoses, American Journal of the Medical 
Sciences, 1892. 
Watson & Curtin : The Treatment of Influenza and Its Sequelae, Amer- 
ican Journal of the Medical Sciences, 1892. 
Merz: Influenza. 1892. 
Bristowe : Cerebral Suppuration following Influenza, British Medical 
Journal, 1891. 
Bartholow : The Causes and Treatment of Influenza, Medical News, 
1889. 
Lee : An Analysis of the Statistics of Forty-one Thousand Five Hun- 
dred Cases of Epidemic Influenza, Journal of the American Medical 
Association, 1891. 
William Judkins Conklin. 
INSANITY OF PUBERTY AND ADOLESCENCE. 
The only addition of importance to what has already 
been said in the body of this work upon the develop- 
mental insanities, viz., climacteric and senile insanity and 
the insanity of puberty and adolescence, relates to the 
latter class. In fact, the pathology of the insanity of 
puberty has become a favorite study of late years through 
the growing recognition of the profound influence of the 
state of growth upon the rise, nature, progress, and future 
of mental disease in the individual. 
Hereditary Influence.-We are largely indebted to 
Clouston for stimulating inquiry in this direction. He is 
now prepared to state very strongly, as the result of his 
experience and careful inquiries into family histories of 
individual cases in which there was an opportunity of 
obtaining reliable facts, that practically without excep- 
tion the typical clinical case of adolescent insanity (of the 
kind described, for example, on p. 128, Vol. IV., of this 
Handbook) has in his or her ancestry, immediate or col- 
lateral, one of the following neuroses, in the following 
order of frequency : 
1. Insanity. 
2. Neurotic instability. 
3. Intemperance amounting to dipsomania. 
4. Epilepsy. 
5. Hereditary tuberculosis. 
6. General diseases of the nervous system. 
7. Congenital imbecility or idiocy. 
He finds such hereditary predisposition in forty-five per 
cent, among adolescents, while but twenty-three per cent, 
of other cases are thus handicapped. 
Our division of the insanities of puberty and adoles- 
cence into several groups, according to the various mani- 
festations of mental disease in this transitional epoch, 
viz., the genuine hebephrenia of Hecker, stupor, hys- 
terical, and masturbatory insanity, receives support 
and further development in a comparatively recent in- 
vestigation of the insanity of puberty by Mairet, partic- 
ularly in the matter of stupor, which, as we have pointed 
out, occurs almost exclusively in adolescents. 
Stupor.- Clinical observation shows, he finds, that 
puberty can give rise to insanity, and that the insanity of 
puberty has not always the same clinical signs. Accord- 
ingly tins form may be subdivided into insanity of puberty 
with arrest of intellectual development, anil simple in- 
sanity of puberty. The latter may appear under several 
different forms : Melancholic stupor, choreic mania or 
maniacal chorea, impulsive mania, and hysterical mania. 
The form of stupor which he describes as peculiar to 
puberty is identical with stuporous insanity (so-called 
acute dementia), as distinguished from true melancholic 
stupor, and merits more ample description than we have 
accorded it.1 In three out of seven cases Mairet found 
puberty to be the sole predisposing cause, while its action 
was favored in the remaining four by hereditary predis- 
position. The sex also plays a conspicuous role in the 
causation, as most of the subjects are females. Onanism 
and mental overwork are occasional factors. Sometimes 
there is no apparent cause, the stupor appearing suddenly 
and unexpectedly. A common exciting cause is a moral 
one, such as crime or other disgrace. 
There is usually a prodromic period marked by a 
variety of nervous and general symptoms, chiefly chlo- 
rosis and irregular menstruation in girls, and by physical 
fatigue, palpitations, and cerebral hyperaemia in men. 
The onset of the stupor of puberty is usually sudden, and 
(SUPPLEMENT.) 
in most cases is manifested by hallucinations, ideas of 
fear, and intense maniacal excitement. Sometimes these 
symptoms are accompanied by fever of an ataxo-dynamic 
character. Rarely, stupor itself begins the attack. Hys- 
terical manifestations may also appear before or with the 
excitement. Ideas of grandeur may take the place of 
those of fear. The early physical symptoms are refusal 
of food, sordes, dry tongue, and constipation due to rapid 
exhaustion. The circulation is poor, and sometimes sen- 
sation is much diminished. This period lasts but a short 
time, sometimes only a few* days, but generally several 
weeks, to give way to a new phase which is the essence 
of the disorder, stupor. The change is usually gradual, 
the hallucinations slowly disappearing, and the stupor 
growing more profound. The patient stands motionless 
wherever he may happen to be, the head bent, the arms 
hanging limp. The saliva escapes from his mouth, and 
his evacuations are passed involuntarily and unnoticed. 
All food is refused and there seems to be no sensation of 
hunger. The patient answers no questions and cannot 
be aroused. Thal he feels and even hears is sometimes 
evidenced, however, by his turning his head to the ques- 
tioner. The circulation is retarded, the heart-sounds 
clear but feeble, and the pulse more or less rapid, small, 
compressible, and excitable. The extremities are cold 
and, perhaps, oedematous. The temperature is below 
normal. Menstruation is suspended. Sensation is much 
diminished, but not abolished. The general and cerebral 
nutrition is lessened. Although thus plunged in stupor, 
the patient may suddenly have an attack of excitement. 
Oftentimes this is limited to violent laughter, lasting ten 
minutes or a quarter of an hour, without any apparent 
knowledge on the part of the patient why he does so. At 
other times the disturbance is more general, and then the 
patient will cry, repeat monotonously the same words, or 
more often the same sounds, to dance, etc., while the 
dull, heavy condition persists. Other patients perform 
ridiculous acts, such as swimming movements, contor- 
tions, etc., or else they suddenly throw themselves upon 
others and beat them, and soon fall back into stupor. 
These attacks are produced quickly and are of short 
duration, from a quarter of an hour to an hour, to reap- 
pear after a time. The period of stupor, the principal 
feature of the disorder, lasts from several weeks to as 
many months. It is a most favorable form of insanity 
in respect to recovery, which takes place gradually as a 
rule. It is impossible to confound this with any other 
form of mental alienation. It is sometimes distinguished 
with difficulty from the melancholy, with stupor of older 
patients, but differs therefrom chiefly in the severity of 
the onset and the rapidity of the emaciation. 
Choreic Insanity (or " Maniacal Chorea.'')-The 
insanity which accompanies acute chorea also belongs to 
this period of life, is of pubescent or adolescent nature, 
and belongs exclusively to the group under consideration. 
All the cases of insanity associated with acute chorea on 
record have occurred w ithin the pubescent and adolescent 
period, between the ages of thirteen and twenty-three. 
Most of them have the mental or nervous predisposition, 
inherited or acquired, so common in the insanity of pu- 
berty, and all of them, as a rule, have manifested one or 
other of the physical ailments common to this critical 
period, viz. : anaemia, chlorosis, scanty menstruation, 
pallor, palpitation of the heart, headache, etc. It is now 
generally recognized that chorea in some form is almost 
invariably associated with mental changes varying from 
simple impairment of memory, unusual and extensive 
irritability, etc., to acute mania or dementia. It is equally 
a fact that chorea is in its most developed state at this 
period, and that the accompanying mental manifestations 
are most marked and peculiar, the severe, dangerous, and 
fatal cases occurring then. It is also noticeable that in 
almost every case the choreic and mental symptoms ap- 
pear and subside at about the same time, thus giving proof 
by evolution also of the close alliance of the two diseases. 
This intimate union can only be explained by community 
of origin, chorea and insanity being two independent 
branches from the same trunk. Consequently, when wre 
find chorea, essentially a disease of growth, intimately 
499 Insanity. 
Insanity. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
united in youth with mental disorder, the pubescent nature 
of that insanity is evident. As the acute forms of-both 
disorders do not appear together at any other time of life, 
choreic insanity, or maniacal chorea, plainly belongs in 
the category of insanity of puberty and adolescence. 
The choreic form of adolescent insanity is more com- 
mon in the male sex, and heredity plays a more promi- 
nent part than in the other varieties. Of the prodromic 
period cephalalgia is the most frequent and important 
symptom. Irritability and mental confusion, or change 
in disposition and insomnia, are present. 
The onset is generally abrupt, following close upon the 
exciting cause. Usually the choreic and mental symp- 
toms appear at about the same time-either the chorea 
precedes the psychical trouble, as in a case reported by 
Thore, or the psychical change takes precedence, of which 
the case to be described later is an example. With the 
onset may appear delusions or hallucinations which may 
later dominate the scene. In our case the peculiar 
nature of the initiatory excitement shows their presence, 
although none were expressed. Insomnia and nightmare 
are common. Fever is not an uncommon accompani- 
ment at this stage. The chorea, whether general or 
localized, reaches its height early in the attack, which is 
usually not the case with the insanity. The choreic 
movements also are almost invariably increased during 
the mental agitation. 
The next and principal stage is that of choreic mania, 
which may be either simple or hallucinatory. The 
maniacal condition is the same, as a rule, as that of ordi- 
nary mania, except perhaps for its marked irritability. 
The patient may become readily aggressive even when 
not excited, or, as in our case, he may present a marked 
condition of hebetude and mental incoherence. These 
patients are at times, like others of the adolescent class, 
poetical and dramatic in speech and writing, as well as 
vain and declamatory. The attacks of agitation in the 
more marked and characteristic cases consist in run- 
ning, jumping, leaping, shouting, nightmares, etc. 
They are also apt to be especially destructive and homi- 
cidal. These attacks are almost always spasmodic and 
impulsive, and are sometimes followed by a state of men- 
tal and bodily weakness. Sometimes the attacks are not 
prompted by hallucinations, as is evidenced by the ac- 
counts given by recovered patients; but as a rule they 
spring from hallucinations and delusions chiefly of the 
nature of fear. 
The duration of acute choreic insanity is very variable, 
usually several months, but occasionally it lasts as many 
years. One of Mairet's cases recovered in four years. 
The prognosis is comparatively good, but less so than 
that of the stupor of this period, perhaps because the 
hereditary predisposition is greater in this form. The fol- 
lowing case presents most of the usual features of the dis- 
order, but the severe motor symptoms so far predomi- 
nated as to mask the mental manifestations, and perhaps 
even to take the place of, or prevent, the characteristic 
maniacal outbursts. It properly belongs, as we have 
said, to the other class, represented by the cases whose 
condition is that of hebetude and mental incoherence. 
W. W , married, twenty-three years of age, was 
admitted to the West Riding Asylum February 18, 1882. 
The certifying physicians stated that the patient was a 
violent lunatic and gave the following facts: 1. " Talks 
incoherently, taking no notice of any questions put to 
him." 2. Relatives report that, "he will sit for hours 
without speaking." The family physician stated: "He 
is by nature eccentric in his habits and inclined to be 
self-willed. Just before the attack he became depressed 
in spirits, irritable and suspicious of those about him. 
During the attack he was sometimes violent, sometimes 
depressed, but had lucid intervals; raved indifferently on 
various subjects, and would strike with great violence 
indiscriminately." The patient was brought to the asylum 
securely bound in a strait-waistcoat which was reinforced 
by heavy leathern straps. As soon as he was freed from 
restraint he was seen to be suffering from severe chorea. 
He was placed in a padded room and became much 
quieter. 
Previous History.-Nothing satisfactory to be learned 
as to hereditary predisposition. No personal history of 
convulsions or rheumatism. Had been rather delicate, 
and had an attack of pleurisy with inflammation of the 
lungs several years before. His domestic circumstances 
had been satisfactory. Just before and ever since his 
marriage, six months before admission, he had worked 
very hard at his trade, carving and gilding. About four 
weeks before admission he was obliged to leave his work 
on account of severe continuous and general cephalalgia, 
which confined him to bed for two weeks. At this time 
alteration in his manner and conduct became for the 
first time noticeable. He was dull, preoccupied, and 
reticent, appeared dazed and indifferent to his condition 
and surroundings. Later he returned to his work and 
seemed " like himself " in every way. A week later he 
returned home in a confused state of mind and soon be- 
came delirious. For the next two days he was much 
excited, refusing to go to bed or to take food, threaten- 
ing to throw himself out of the window, and weeping at 
trifles. No hallucinations or delusions appear to have 
been expressed. Just after the excitement became pro- 
nounced he began to wriggle about, contort his face, 
protrude his tongue, etc. This disturbance subsided in 
a day or two. He then conversed freely and naturally, 
and said that he had fallen in attempting to board a 
horse-car just before his attack came on, but did not 
meet with any injury ; that hethen became confused and 
wandered about the town a long time before he could 
find his home. Three days before his admission, when 
supposed to be rapidly convalescing, his former condition 
returned with renewed intensity, being ushered in by 
rapid and disconnected talk. From this time he became 
very unmanageable and his movements so energetic that 
he was with difficulty prevented from falling out of bed. 
His knuckles and elbows were also abraded from contact 
with the wall. He showed at this time no disposition to 
violence. 
Physical Appearance.-Pale and emaciated. Pupils 
dilated, the right excessively so and only slightly respon- 
sive to light. All his voluntary muscles appear to be 
affected with chorea. He incessantly writhes and plunges 
about the bed, tosses his arms, clinches his fists, contorts 
the face, etc. Abrasions on knuckles and elbows. Skin 
over sacrum reddened, and on the tongue an ulcer, a quar- 
ter of an inch in diameter, caused by biting. Pulse, 
140, and of fair strength. Heart and lungs normal; 
appetite fair. He passes his evacuations in bed. 
Mental Condition.-Though questioned in an interval 
of comparative calmness, the patient can evidently make 
nothing of what is said to him. He is ignorant of where 
he is, why he is here, hew long he has been here. He 
makes incoherent, nonsensical replies to the simplest 
questions, but protrudes his tongue when asked. Ex- 
pression lost and wondering. During sleep there have 
been slight movements of the upper extremities and head 
occasionally. 
February 23d to 26th.-Distinct improvement on the 
whole. The choreic movements are now absent during 
sleep. By day he is occasionally quite still, and although 
there is at present much movement of the head and facial 
muscles, he has been quite free from spasm. A small 
eschar has formed over the sacrum, and the abrasions on 
the elbows and hands are inflamed. Is fed by the at- 
tendant with soft food, but has great difficulty in prop- 
erly masticating it. Still irrational and incoherent. He 
talks in a whisper as if conversing with someone, and 
most disconnectedly. Says he is in " Fletcher's Mills." 
March 4th.-He is not still a minute at a time, but the 
movements are now confined to the face and upper ex- 
tremities. He talks in a low tone most of the time. Oc- 
casionally he jerks out a sensible reply after evidently 
trying to collect his thoughts, but soon wanders off onto 
a variety of subjects. 
March 8th.-He is quieter, but still scowls and rolls 
about somewhat. Touching any part seems to excite 
muscular contraction. Still unable to concentrate his 
thoughts or to keep them in the right channel, just as he 
fails to direct his muscular movements properly after 
500 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Insanity. 
Insanity. 
making a good beginning. He can tell the time and 
answer simple questions, when roused and made to apply 
his mind. Still passes his evacuations in bed. Bedsore 
deep. 
March 11th to 19th.-There is but little mental im- 
provement, although the patient is generally free from 
morbid movements. He often starts up and looks about 
him, muttering disconnectedly. He replies to a simple 
question: "They were laughing at me-cither jump 
over here or over there." Allows the medicine to drool 
from his mouth without attempting to swallow. Gives 
an occasional rational answer after much pressing. Still 
unclean in his habits. 
March 26th.-The patient has been for some time en- 
tirely free from choreic movement. Sits up most of the 
day. Has become clean in his habits. Whole expression 
brighter. Answers simple questions correctly, but not 
readily. Still starts wonderingiy when addressed, and 
makes strenuous but vain attempts to understand and 
reply. A fortnight later the patient had, in great meas- 
ure, recovered his intelligence. He recognized his sur- 
roundings and that his mind had been deranged. His 
memory had become nearly restored, but he was still 
confused and wandering in manner, and his ideas were 
not perfectly coherent. Expression rather perplexed and 
vacant. Was still pale and thin. Appetite and sleep, 
excellent. Gait fairly steady. Bedsore healed. Three 
weeks later, he was discharged, recovered. There was 
some elevation of temperature during the three weeks 
immediately following his admission, but never rising 
above 101.3° F. 
It is well in conclusion to re-group the insanities of 
this period, giving precedence to more characteristic 
varieties, as follows : 
Insanities of Pubebty and Adolescence. 
Pure. Forms. 
(SUPPLEMENT.) 
cesses underlie the manifold, subtle, and delicate move- 
ments of the facial muscles as well as the more palpable 
movements of the muscles of the trunk and extremities. 
The physiological basis of the gesticulations accompany- 
ing ordinary conversation, as well as the more finished 
gestures of the orator, is undoubtedly the same. All ex- 
plorers among barbarous tribes give interesting reports 
of this language of signs. Stanley's observation of the 
gesticulations of the tribes in Central Africa, as well as 
the statements of the early discoverers and settlers of 
America, confirm this idea that there is a sign language 
common to all races of men. This in turn implies that 
the functional activities of the central nerve-mechanism 
are the same, both in savage and civilized races, and af- 
fords interesting proof of the unity of the human race. 
Correct physiognomical knowledge, therefore, depends 
on a proper understanding of the physiology of the cen- 
tral nervous mechanism. Ignorance as to the functions 
of the brain and cord led the earlier writers into the 
most absurd interpretations. Even so shrewd an ob- 
server as Aristotle attempted to explain the physiognomy 
of man by a system of meaningless analogies. Fancied 
resemblances to wild animals, such as a broad expanse 
of chest and shoulders, and certain conditions of the hair 
and beard were supposed to indicate the possession of 
certain qualities of mind, such as bravery, energy, and 
the like. 
It is not to be wondered at that the ancients, with their 
limited knowledge of physiology, should have entertained 
crude notions concerning the meaning of facial expres- 
sion. Undoubtedly they were familiar with anatomy, 
but the subtle connection between the central innervat- 
ing organ and the external muscular apparatus was 
entirely unknown to them. To have perceived in a gen- 
eral way that a certain cast of countenance was associ- 
ated with a peculiar mental development was the utmost 
advance that their limited knowledge of animal physi- 
ology would allow. Hence, though they excelled in 
copying, they singularly failed in explaining nature. 
And, as is often the case, the domain that properly be- 
longs to science was, through ignorance, relegated to 
charlatanism. Analysis of the human countenance was 
given over chiefly to soothsayers and magicians, who 
attempted no rational explanation of the various muscu- 
lar movements of the face, but who pretended to read 
therein certain prognostications for the future. 
It is interesting to trace the gradual development of 
physiognomic science from the earliest times to the pres- 
ent, and to notice how gradually correct physiological 
knowledge was attended by broader and more intelligent 
views as to the real meaning of physical expression. 
Nothing could be more absurd and childish than the va- 
garies of the ancient writers upon this subject, nearly all 
of whom either thought that expression was due to the 
mysterious influence upon the brain of certain abdominal 
vapors, or that the Aristotleian doctrine of resemblances 
gave the correct clue to the expression of the emotions. 
Throughout the Middle Ages the study of the physiog- 
nomy became so identified with astrology and chirology as 
to lose even what loose scientific value it had previously 
attained. Mantegazza calls the seventeenth century the 
golden age of astrological physiognomy. " Then more 
than ever," he says, " did men have a passion for mys- 
terious things, for mysteries which have a scientific ap- 
pearance." The countenance and the heavens were 
mapped out, and not only character, but future events 
in the life of the individual were supposed to be prog- 
nosticated from a comparison between the lines of the 
face and the position of the stars in the sky. 
G. B. Porta, of Naples, whose work " Della fisonomia 
dell 'uomo " was published in 1627, did much toward sev- 
ering the absurd connection between physiognomy and 
astrology that had arisen during the Middle Ages. He 
was nevertheless a strong believer in the doctrine of re- 
semblances, and his comparisons of the heads of men with 
those of birds and lower animals are amusing illustra- 
tions of the extent to which a blind subservience to a 
theory may lead one. Notwithstanding the absurdity of 
many of his comparisons, he still deserves great credit as 
Occurring only in youth 
and essentially of the 
adolescent type. 
Hebephrenia. 
Acute Choreic Insanity. 
Stupor. 
Mixed Forms. 
Occurring usually but 
not exclusively in young 
people. 
Hysterical Insanity. 
Masturbatory Insanity. 
The reader is referred to the contributions of Mairet2 
to this subject, from which we have quoted in this article, 
as well as Clouston's exhaustive lectures on the " Neu- 
roses of Development," for further study of this subject. 
Henry R. Stedman. 
1 Reference Handbook Medical Sciences, Vol. IV., p. 127. 
a Annales Medico-psychologiques, vol. viii., 1888, and vols. ix. and x. 
of 1889. 
INSANITY, THE PHYSICAL EXPRESSION OF. 
I. Introductory and Retrospective. 
Francis Warner has defined expression to be " the out- 
ward indication of some inherent property or function." 
All outward muscular movements, whether of the face, 
trunk, or extremities, succeed definite functional activity 
of some portion of the central nervous system. This 
larger use of the word expression is comparatively recent. 
Muscular movement as an index of cell activity within 
the encephalon is the latest advancement that physiog- 
nomical science has made. Viewed in this light, physi- 
cal expression deserves serious study. Particularly does 
the physical expression of the insane merit investigation, 
for it must be presupposed that any disturbance of func- 
tion in the central nervous mechanism would be quite 
likely to be reflected in perverted muscular movement at 
the periphery. 
Previous to the present century study of physical ex- 
pression was limited to the face. Now, while it is true 
that the expression of the emotions receives its most per- 
fect and frequent demonstration in the facial region, it 
must not be forgotten that the entire muscular periphery 
is likewise a participant. The same physiological pro- 
501 Insanity. 
Insanity. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
being one of the first writers that attempted to trace a 
tangible relationship between the countenance and the 
mental and moral development of the individual. De la 
Chambre followed Porta in 1660, with his " L'Art de 
connaitre les Hommes," in which he showed a tendency 
to explain the countenance and its changes in a more 
rational way. 
In 1747 James Parsons, M.D., delivered a short course 
in the Croonian Lectures on Muscular Motion. These 
were published in the Philosophical Transactions under 
the title, " Human Physiognomy Explained." This 
work, though quite short, is deserving of great praise, 
for it was a very sincere attempt at explaining facial ex- 
pression in a more intelligent manner. He endeavored 
to refer the expression of the countenance to muscular 
movements in that locality, and by a series of plates 
sought to establish a relationship between the movements 
of certain facial muscles and specific states of mind. 
" The muscles," he says, " are the true agents of every 
passion of the mind, and the basis upon which our doc- 
trine is founded." The soundness of his views is quite 
remarkable, and his essay is a prominent landmark in 
the progress of physiognomic science. The following 
quotation from his Lectures will meet with the approval 
of modern physiology : " First, every person has a par- 
ticular bent or disposition of mind, which oftener reigns 
in him than any other ; secondly, that this habitual dis- 
position, causing the muscles of the face that are des- 
tined to express it frequently to act in obedience to that 
bent of mind, brings on at length an habitual appearance 
of that passion in the face, and moulds it into a constant 
consent with the mind. In the course of my own 
acquaintance, I know some persons who wear on their 
countenances a constant cheerfulness, complacency, and 
openness ; and by experience I know it to be their con- 
tinual disposition of mind ; and on the other hand, I do 
know of some on whose faces a settled moroseness al- 
ways strikes the beholder, and know it to be their own 
constant plague and that of those among whom they 
come." 
After the appearance of Parsons's Lectures nothing of 
any especial worth was published until the year 1783, 
when Lavater, a Swiss clergyman, published his " Es- 
says on Physiognomy Destined to Promote the Love and 
the Knowledge of Mankind." Lavater was an enthusi- 
ast on his subject, and it is remarkable that, being neither 
a physician nor an anatomist, he should have advanced 
views at once so much in accord with modern physio- 
logical and anatomical knowledge. He struck the key- 
note of a sound physiognomic science when he declared 
that outward expression was but the reflection of what 
was within, that it was the outward effect of an inner 
cause. He says : " There is not a living being which 
does not, at least after its manner, draw some inferences 
from the external to the internal ; which does not judge 
concerning that which is not by that which is apparent 
to the senses. This universal though tacit confession 
that the exterior, the visible, the superficies of objects 
indicate their nature, their properties, and that every 
outward sign is the symbol of some inherent quality, I 
hold to be equally certain and important to the science of 
physiognomy. " 
Lavater, being a shrewd and acute observer, was not 
misled by mere resemblances to infer similarity of dispo- 
sition and character. He recognized the incorrectness of 
the ancient method of comparing resemblances, and says, 
" What the great Aristotle has written on physiognomy 
appears to me extremely superficial, useless, and often 
self-contradictory, especially his general reasoning." Of 
Porta, the Italian physiognomist, he says : " He might 
more effectually have examined the excessive dissimilar- 
ity than the very small and almost imperceptible resem- 
blances which can exist." And again : " It is singular 
enough that he has also compared the heads of men and 
birds. He speaks little concerning the horse, elephant, 
and monkey, though it is certain that these animals have 
the most resemblance to man." By recognizing the fact 
that the cranium bore some relation in size and external 
configuration to its contents, and that in proportion as 
one ascends the scale of animal life important modifica- 
tions are met with in the size and shape of the skull, he 
tacitly admitted the relation between the cranium and 
the cerebrum, and the relationship between the develop- 
ment of the latter and facial expression. 
In an article on "Medicinal Semiotics," Lavater sug- 
gests the influence upon expression of pathological con- 
ditions. Many physicians, from Hippocrates to his time, 
had accurately described the characteristic facies of dis- 
ease, and yet few of them realized the physiological and 
pathological import of what they so faithfully described. 
Lavater, though not a physician, still inferred that the 
peculiar facies of different diseases suggests certain 
changed physiological conditions in the patients them- 
selves. Lavater very nearly touched the true explanation 
of facial expression/ 
It is an interesting coincidence that while the Swiss 
clergyman Lavater was writing his views of physiog- 
nomy, at nearly the same time, and in another country, 
the Dutch physician Camper was working out a theory 
of physiognomy in nearly the same channel. As might 
be expected, the physician and anatomist, from his 
knowledge of the different parts of the body and their 
physiological relation to each other, would be more 
likely to arrive at a comprehensive and exact theory than 
a layman. He clearly enunciated the correct physiologi- 
cal theory of physical expression when he said: "As 
dissecting of human bodies has been my constant occu- 
pation, I have had frequent opportunities of examining 
which of the nerves, communicating with these more 
active parts, must have been particularly affected ; con- 
sequently which of the muscles must have been excited 
to action by these nerves ; and from the action of these 
muscles depending upon their origins and insertions, 
course and connections, we may easily learn what pleats 
in the face, what kind of action in the hands, and so 
forth, they must necessarily occasion." 
The next writer connecting the latter part of the last 
century with the present time is Sir Charles Bell, famous 
as the discoverer of the motor and sensitive nerves. Bell, 
by his accurate anatomical knowledge of the nerves, laid 
the foundation for all that has been written during the 
present century upon the subject of physiognomy. He 
first cleared away the confusion which had hitherto sur- 
rounded the anatomy of the cerebral and spinal nerves, 
and traced these nerves definitely to their terminations 
and origins. He demonstrated clearly the mechanism of 
facial expression. The physiology of reflex and auto- 
matic action, as well as the important functions sustained 
by the centres of the cerebral cortex, both in the motor 
and intellectual activities of life, had scarcely come to be 
understood in his day, otherwise he would have perceived 
that the causes of expression in man and the lower ani- 
mals are often the same ; that in each nervous energy is 
liberated from the cells within the central nervous mech- 
anism, and subsequently transmitted along the nerve- 
channels to their terminations in muscular structure ; 
that the difference between the causes of expression in 
man and the lower animals is really less than he imag- 
ined, being a difference in degree rather than in kind, and 
due rather to complexity of structure attained in the 
cerebral cortex of man. 
Dr. G. B. Duchenne's "Mechanism of the Human 
Physiognomy," published in 1862, was an ingenious and 
interesting attempt to demonstrate the mechanism of fa- 
cial expression. By the aid of the two poles of a battery 
Duchenne sought to isolate certain facial muscles, and by 
causing them to act independently of the others, produce 
artificially the expressions caused by the natural action 
of these same muscles. It seems questionable, however, 
whether the action of the electric fluid upon the nervous 
filaments in the face is precisely similar to the action of 
the nervous centres within the brain upon these same 
nervous and muscular tracts. In fact it is very doubtful 
whether the action upon the muscular periphery of the 
feelings, such as grief, joy, disgust, and the like, is of the 
same quality and intensity as that produced by the cells 
of a galvanic battery. Again, it is very questionable 
whether the actual results which he has shown in a series 
502 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Insanity. 
Insanity. 
of photographs are faithful representations of the various 
states of mind ascribed to them. The field is one in 
■which the author's imagination may very easily lead him 
astray. Having formed a preconceived idea of what a 
certain artificially produced expression may mean, it is 
very easy to recognize that particular expression. But 
one who has not previously read the author's description 
of the plate may, as Darwin says, very easily conceive 
it to mean something else. 
Pierre Gratiolet's lectures, delivered at the Sorbonne, 
and published in 1865, were a valuable addition to the 
subject, and particularly interesting because they were 
the first contribution recognizing that physiognomical 
changes were only a part of a wider series of muscular 
movements in other parts of the body. Previous to the 
appearance of these lectures all writers upon the physi- 
ognomy limited their studies to the facial region, but 
Gratiolet saw that muscular movements of other parts 
than the face entered into expression. In his " De la 
Physiognomic et des Mouvements d'Expression " he says : 
" The face is not the only portion of the body capable of 
expressing the feelings; on the contrary, the hand, the 
foot of man and animals, the tail of certain carnivora 
such as dogs and cats, have expressions that cannot be 
misunderstood. We may add that there is no movement 
that does not represent expression and follow the laws of 
expression." 
In 1872 was published Darwin's " Expression of the 
Emotions in Man and Animals." Darwin, with the clear 
insight of the naturalist, fully recognized the meaning 
of facial expression, or more properly, physical expres- 
sion. Both in man and the lower animals he perceived 
that the various muscular movements of expression, 
whether occurring in the face or in the extremities, were 
merely the outward reflection of interior states of the 
central nervous system. His wonderful acquaintance 
with animal life, reinforced by the vast amount of ma- 
terial accumulated during his busy life, makes his work 
an exceedingly interesting and instructive one. As Man- 
tegazza says, "with his large and comprehensive spirit 
he traced the general laws which govern expression in 
the entire animal kingdom. His work is one of the most 
splendid monuments raised by his genius, and one can 
say without exaggeration that expression, as far as it is a 
special branch of comparative biology, was established 
as a new science only in the work published in 1872." 
In 1885 was published " La Physionomie et les Senti- 
ments," by Mantegazza, and in 1886 "Physical Expres- 
sion," by Dr. F. Warner. Both volumes are a fitting 
conclusion and summary to all that had previously ap- 
peared upon this subject, and a pertinent introduction to 
the various modifications of physical expression in insan- 
ity. A clear understanding of the mechanism of physi- 
cal expression and close observation of the insane, demon- 
strate the physiological laws of cause and effect underly- 
ing the remarkable changes in expression that occur in 
various stages of insanity. 
II. The Mechanism and Physiology of Expkession. 
In man the central nervous system has reached its 
highest development. Beginning with the lowest and 
most rudimentary forms of animal life, a single centre 
with afferent and efferent nerve-tracts leading to and 
from the muscular periphery, is typical of nervous struct- 
ure throughout the animal kingdom. Becoming more 
and more complex as we ascend the scale of animal life, 
in man this nervous structure attains vast complexity. 
In him the central nervous system is composed of intri- 
cate series of cells connected with each other, layer upon 
layer, the areas above being connected with those below, 
and so specialized that different areas have specific func- 
tions, and yet all subject to control of the cortical gray 
matter. 
Three factors enter into the Mechanism of Expression : 
I. The storage and discharge of nerve-force from the 
central nervous system. 
II. The power of inhibition possessed by the cerebral 
cortex. 
Ill, The trophic changes consequent upon the proc- 
esses of waste and repair that are constantly occurring 
in the cerebral cells. 
I. The storage and discharge of nerve-force from the 
central nervous system. Physiological and anatomical 
data lead to the conviction that the mysterious property 
known as nerveforce or energy is in some way identified 
with functional activity of the cerebral cortex, and that, 
after leaving the cortex, its route is downward to the 
corpora striata and thence onward through the crura, 
the corpora quadrigemina, the pons varolii, and the me- 
dulla to the peripheral muscles. However it may be 
modified by the structure through which it passes, there 
is little doubt that this is the route. Exactly what this 
nerve-force is would be difficult to say. It is undoubt- 
edly a form of energy, and the nervous system is the 
special region in which its manifestations may be stud- 
ied. In some respects it is singularly analogous to that 
mysterious energy which is now being utilized in mani- 
fold ways in the daily life of mankind. Like the electri- 
cal fluid, it is invisible and realized rather by what it 
accomplishes than by any recognizable attribute. 
The cortex cerebri seems to be the goal to which are 
referred all sensations received from without through 
the various channels of sense. Such sensations are 
gathered up by the different expansions and terminations 
of innumerable afferent nerve-filaments in the organs of 
special sense, like the eye and ear, or in the infinitesimal 
fibres of the nerves of touch in the skin, and are passed 
on through various afferent nerve-tracts to the ganglia in 
the optic thalami, where they are in some way modified 
and transferred to the cortex, there to serve as stimuli, 
not only to higher intellectual action, but to the genera- 
tion of nerve-force. The cortex is, therefore, the object- 
ive point toward which all sensations received from 
without are directed. It is undoubtedly the seat of all 
intellectual processes and the great reservoir of nerve- 
energy. 
However imperfectly we can define this nerve-force, 
there is no doubt that it conforms to the law of " Con- 
servation of Force or Energy," which is recognizable 
everywhere in the great natural world about us. In ac- 
cordance with this well-known law, either the energy, 
force, or whatever we may choose to call it, will remain 
stored up as potential energy, or it will be distributed 
and appear in some more active form as motion. Ganot 
says : " When the form of a body is changed by the action 
of forces, either the work done against the internal forces 
will remain stored up as potential energy, as in a com- 
pressed spring, or will have been replaced by the develop- 
ment of an equivalent of heat. Now, this being pre- 
mised, we see that the energy communicated to any body, 
or system of bodies, is withdrawn from some fund of 
energy previously existing ; thus, the energy communi- 
cated to the piston of a steam-engine is withdrawn from 
the heat of the steam ; we also see that of the energy 
thus communicated none is destroyed, but is merely 
distributed, and exists either as potential energy or as 
motion of the bodies acted upon, or has been replaced by 
an equivalent of heat. This fact is called the conserva- 
tion of force, or more properly, the conservation of en- 
ergy " (Ganot: " Elementary Treatise on Physics," p. 40). 
In accordance with this same law the actual forces in the 
world about us, such as the waves of light and sound, 
and the ponderability and resistance of bodies with 
which we may come in contact, all these natural forces 
are transmitted to the cortex through the various chan- 
nels of sense ; there they are not lost but merely trans- 
formed into potential energy, which either remains stored 
up in the delicate nerve-centres of this region, or, on be- 
ing liberated and distributed along different efferent 
routes, appears at the periphery as muscular movement. 
The comparison with the storage of steam within the 
boiler is not inapt. Such an accumulation of force must 
be relieved. In the case of the boiler, the steam, which 
represents the force, must be liberated at the safety-valve 
or converted into heat or power ; and, in the case of the 
brain, the potential energy received through the various 
sensory channels must seek relief through the different 
503 Insanity. 
Inga nity. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
efferent outlets which have their termination in the mus- 
cles. Hence muscular movement, in other words, physi- 
cal expression, is the one universal method by which the 
higher brain-cells are relieved of their stored energy. 
Darwin thus admirably describes this generation and 
liberation of nerve-energy : 
" A sensitive nerve when irritated transmits some in- 
fluence to the nerve-cell whence it proceeds ; and this 
transmits its influence, first to the corresponding nerve- 
cell on the opposite side of the body, and then upward 
and downward along the cerebro-spinal column to other 
nerve-cells, to a greater or less extent, according to the 
strength of the excitement ; so that, ultimately, the 
whole nervous system may be affected. This involun- 
tary transmission of nerve-force may or may not be ac- 
companied by consciousness. Why the irritation of a 
nerve-cell should generate or liberate nerve-force is not 
known ; but that this is the case seems to be the conclu- 
sion arrived at by all the greatest physiologists, such as 
Muller, Virchow, Bernard, etc. As Mr. Herbert Spen- 
cer remarks, it may be received as an ' unquestionable 
truth that, at any moment, the existing quantity of liber- 
ated nerve-force, which in an inscrutable way produces 
in us the state we call feeling, must expend itself in some 
direction-must generate an equivalent manifestation of 
force somewhere ; ' so that, when the cerebro spinal sys- 
tem is highly excited, and nerve-force is liberated in ex- 
cess, it may be expended in intense sensations, active 
thought, violent movements, or increased activity of the 
glands. Mr. Spencer further maintains that an ' over- 
flow of nerve-force, undirected by any motive, will mani- 
festly take the most habitual routes, and, if these do not 
suffice, will next overflow into the less habitual ones.' 
Consequently the facial and respiratory muscles, which 
are the most used, will be apt to be first brought into ac- 
tion ; then those of the upper extremities, next those of 
the lower, and finally those of the whole body." 
The cortex is therefore quite constantly excited by the 
various stimuli transmitted to it from the ganglia of the 
optic thalami, and just as constantly is it sending forth 
activities through innumerable efferent nerve-channels to 
the ganglia of the corpora striata, there to be newly ar- 
ranged and organized before being transmitted to the 
tracts at the base of the brain and thence to the various 
muscles. The cortex, therefore, plays a most important 
part in all the motor activities of life. It is the great store- 
house of nerve-force, as well as the seat of all intellectual 
action. In a certain sense the brain is a great reflex organ ; 
it is continually receiving stimuli from without, which 
act as excitants to its various centres, and these centres, 
in obedience to the stimulations received from without, 
are constantly discharging nerve-energy which may be 
measured and realized in the countless motor activities 
that go to make up the life of mankind. Nerve-energy 
is in part, therefore, measured by muscular activity. 
And thus physical expression becomes one of the im- 
portant agencies by which we estimate the nerve-force 
and vitality of the individual. It will be interesting 
subsequently to observe how normal and healthy physical 
expression is perverted by the various functional and 
organic conditions of the brain in insanity. 
This discharge of nerve-force from the brain is either 
voluntary or involuntary. All the muscular movements 
that enter into the daily life of man come under one 
class or the other. It is needless to enter into the much- 
discussed question as to whether independent motor cen- 
tres exist in the anterior convolutions of the cortex. 
The important fact to be remembered is that nerve-force 
passes down from the cortex to the corpus striatum, and 
whether it is essentially motor in character before or 
after it leaves the cortex or corpus striatum, the route 
followed by it from the cortical centres to the peripheral 
muscle is always downward through the structures men- 
tioned ; and another interesting fact is that automatic 
and habitual movements become retained, or organized, 
as the physiologists say, in the corpora striata. It is now 
considered that all the ordinary movements of daily life, 
such as walking and the like, and many muscular move- 
ments of complex character which have been acquired 
(SUPPLEMENT.) 
by hard and constant application, are at last permanently 
organized in the corpora striata, so that, l^v a single effort 
of the will, their easy and almost unconscious perform- 
ance may be elicited. 
Many purely reflex, as well as acquired, muscular 
movements are undoubtedly effected through the action 
of the optic thalami and the corpora striata without once 
calling upon the higher centres in the cortex. Sensory 
impressions are received in the centres of the thalamus, 
and excite into activity certain centres in the corpus 
striatum, and, as a result, certain muscular movements 
ensue. Such movements are purely reflex and automatic, 
and are often independent of volition and consciousness. 
Undoubtedly this purely automatic action of the basal 
ganglia, entirely independent of the cortical centres, is 
of more common occurrence among the lower animals 
than in man. Still there are many instances on record 
now to prove that many most complicated acts have 
been performed by men at a time when their conscious- 
ness and volition-in other words, the centres in the cor- 
tex-were entirely in abeyance or quiescent. 
On this point Ferrier says: "In man, however, the 
shorter circle through the optic thalami and corpora 
striata does not appear sufficient, for the interruption of 
the conscious circle through the hemispheres by lesion 
of the cortical motor centres produces paralysis of a very 
complete and enduring character. 
" This goes far to show that even the most habitual, 
or even the most automatic, actions of man require the 
co-operation of the centres of conscious activity, a view 
which is taken and strongly argued by Dr. Ireland. 
" But though the basal ganglia may not, of themselves, 
suffice for the execution of the habitual movements of 
man, there is every reason for believing that they do so 
to a large extent, from the fact that the performance of 
habitual actions exercises but little interference with 
the conscious activity of the hemispheres in other direc- 
tions. 
"We may express it thus, that in actions requiring 
conscious discrimination and voluntary effort the larger 
circle of the hemispheres is involved, but that in the ac- 
tions which have become habitual and automatic the 
larger circle is greatly relieved by the organic nexus be- 
tween impression and action which has been established 
between the sensory and motor basal ganglia. The op- 
tic thalami and corpora striata form thus a sensory-motor 
mechanism, according to the views of Dr. Carpenter. 
I would use the term, however, only in the generic 
sense of afferent-efferent, it having been shown that 
sensation, or consciousness of impressions, is not a func- 
tion of the optic thalami. Hence the reaction between 
the optic thalami and the corpora striata, being below 
the domain of consciousness, is outside the sphere of 
psychical activity, properly so-called " (Ferrier, "Func- 
tions of the Brain," chap. x.). 
Just as the ordinary habitual movements of daily life 
become organized in the corpora striata and only await 
the proper stimulus for their elicitation, so has Ferrier 
advanced the theory that the co-ordination of sensory im- 
pression with the mechanism of emotional expression is 
situated in the corpora quadrigemina. He says : "The 
foregoing considerations on the relations between the 
phenomena of irritation and destruction of the corpora 
quadrigemina, though in many respects professedly of 
a hypothetical nature, tend to support the view that 
these ganglia are the centres specially concerned in the 
reflex expressions of feeling or emotion. This is ren- 
dered still more probable by the recently demonstrated 
influence which the corpora quadrigemina, or, more 
properly, the deeper parts of the corpora quadrigemina, 
exert on the functions of circulation and respiration, 
modifications of which are one of the most frequent con- 
comitants of states of feelingoremotion" (Ibid., chap, 
v., p. 83). 
It is worthy of note also that the third and fourth pair 
of cranial nerves, as well as the sensory roots of the fifth 
pair, have their origin in the corpora quadrigemina. All 
these nerves play a certain part in facial expression. The 
third nerve, both by its action on the muscles of the eye- 
504 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Insanity. 
Insanity. 
ball and by its connection with the iris, exerts a more or 
less prominent influence on the changes of facial expres- 
sion. In like manner the fifth nerve, though chiefly 
sensory, still by its motor distribution to the pterygoid, 
masseter, and temporal muscles, is in some degree influ- 
ential in certain pathological states of expression. 
Chief among the factors in physical expression, and 
particularly in facial expression, is what physiologists 
have called muscular tonicity. It is that condition of the 
muscles by which a continuous, normal tension is main- 
tained, and is undoubtedly due to the constant transmis- 
sion of nerve-force from the cerebral centres through va- 
rious efferent paths to the muscular periphery. This 
particular discharge of nerve-energy is purely involun- 
tary, and is not recognized in the individual conscious- 
ness. Duchenne, in his " Mecanisme de la Physionomie 
humaine," speaking of tonicite musculaire, says that this 
force never sleeps, that it never ceases, except at death, 
and that by means of it that equipoise and natural equi- 
librium of the facial muscles is kept up which consti- 
tutes the natural and distinctive physiognomy of the in- 
dividual. " It is thus," he says, " that the physiognomy 
in repose is established, the individual physiognomy 
which consequently ought to be the reflection of our ha- 
bitual sentiments, the facies of our passions." Mante- 
gazza, also, in " La Physionomie et les Sentiments," refers 
to this constant innervation of the muscles that enters so 
largely into healthy expression, and contributes to what 
he calls the vivacity of the muscles. " This vivacity of 
the countenance," he says, " is the signal that the nerve- 
centres are in the best possible condition." And again, 
" The good face, or the countenance of health, means 
that the physiognomy expresses a good general nutrition, 
an excellent chemical composition of the blood, and a 
powerful and well-balanced innervation." 
Impairment of muscular tonicity is one cause of the 
changed expression among the insane. Organic and 
even functional disease of the cortex quite frequently 
impairs this transmission of nerve-force from the brain 
to the muscles which, as we have seen in health, should 
be constant, of uniform strength, and not intermittent. 
Our meagre knowledge of the pathology of insanity con- 
firms the inference that normal muscular tonicity is pro- 
duced by a certain constant action maintained by the 
higher cerebral centres upon the terminal muscular ex- 
pansions ; that the nerve-force is stored up in the corti- 
cal centres, and that it is undergoing continuous dis- 
charge and distribution to the innumerable deep and 
superficial muscles of the body. 
II. The power of inhibition possessed by the cerebral car- 
ter. Besides being a repository of nerve-force, the cortex 
undoubtedly exercises an inhibitory function, not only 
over its own centres, but more particularly upon those 
below them. The whole subject of inhibition is of great 
importance in any discussion of physical expression, and 
will be considered more in detail in the following chap- 
ter on the physical expression of the insane. Briefly, in- 
hibition is the power of restraining nerve-function which 
one part of the brain or nervous system possesses over 
some other part. Many physiological and pathological 
facts suggest the idea that the chief inhibitory centres 
are located in the cortex. Study of the physical expres- 
sion of the insane confirms this view. 
In some diseased conditions central irritability is so 
great and the power of healthy inhibition so slight, that 
all manner of purposeless movements ensue. Chorea 
and certain states of mania and melancholia illustrate 
this. The irregular, spasmodic, and useless muscular 
movements that characterize these and other diseases of 
the central nervous system are due to the uninhibited 
discharge of nerve-force from the higher brain-centres. 
In health the restraining of all such excessive and mean- 
ingless discharge seems to be one very important func- 
tion of the cortex. But even in health it is noticeable 
that this power of inhibition varies with the growth and 
development of the individual, being stronger at one time 
in the life of the same individual than at another, and 
even varying with the health and strength of the person. 
This subnormal inhibition is of common occurrence in 
(SUPPLEMENT.) 
so-called " nervous" people. Such persons are charac- 
terized by excess of muscular movement, quite often by 
extravagances of speech, though not sufficiently extreme 
to be called pathological. Finally, this power of healthy 
inhibition is modified greatly by hereditary influence. 
The inhibitory and coordinating power possessed by 
the higher nerve-centres in the brain is slight in infancy, 
and increases with age and development. The infinite 
random and meaningless movements of the infant's arms, 
legs, and facial muscles in response to external stimuli, 
are only so many outlets for nerve-force unchecked by 
inhibition and co-ordination. They constitute the physi- 
cal expression of the infant, and illustrate perfectly its 
automatic and reflex character. Meynert says : " Jn con- 
sequence of irradiation and the lack of cortical inhibi- 
tion upon the subcortical gray substance, we find in the 
child imperfect mimical expression ; and in its stead we 
have pronounced spasmodic contractions, which, accord- 
ing to the spirit of the observer, are interpreted either as 
laughing or crying. The same is true of those afflicted 
with dementia paralytica" ("Psychiatry," Am. Trans., 
Appendix, p. 273). Defective inhibition, due to organic 
or functional disease of the cortex, is one of the chief 
factors of the morbid physical expression of the insane. 
Excessive and needless movements of the various mus- 
cles of the face and body may be due in the child to the 
imperfect development of the inhibitory centres, or in the 
adult to pathological conditions of these same centres ; 
or among adults we may find those in whom healthy in- 
hibitory power has never been developed, simply from 
lack of proper training in childhood. 
III. The trophic changes consequent upon the processes of 
waste and repair that are constantly occurring in the cerebral 
cells. The entire question of cell waste and nutrition is 
imperfectly understood. There is no doubt that this 
branch of cerebral dynamics will receive constantly in- 
creasing attention from the physiologist and pathologist 
of the future. This process by which the cell stores up 
energy, which in some mysterious way it abstracts from 
the external world and then liberates through efferent 
tracts to the muscular system, is an admirable illustration 
of the law of " Convertibility of Forces." Not one of 
the forces of nature is lost; it is simply transformed and 
appears in some other form. But while the cell is en- 
gaged in this delicate process still another series of 
changes is taking place within its own structure, the pro- 
cess of waste and repair. No more delicate adjustment 
exists in the entire natural world than this equilibration 
that is maintained in the normal cerebral cell. The 
slightest disturbance in the protoplasm means impair- 
ment of function. This impairment of function, due to 
primary nutritional defect in the cell, may appear at the 
periphery as imperfect muscular tonicity, or in impaired 
nutrition of external parts, or in sluggish and irregular 
muscular movement. As Warner says, " It appears 
probable that a very distinct analogy may be made be- 
tween series of movements and series of acts of growth, 
and that similar laws may govern both " (" Physical Ex- 
pression," p. 81). Both " trophic action " and "kinetic 
action " are the expression of cell activity in the central 
nerve-mechanism. 
Concerning the importance of the cerebral cell, Dr. 
Lewis says: "We may safely exalt the nerve-cell to a 
position of the very highest importance in our problems 
of mind. It is on this account highly important that the 
nerve-cell of the cerebral cortex should be the subject of 
careful study by all interested in psychological medicine, 
and that due attention should be paid to the conditioning 
of its functional activities, and to the results of its nutri- 
tional impairment, disease, and death. 
" Suspended within a sac in direct connection with the 
lymph-channels surrounding the blood-vessels, or rather 
its own special nutrient capillary, the nerve-cell becomes 
liable to any influence, however trivial, disturbing the 
blood stream in its neighborhood. A quickened circula- 
tion, a retarded flow, an anaemic state of the cortex must 
influence the functional activity of these centres of feel- 
ing and thought. A vitiated quality of the blood, or the 
presence of toxic agents introduced from without, or 
505 Insanity. 
Insanity. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
elaborated within, the economy will affect them in a 
greater or less degree, while the activity of the lymph 
connective system in the removal of the effete products 
of functional wear and tear will play an all-important 
role in the same direction " (" Text-Book of Mental Dis- 
eases," p. 484. W. Bevan Lewis). Likewise Dr. Edward 
Cowles, in the Shattuck Lecture for 1891, bears excellent 
testimony to the train of symptoms following "weak- 
ness and toxic irritation of the central mechanism " 
(" Shattuck Lecture for 1891," p. 52). Thus it happens 
that nutritional changes hereditarily pre-established in 
the cerebral cell, or initiated therein by overwork and 
neglect of the laws of health, become reflected outward 
in the physical expression of the individual. Clinical 
illustration is abundant among the insane ; but of this 
more hereafter. 
Finally, it may be said that physical expression (and 
particularly that portion that is circumscribed by the 
facial region) is largely automatic, for the most part in- 
voluntary, and that it is developed in an entirely mechan- 
ical way. It belongs to the large class of reflex move- 
ments, and is one of the ways in which stimulations 
initiated within a central organ, or communicated to it 
from without, are reflected outward along certain nerve- 
tracts to terminal muscular attachments. The expression 
of the emotions, for instance, may be referred back to 
certain broad fundamental principles that obtain in the 
lowest radiata as well as in man. Physiologists are 
quite well agreed that the various emotions seek expres- 
sion in muscular movements that are either defensive or 
sympathetic in character. Meynert says: "As move- 
ments of expression vary with the emotions, these move- 
ments must be either of an aggressive or repulsive char- 
acter. We will find, with regard to the child in particular, 
that all physiognomic phenomena come under these two 
heads" (Meynert: "Psychiatry," Appendix). It is in 
obedience to this fundamental principle that the jelly-fish 
approaches toward and endeavors to enclose whatever is 
agreeable in the way of food, and contracts from and re- 
pels whatever is disagreeable in character. In like man- 
ner man, though in an infinitely more complex way, as 
might be inferred from his highly complicated and 
specialized nervous mechanism, draws near or touches 
whatever is pleasing, and shrinks from or repels what- 
ever is displeasing. The principle in either case is the 
same, though in man the mechanism through which the 
feelings are expressed, as well as the feelings themselves, 
have become so complex that the original physiological 
principle is nearly lost sight of. 
Individual expression, then, is a variable quantity, de- 
veloping and changing with the growth of the person, 
and varying with his moods. In infancy physical expres- 
sion is simple in character, is limited to innumerable re- 
flex movements which, in the main, are sympathetic or 
defensive. At this age nerve-force is generated and lib- 
erated along different efferent routes, with little restraint. 
Soon after, or even during early infancy, inhibitory 
power is developed in the cortical centres, and nerve- 
force is conserved for future use. Undoubtedly, in ear- 
liest childhood muscular tonicity is established by the 
continuous normal discharge of nerve-force from the 
cerebral cortex over the shortest and easiest, and for that 
very reason, the most habitual routes to the muscular 
periphery. This tonic action of the cerebral cells, which 
gives to each countenance its characteristic expression, 
unquestionably receives a powerful influence through 
heredity. This transmission of the cerebral cell-structure 
to offspring explains the similar expressions so often seen 
in different members of the same family. Hereditary 
transmission plus the inhibitory influences that are devel- 
oped by education, discipline, and the many attritions of 
civilized life, modify the tonic action of the cerebral cells 
upon the facial and other muscles, so that when adult 
life is reached an individual acquires that expression of 
maturity that is peculiar to him. It is difficult to define 
just what it is, and how this mature expression of the 
adult differs from a certain unfinished and undeveloped 
expression of childhood and early youth ; there is, how- 
ever, a vast difference in the facial expression of an indi- 
(SUPPLEMENT.) 
vidual in these two periods of his life, and there can be 
no doubt that the mature expression of adult life depends 
upon, or corresponds to, a modification of the cell-struct- 
ure of the cerebrum. Even in early infancy a wonderful 
change is noticed in the facial expression during the 
first few months. Photographs taken during the first 
few weeks and months of infancy, illustrate perfectly 
the outward nerve-muscular manifestations which cor- 
respond to an inner development. Muscular move- 
ments, at first only fleeting, by constant repetition be- 
come habitual and permanent. In this mechanical way 
will heredity, the social, intellectual, and moral life of 
the individual mould the physiognomy. 
An explanation is here found for those singular rever- 
sions in old age to certain family expressions which have 
characterized parents, uncles, aunts, or grandparents. 
Conolly thus refers to this interesting fact: "On the 
other hand, persons of ardent dispositions, who have worn 
all through their active years the physiognomy of an ex- 
citable mind, sometimes lose by degrees all this muscular 
agitation, and as they descend into the calm twilight of 
age, revert in appearance to that of parents or uncles or 
aunts still remembered by friends of the family. After 
death the face often exhibits these resemblances ; and, 
above all, the placidity which human events can disturb no 
more. When there are exceptions to this, and the coun- 
tenance bears in the latest years of life the stamp of mean 
or angry sentiments, which sometimes indeed shock our 
observation even in the coffin, the effect seems to be a 
result of the habitual impress of such feelings on the 
muscular part of the physiognomy during the greater 
part of life, with few or no benign alternations" ("The 
Physiognomy of Insanity," by John Conolly, M.D., Med. 
Times and Gazette, May 15, 1858, page 498). 
Quite striking and interesting is the change that is 
sometimes witnessed in the faces of the chronic insane 
after death. In the faces of these cases there seems to be a 
partial reversion toward former and more natural ex- 
pression at the time when death puts an end to the dis- 
eased action of the brain cells. Such cases will, after life 
is extinct, look more natural and more like their former 
selves, so their old friends say, than they have appeared 
for years. It would seem that in these cases a strong in- 
dividual expression had been attained through the influ- 
ences of heredity and early training, which had been 
modified for many years by the perverted motor action 
due to slight pathological changes of the brain, but 
which expression had returned immediately upon the 
cessation of the diseased action of the cerebral centres. 
On two or three occasions within my own experience, 
when I felt regret for the sad change of countenance that 
the friends must see in the face of some patient about to 
die, and who, for years, had been afflicted with chronic 
alienation, I have been singularly surprised to see how 
much better the face appeared after death. Certain lines 
of expression, and a peculiarly unpleasant cast of coun- 
tenance that I had been accustomed to see for years, and 
to regard as habitual, had entirely vanished with the ces- 
sation of life, and a completely different and, to me, new 
expression (but which the friends recognized as charac- 
teristic of a condition of mental health in bygone years), 
had taken its place. This singular phenomenon was no- 
ticed by Dickens in " Little Dorrit." The Father of the 
Marshalsea says : " Unless my face when I am dead sub- 
sides into the long-departed look, they say such things 
happen, I don't know, my children will never have seen 
me." 
The study of the physical expression of the insane en- 
ables one to observe the mechanism of expression from a 
pathological stand point, and yields still further confirma- 
tory evidence of the reflex and involuntary character of 
expression in general. 
III. The Physical Expression of Insanity. 
Knowledge of the mechanism of facial expression in 
health suggests the inference that the physiognomy must 
be variously modified by disease. If individual expres- 
sion be due to a close functional relationship between 
506 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Insanity. 
Insanity. 
activity of the cell-structure of the encephalon and mus- 
cular movement at the periphery, it is evident that dis- 
eased conditions of the central nervous system must in 
some way exert an influence upon the physiognomy. 
Gowers, following in the line of Hughlings Jackson's 
investigation, to the effect " that the whole brain is made 
up of structures which subserve sensory-motor processes, 
and that into such processes all its functions may be re- 
solved," adds, "but that every structure of the brain 
concerned with sensation proper is connected, directly or 
indirectly, with a part concerned with motion, may be 
regarded as a proposition scarcely needing proof." Ac- 
cording to this theory the motor disturbances in epilepsy 
are due to morbid functional conditions in the convolu- 
tions, thus demonstrating a most intimate relationship 
between peripheral muscular movement and diseased cell- 
activity in the cortex. 
In epilepsy an illustration is presented of great motor 
disturbance and marked alteration of the physiognomy, 
due to some powerful temporary interruption of healthy 
cell action in the convolutions. In insanity, and many 
other allied morbid states, additional opportunity is af- 
forded for observing still further physiognomical altera- 
tions due to morbid, though more persistent, changes in 
the nerve-centres of the convolutions. 
Indeed, it is interesting to note, in this connection, the 
remarkable influence that habitual mental and moral con- 
ditions exert upon the physiognomy. Certain types of 
character are apt to be associated with a certain configu- 
ration of countenance. So universally has this been ob- 
served, and so frequently have certain mental and moral 
traits been associated with peculiar facial expressions, 
that artists and dramatic actors have represented their 
characters with this or that cast of countenance accord- 
ing to the character of the individual they wish to por- 
tray. We often say of the person whom we may pass 
on the crowded street of a city that he has an ugly face, 
and we feel quite confident that he may be a man of low, 
brutal instincts; or, meeting another person, we say of 
him that his countenance is that of a noble, high-minded 
individual. Note the faces of the convict class in our 
prisons and penitentiaries; they are nearly all of them 
unpleasant to look upon, and many are positively repul- 
sive. The photographs of noted criminals present few 
features that are attractive. 
The physiological reason for this individuality of ex- 
pression undoubtedly lies in the fact that the expressions 
oftenest repeated in the face are those most likely to re- 
main, and in time these become the predominant expres- 
sions which individualize the countenance. Hence the 
criminal, in quite a mechanical and involuntary way, 
establishes what we recognize as a criminal countenance ; 
men of high moral sentiments, and noble, generous im- 
pulses, acquire a certain permanent facial expression 
associated with these more ennobling sentiments. Un- 
doubtedly, specific cell changes within the cerebral cen- 
tres correspond to these variations in personal character, 
and have their indices in the face. 
In this connection it is interesting to notice the methods 
of great dramatic readers and actors. These attain their 
marvellous perfection in the portrayal of their assumed 
characters, not by studying their attitudes and facial ex- 
pression before a mirror, but by a process of intense ab- 
straction they lose themselves and become identified with 
the assumed character to the degree which produces in 
their appropriate brain-centres conditions identical with 
those which are real in the characters they represent. 
The difference is this: in the one the expression is the 
reflex of real character, while in the other imagination 
and the power of abstraction throw the brain-centres, 
for the time being, into the same physiological state 
which, through muscular channels, is reflected in the 
countenance and attitudes. 
Few possess this great gift, and the difference between 
the common actor and the great histrionic masters is that 
the former are usually mere mechanical imitators, while 
the latter absorb, in the way described, the character 
they seek to portray, and, for the time being, think, 
breathe, act, and live in the assumed part. Who that 
(SUPPLEMENT.) 
has seen Salvini impersonate Othello has not felt, at mo- 
ments in the progress of the play, that it was the real 
Othello whom he saw and heard speak, and not Salvini ? 
And in the wondrous play of his features how plainly 
could the English auditor read the thoughts and feelings 
of the Moor, and interpret the words of the great trage- 
dian, though unfamiliar with the language in which they 
were spoken. 
The association of a lower grade of physical health 
with permanent and fixed criminal tendencies is not 
always imaginary. Many habitual criminals have been 
born of unhealthy or intemperate parents, and have spent 
the formative and growing part of their lives amid hy- 
gienic surroundings and conditions that were well calcu- 
lated to stunt all healthy physical development. Steven- 
son, in the most interesting psychological study, Dr. 
Jekyll and Mr. Hyde, recognized this association of 
evil qualities with defective physical organization, and a 
healthier and more robust constitution with a more noble 
and generous character. Hyde was stunted, dwarfish, 
and anaemic; Jekyll larger, well proportioned, and 
ruddy. The impression which Hyde left upon the 
lawyer's mind is not an unusual occurrence. " The law- 
yer stood a while when Mr. Hyde had left him, the pict- 
ure of disquietude. Then he began slowly to mount 
the street, pausing every step or two and putting his 
hand to his brow like a man in mental perplexity. The 
problem he was thus debating as he walked was one 
of a class that is rarely solved. Mr. Hyde was pale and 
dwarfish, he gave an impression of deformity without 
any namable malformation, he had a displeasing smile, 
he had borne himself to the lawyer with a sort of mur- 
derous mixture of timidity and boldness, and he spoke 
with a husky, whispering, and somewhat broken voice. 
All these were points against him, but not all of these 
together could explain the hitherto unknown disgust, 
loathing, and fear with which Mr. Utterson regarded him. 
'There must be something else,' said the perplexed 
gentleman. ' There is something more if I could find a 
name for it. God bless me, the man seems hardly 
human ! Something troglodytic, shall we say 2 or can it 
be the old story of Dr. Fell; or is it the mere radiance of 
a foul soul that thus transpires through and transfigures 
its clay continent? ' " 
These various types of countenance have a new in- 
terest to the psychologist when he considers them from a 
physiological point of view. The defective, ill-nurtured 
brain may not lead the individual into insanity, but may, 
even in spite of proper early training, develop a criminal 
tendency and character. In either case, however, the 
cortex by its intimate connection with the motor centres 
below it, and through them with the muscidar periphery, 
is quite certain to modify in some way the muscular 
play of the countenance. We need not wonder, then, at 
the hardened, coarse features of the criminal, for during 
his whole lifetime the higher centres in the brain have 
received but little active development, his entire life has 
been animal and sensuous ; and in the absence of any 
exercise of the higher mental faculties there have never 
been implanted in his countenance those more refined 
and elevated expressions that are the outgrowth of the 
moral and intellectual life. 
Incapable of anatomical demonstration as this may 
seem to be, there can be but little doubt that the higher 
mental faculties do seek expression through activity of 
the cortical centres ; and inasmuch as we know that dis- 
eased conditions of these cortical centres do very materi- 
ally modify facial expression, the inference is reasonable 
that the unpleasant facial expression of criminals has a 
physiological foundation in certain structural conditions 
within the cerebrum. 
The illustrated volume by Inspector Thomas Byrnes, 
of New York, entitled " Professional Criminals of Amer- 
ica," is quite interesting to the physiognomist. With 
few exceptions, the portraits represent men of hardened 
character, and their countenances give strong evidence 
of entire lack of sympathy with whatever is ennobling 
and elevating in life. The expression of their eyes is 
either furtive and treacherous, or suspicious, or else bold 
507 Insanity. 
Insanity. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
and brazen. Their mouth and lower jaw bespeak the 
grasping, selfish, animal life they lead. As might be ex- 
pected, the faces of women malefactors give evidence of 
the most striking degeneration ; there is little left in their 
bold, coarse features to remind one of the gentler, more 
sympathetic qualities of their sex. 
It is interesting to note how facial expression, among 
criminals even, is modified by the degree of intelligence 
of the individual. The shrewd, well-informed, ingeni- 
ous bank burglar, possesses a very different face from 
the low-lived, more ignorant river thief. As Inspector 
Byrnes says, the latter " are as hard-looking brutes as can 
be found ; " while the former may not only be modest and 
gentlemanly in appearance, but even people of consider- 
able education. It is quite evident that these latter are 
the exception, and that they owe their finer countenance 
to their intelligence and intellectual ability, as well as to 
a certain moral development ; for it must be borne in 
mind that many of these professional burglars live dual 
lives. Men of this class often have homes and children 
whom they are educating in good schools. The ties of 
affection exist as strongly in them as among men of cor- 
rect life. It is not difficult in their cases, therefore, to 
account for an improvement in the type of the criminal 
countenance. 
Occasionally there appears one of those strange moral 
monstrosities in whom much shrewdness and even intel- 
lectual ability is associated with an entire absence of con- 
science. Such individuals, while keeping up a show of 
moral and social respectability, may all the while be en- 
tertaining the most criminal plans. As a rule, the facial 
expression of such persons is unpleasant, and their feat- 
ures reveal the more purely sensuous life they are liv- 
ing, as well as the character of the impulses which direct 
their daily thoughts and actions. These unfortunate 
beings usually manifest a persistent tendency to develop 
a morbid passion for cruelty or crime of some sort, and 
this in spite of any careful early training in the right 
direction which they may have received. 
To this class belong such eases as that of William 
B , reported by Dr. Clarke in the Journal of Insanity 
for July 1886 ; and by Dr. Hack Tuke, in the Journal 
of Mental Science for October, 1885. 
E. H. Rulloff, executed at Binghamton, N. Y., and 
whose case was reported in the Journal of Insanity for 
April, 1872, is another illustration of this same class. He 
possessed certain remarkable intellectual accomplish- 
ments, but seemed entirely devoid of any moral sensibil- 
ity. Unfortunately no photograph of his face during 
life could be obtained, while those taken of the plaster- 
cast made after his death are deficient in details. Dr. 
Burr, of Binghamton, in a paper, on Rulloff, read 
before the Medico-Legal Society, September 14, 1871, 
makes some remarks upon this notorious criminal's gen- 
eral appearance which are so pertinent to the subject 
under discussion that, in lieu of a photograph, I cannot 
forbear quoting them. He says: "His countenance 
when in repose was stolid and indifferent ; wrhen giving 
vent to his frequent ebullitions of passion, it was repul- 
sive and forbidding ; but when animated by some subject 
in which he took an interest, like his favorite theme, 
philology, his features assumed a lively, active, and intel- 
ligent expression. In walking he stooped forward, and 
had a shambling, shuttling gait, such as he would be very 
likely to acquire during his long confinement in the vari- 
ous prisons in which he had been incarcerated. 
"His entire organization, as has been remarked of 
the cranium, was coarse. It was not without vigor or 
powers of endurance, but its material was not of the 
best quality, and was wanting in the fine finish which 
is now regarded as the best development of the human 
structure. In some respects his organization resembled 
that deteriorated condition, or that low type of physique, 
which has been declared by Mr. Bruce Thompson, to be 
characteristic of criminals as a class." 
The human countenance, therefore, possesses a singu- 
lar interest for the physician, because in its manifold 
expression he may read the reflected impress of certain 
physiological and pathological changes taking place 
within the cerebral centres. In forming a diagnosis 
nearly every physician is influenced in large measure, 
though often in a tacit and almost unconscious manner' 
by the facial expression of the individual whose case he 
may have under consideration. The wise and observing 
general practitioner often makes a correct diagnosis upon 
first entering the sick-chamber ; he takes in at a glance 
the peculiar facies of his patient and sees in it the pa- 
thognomonic signs of some disease. The dusky counte- 
nance, the sunken cheek, the dilated nostril, the short 
and almost panting breath, indicate phthisis even before 
physical examination. The injected eye, the trembling 
tongue and fingers, the hurried frightened glance over 
the shoulder, the sudden start and involuntary repelling 
motion of the hand, with the intent look of fear peering 
into corners and toward the direction from which any 
novel sound may proceed, suggest the delirium of alco- 
holism. And so the psychiatrist is influenced at times, 
almost more strongly than he can describe, by certain 
glances of the eye and a certain configuration of the 
countenance, and is led to infer alienation, although it 
would be extremely difficult for him to satisfactorily 
convey this evidence, so convincing to himself, to an- 
other person, or to make it satisfactory to a jury. Nev- 
ertheless, it is important evidence to him, and in the ab- 
sence of incoherence, or of any apparent delusion, he is 
induced to believe that his patient is mentally unsound, 
and so persist in his examination or demand repeated ex- 
aminations until he has struck the key-note of his men- 
tal weakness. And how frequently is the reverse true ! 
The examining physician feels sure that the individual 
before him is not insane ; the eye, the countenance in its 
entirety, indicate to him more definitely than he can for- 
mulate the same in language, the repose and the equi- 
poise of health. 
The words of Dr. Luther V. Bell, written some twen- 
ty-five years ago, in a deposition concerning an insane 
woman, are interesting and quite pertinent to the present 
subject. He says : "The reasons which convinced me 
that Mrs. was laboring under a grade of con- 
firmed insanity of long standing, of probable incurabil- 
ity, and to an extent depriving her of responsibility for 
her actions, may be included under two divisions. ' The 
first may be called personal convictions, not capable of 
being fully conveyed to another mind, such as the ex- 
pression of countenance, of eye, of manner, of habit of 
receiving and communicating thought, which a long ac- 
quaintance and domiciliation with the mentally diseased 
compelled me to accept as the truth ; outer proofs of an 
inner morbid condition, yet which can hardly be so de- 
picted or explained to the inexperienced. All profound 
and grave maladies have their specific physiognomy, 
more or less clear and capable of being described ; some 
awfully clear and pathognomonic, like the odor of cancer, 
or the face of advanced phthisis. Insanity has its own 
delicate characteristics of face, eye, manner, reasoning, 
feeling, which can be read by the expert, but which 
would not be appreciable to the merely casual ob- 
server. His power in this regard is not capable of being 
transferred to another mind, but must die with its pos- 
sessor.'' 
It is just here that instantaneous photography assists 
the psychiatrist and enables him to transfer to another or 
to retain for future reference, through the sense of sight, 
all those delicate characteristics of face, eye, manner, 
and the like which are caught by the camera and re- 
tained on the sensitive plate-a thing that was not practi- 
cable at the time Dr. Bell gave his deposition. 
In the present essay it is proposed to analyze the phy- 
siognomy of different insane persons. As one result of 
such analysis we shall find that the facial expression of 
the insane is determined by one or more of several patho- 
logical conditions. By studying these conditions separ- 
ately we gain a clearer view of the significance of physi- 
cal expression in insanity, and thus confirm the views 
already expressed concerning the physiology of physical 
expression. 
These pathological conditions may be considered un- 
der three heads: 
508 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
insanity. 
Insanity. 
I. The trophic or nutritive disturbances which accom- 
pany the disease. 
II. Impairment of healthy inhibition which is so fre- 
quently associated witli insanity, and one result of which 
is weakening of the faculty of attention. 
III. Excessive or defective nerve-muscular activity of 
an involuntary character, dependent upon morbid irri- 
tation or degeneration of the cerebral structure. 
To these may be added the different positions and ex- 
pressions of the eye, which, though possibly dependent 
upon the foregoing pathological conditions, are still of 
such significance as to deserve separate mention. 
In connection with the third condition, that of vary- 
ing motor disturbances, a study of various attitudes of 
the insane, as well as the different positions of the hands 
and the manner of carrying the head and the entire body, 
will be found both suggestive and interesting, as afford- 
ing striking confirmation of the physiological principles 
previously discussed. 
I. Modifications of the Countenance in Insanity which 
are Due to the Trophic or Nutritive Disturbance Attendant 
Upon the Disease.-In a large majority of cases insanity 
is itself caused by depreciated physical health. Dr. C. 
F. Folsom says: "The exhaustion and the disturbed 
cerebral circulation arising from acute and chronic dis- 
eases, profound anaemia, or prolonged mental strain, as- 
sociated with emotional disturbance from any cause, are 
among the antecedents of insanity" (" Mental Diseases," 
p. 117). The association of neurotic and unhealthy phys- 
ical conditions in different members of the same family 
is quite common. Of most frequent occurrence is the 
association, among different individuals of one family, 
or an alternation in the same person, of phthisis and 
insanity. 
Aside from such causes as hereditary transmission, 
alcoholic and venereal excesses, traumatism, and with 
the exception of its occasional appearance as one of the 
sequelae of some other disease such as epilepsy or some 
of the acute infectious diseases as measles, scarlet fever, 
and the like, insanity in the large majority of cases is 
caused by depreciated physical health with or without 
the association of some moral disturbance. The most 
frequent history given the physician is the following 
sequence : Overwork, loss of sleep, loss of appetite, 
indigestion, emaciation, increased worriment of mind, 
and, finally, actual insanity. The insanity appears as the 
result of the imperfect nutrition of the brain, which was 
in its turn produced by disordered health caused by im- 
proper attention to rest and digestion. 
On the other hand, insanity itself may act as a cause of 
the deterioration of physical health. Oftentimes it ag- 
gravates the profound physical depression which was, 
in the first instance, the primary cause of the mental 
disturbance. We readily understand the reason for this 
secondary action of the brain upon the general health 
when we consider that this delicate organ presides over 
the entire nervous system, and that any disturbance in 
its action is sure to modify the healthy distribution of 
nervous force in the different parts of the body. Re- 
peated and long-continued congestions of the delicate 
centres in the cerebral cortex, attendant on nearly all 
attacks of acute insanity as well as in the exacerbations 
occurring among the more chronic forms of the disease, 
lead to imperfect restoration of cell-structure in this 
organ, or to an unhealthy hyperplasia of the delicate tis- 
sues. Such changes in the brain result in its imperfect 
nutrition. Impaired nutrition of the brain leads to de- 
fective bodily health in various ways: either the mor- 
bid ideas which are the result of the brain disturbance 
lead to refusal of food, or the supply of healthy nervous 
energy to the entire alimentary canal is so interfered 
with that all the processes of digestion are improperly 
performed and healthy assimilation is impossible, or the 
activity of the cells in the cortex may so interfere with 
normal vaso-motor innervation that the natural circula- 
tion of the blood in other parts of the body is disturbed. 
In either case a depreciated state of bodily health, a de- 
cidedly lowered vitality, with diminished resistance, is the 
result. 
This depreciated state of the general health is mani- 
fested in the condition of the skin, the hair, and mucous 
membranes. Every physician who attends upon the in- 
sane is familiar with the cold, clammy hands so character- 
istic of this class of patients ; or with the dry, scaly state 
of the epidermis ; the brittle, dry hair ; the furred tongue 
and oftentimes offensive breath ; the peculiar flabby con- 
dition of the skin of the face, with its pasty, lustreless 
color. All these characteristics, though not always pres- 
ent, still prevail in the majority of cases, and indicate that 
the general health has been impaired either by the cere- 
bral disturbance itself, or by the constitutional causes 
leading to the brain trouble. 
Although the photograph cannot preserve all the con- 
ditions of ill health above referred to, still the flabby 
countenance with its lack of healthy tonicity; the " lean 
and hungry look," and many of the signs of impaired 
vitality, are well retained and form a striking feature of 
any collection of portraits of the insane. 
In a general way the study of the countenances of the 
insane leads to the conclusion that nearly all acute, re- 
cent, and very active insanity is attended with emacia- 
tion, sometimes only slight in degree, at other times 
quite extreme. This is quite noticeable in acute mania, 
acute melancholia, in the depressed stage of folie circu- 
laire, during the active excitement of paresis, in acute 
primary dementia, or in dementia secondary to acute or 
chronic insanity, especially where the progress of the 
disease has been rapid. 
Those forms of insanity in which there is an exces- 
sive elimination of nerve-force from the cerebral cen- 
tres, are always attended by emaciation. In acute 
mania, some forms of acute melancholia, the maniacal 
stage of paresis, this constant and extreme elimination of 
nervous energy is manifested in almost incessant motor 
activity, and in these cases we always notice emaciation 
and general physical prostration. 
Case XLII (see p. 519), acute mania, illustrates the 
emaciation attendant upon constant motor excitement 
in Fig. 337, A ; while in Fig. 338, B, the return to health 
is evidenced as much by change in nutrition as by intelli- 
gence of expression. 
In other cases the nervous system may be profoundly 
affected, and, though motor activity is not a symptom, 
still the trophic disturbances are as pronounced as in 
those to which we have just referred. In these cases the 
motor and the ideational centres seem to be overcome by 
the force and suddenness of the nervous shock, and there 
ensues an entire absence of activity in these same cen- 
tres. There is no longer an elimination of healthy ner- 
vous energy from the cerebral region, and hence there is 
not only a cessation of normal functional activity of all 
the bodily organs such as the stomach, intestines, liver, 
kidneys, heart, and lungs, but there is also a paralysis of 
the centres in the cortex. As a result the patient is not 
only utterly exhausted and physically prostrated, but he is 
also mentally confused and dazed. An illustration of this 
condition, with its attendant trophic disturbance, is seen 
in Case XXXI., A and B (Figs. 313 and 314). This pa- 
tient came into the asylum in a state of complete mental 
stupor ; she would neither eat nor speak, gave no heed 
to personal cleanliness, but would void her urine and 
faeces wherever she might happen to be, whether stand- 
ing up or lying in bed. She would stand for hours in 
the attitude seen in A, her eyes fixed and motionless, and 
no amount of urging could excite her attention. She be- 
came exceedingly emaciated, although she was fed daily 
upon the most nutritious diet. Comparison of pictures 
A and B with C (Fig. 315), taken at time of discharge and 
recovery, illustrates the wonderful nutritive disturbances 
that occurred during her sickness. Undoubtedly, the 
profound trophic alterations in her case were due pri- 
marily to the extent and severity of the diseased action 
in the cortical centres. 
Another fact is worthy of notice. 
Whenever a patient, suffering with some form of in- 
sanity, after a long period of mental disturbance, begins 
to regain flesh and weight without making any corre- 
sponding mental improvement, we have reason to fear 
509 Insanity. 
Insanity. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
that the alienation in this patient may become chronic. 
In such cases it is not at all improbable that the cerebral 
structure has accommodated itself to the morbid pro- 
cesses which have been disturbing it for so long a 
time. The cells in the cortical region continue to act in 
and recovery. In nearly all cases of chronic insanity 
there is that condition of lowered vitality which is gen- 
erally the inevitable accompaniment of the disease. The 
flabby skin, lustreless eye, general absence of healthy 
plumpness, and the drooping head, all indicate deficiency 
of normal nutrition. All these symptoms are more 
manifest in the persons themselves than in their photo- 
graphs ; yet the latter plainly signify the trophic disturb- 
ances associated with the disease. 
Melancholia is almost invariably attended by pro- 
nounced trophic disturbances, and photographs of this 
class always show what marked inroads upon physical 
health this especial form of mental disease may make. 
In no case is this more noticeable than in XXXIII. (see 
page 528). The emaciation was extreme. Every mental 
faculty seemed paralyzed, and many bodily functions, 
such as digestion, assimilation, and nutrition appeared 
to be almost entirely suspended. His gradual return to 
mental health is marked by corresponding improvement 
in nutrition, and shows quite plainly in Figs. 346, 347, 
and 348. 
This depreciation of physical health during the height 
of the attack, its return and perfect establishment at time 
Fig. 313.-Case XXXI. Melancholia with Stupor. A, showing full- 
length attitude maintained for hours. Ocular divergence, self-absorp- 
tion, and emaciation. (From photograph taken by author.) 
their newly acquired morbid manner, while those parts 
which more particularly preside over the functions of 
nutrition and assimilation and of organic life act auto- 
matically and as naturally as ever. Thus, though the 
individual may have all the symptoms of chronic delu- 
Fig. 315.-Case XXXI. C, same person after recovery. (From photo- 
graph taken by author.) 
of mental recovery, is quite noticeable in the portraits of 
Case XXXI., A, B, and C. In Case XL1L, Fig. 338. B, 
taken at time of recovery, when compared with A (Fig. 
337), presents very marked changes in physical health. 
Alternations in loss and increase of flesh are often no- 
ticeable in cases of insanity. During the active stage of 
paresis, when there is very marked cerebral activity, at- 
tended with pyrexia and great motor disturbance, there 
is much tissue waste, and the patient becomes quite ema- 
ciated. When the excitement abates, the fever disap- 
pears, and motor activity ceases, then the appetite is apt 
to increase to an excessive degree, assimilation goes on as 
usual, and the patient sinks into a passive, quiescent state 
in which flesh is accumulated to an almost unnatural de- 
gree. In cases of folie circulaire there is often increase 
of flesh and strength during the active stage, and during 
the period of depression there is marked emaciation. All 
the processes of assimilation seem to be in sympathy with 
the depression of mind, and when the reaction comes 
increased appetite and improved assimilation, together 
with increase of flesh and strength, also reappear. 
In other cases, although there is no real improvement 
in the mind, still a change in the character of the delu- 
sions leads to a more hearty ingestion and assimilation, 
and the patient's physical health improves, although men- 
tally he may still be far from well. 
In many of the chronic forms of insanity, where there 
Fig. 314.-Case XXXI. B, showing nearer view of head. (From photo- 
graph taken by author.) 
sional insanity, or of mental weakness in some form, 
still the processes of nutrition and assimilation are nor- 
mally performed, and he may attain a good degree of 
physical though not of mental health. 
More frequently, however, increase of flesh and perfect 
physical health are coincident with mental convalescence 
510 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Insanity* 
Insanity. 
is little undue motor activity, and especially in that form 
known as paranoia, the bodily functions are carried on 
quite naturally. In a well-regulated hospital there is so 
little to disturb the lives of these patients, their hours of 
eating, sleeping, and bathing are so regular, that even 
though their cerebral condition is in no way improved, 
their physical health is quite good, and oftentimes the 
accumulation of flesh in these cases is almost pathologi- 
cal. A removal of such patients to a less favorable situ- 
ation often results in a rapid deterioration of their physi- 
cal health, or at least in a loss of their flesh. In all 
cases of chronic insanity, however, marked improvement 
in physical health is more apparent than real. There is, 
as we have seen, an occasional accumulation of adipose 
tissue ; but in such cases there is often a deficiency in 
that general vitality and energy which we associate 
with health, and which is so effective in resisting dis- 
ease. 
To briefly recapitulate what has been said concerning 
the trophic and nutritive modifications of the physiog- 
nomy in insanity : 
1. In the majority of cases there is impaired general 
nutrition due either to (a) congenital brain deficiency ; (b) 
to abnormal or excessive elimination of nervous energy 
from the brain, thereby weakening and interfering with 
the functional activity of that organ ; or (c) to permanent 
brain weakness acquired as a result of chronic insanity. 
In these three ways the functional activity of the brain 
as a distributor of nervous energy to the organs of diges- 
tion and assimilation is interfered with, and the general 
health suffers as a result. 
2. Occasional alternations of flesh and emaciation, of 
improved and impaired physical health in the same indi- 
vidual, and due to fluctuations in the functional activity 
of the brain. 
3. Occasional coexistence of physical health and men- 
tal disease-a condition of things which is oftener ap- 
parent than real, and dependent largely upon the for- 
tunate environment of the patient. 
II. Modifications in the Physical Expression of the In- 
sane, Due to Impaired Inhibition.-The inhibitory power 
is recognized as playing a most important part in the 
intellectual and physical life of man. Whether inhibi- 
tion is a purely metaphysical attribute of mind, or a spe- 
cial function having its seat in specific centres of the 
brain, its importance as a factor in the life of the indi- 
vidual cannot be doubted. Many writers have denied 
the existence of special inhibitory centres. Many phys- 
iological and psychological facts confirm their views. 
G. II. Lewes argues with much force against the exist- 
ence of special centres of inhibition. He attempts to 
explain the phenomena of inhibition by what he calls the 
Law of Arrest. " The Law of Arrest is only another 
aspect of the Law of Discharge, and may be regarded as 
the conflict of excitations." According to this theory, 
each nerve tract and centre possesses inherent inhibitory 
properties of its own. The strongest excitations prevail: 
" The discharge is only the resultant of the conflict along 
the line of least resistance ; the arrest is the effect of the 
conflict along the line of greatest resistance " (G. II. 
Lewes, "Physical Basis of Mind "). 
Meynert advances the theory that the gray matter of 
the brain and cord presents a certain resistance to nerve- 
conduction. Increased irradiation of any irritation is ac- 
companied by increased resistance in nerve-conduction. 
" It is evident then," he says, " that inhibition resulting 
from resistances introduced in nerve-tracts accompanies 
the simplest reflex processes." 
Many physiological and pathological data lead us to 
infer that nerve-tissue, and particularly the gray matter, 
possesses certain inherent tendencies to resistance to 
nerve-conduction. Herein man widely differs from the 
lower animals. For in them, this resistance to nerve- 
conduction, which we recognize in man as a part of his 
inhibitory faculty, is incapable of development, but re- 
mains stationary through life just as it was transmitted 
at birth by heredity. In man, on the contrary, this 
property of resistance may be developed by individual 
training and experience. Hence the inhibitory power 
varies with the person : there is no universal inhibitory 
standard that can be applied to all alike. 
The possession of a high degree of inhibition is often 
due to an active exercise of the will-power ; hence, per- 
fect inhibitory capacity is usually associated in the same 
individual with a strong and active manifestation of the 
will. Carpenter says : "Now the man in full possession 
of his volitional power can use it, (1) in giving bodily 
effect to his mental decision, by either putting in action 
the muscles which will execute the movements he has 
determined on, or by restraining them from the action to 
which they are prompted by some other impulse ; and 
(2) in controlling and directing that succession of mental 
operations by which the determination is arrived at " 
(Carpenter, " Mental Physiology," p. 378). 
In the gradual evolution of the inhibitory power the 
will plays a most prominent part. By active and con- 
stant exercise of the will an individual may develop 
marked inhibitory power. Inhibition represents gradual 
growth, therefore, and varies at different periods in the 
life of the same individual. At birth, and during early in- 
fancy, it scarcely exists. Every act that the infant per- 
forms is the impulsive and spasmodic result of sensory 
stimulation. During childhood the inhibitory power re- 
ceives its first training and development. The child learns 
to govern himself. Experience and his parents teach him 
that the mere impulsive gratification of every whim that 
may arise, of every appetite that suggests itself, is not 
only not desirable, but may be fraught with disastrous 
results, both here and hereafter. In youth and manhood 
this power of inhibition receives constant education. 
The experiences of life all tend to develop it, if the will 
insists upon it. 
In the cultivation of man's moral nature the successful 
development of inhibition receives a good illustration. 
Man's unbridled animal instincts might lead him into 
habits of vicious and selfish indulgence, of which the 
criminal records present abundant illustrations. The 
teachings, however, of religion, morality, and even the 
instinct of self-preservation, lead him to place a check 
upon these mere animal indulgences. At first the con- 
flict may be difficult, as the history not only of individ- 
uals but even of entire nations, will testify. Individual 
persistence succeeds, however, in implanting in the per- 
son such power for resistance that these temptations not 
only cease to have any allurement, but even become 
loathsome. Such inhibitory resistance is transmitted by 
heredity. 
The inhibitory power, therefore, may vary greatly 
among races of men as well as among individuals. Edu- 
cation is certainly a prominent factor in its development. 
Civilized man possesses the inhibitory power to a greater 
degree than the savage ; the educated, in this as in many 
other respects, are vastly superior to the ignorant. In- 
deed, success in life may be measured by the degree of 
healthy inhibition possessed by the individual. 
Climatic and hereditary conditions exert a powerful in- 
fluence in modifying and developing the inhibitory power. 
And thus we can understand why it is that the people of 
one nationality and climate differ so materially from 
those of another in the possession of this faculty. 
We may briefly summarize by saying that inhibition 
seems to be a restraining pow'er which is implanted in the 
mind, and incorporated as it were in the nervous system 
of the individual. It is largely a matter of individual 
growth, and depends for its successful development upon 
the strong and healthy exercise of the will. There is also 
evidence that the inhibitory power is modified in various 
ways by climatic and hereditary influence. It is also evi- 
dent that, when once this inhibitory and restraining power 
is implanted within the nervous organization of an in- 
dividual, its habitual and almost involuntary exercise is 
elicited by the presentation of the proper stimulus. Thus 
habits and tendencies which have only been repressed 
with the greatest difficulty and after the most active ex- 
ercise of the will, receive frequent and comparatively easy 
restraint when once a tendency to their inhibition has been 
fairly established by the individual. 
The inhibitory power seems to be intimately associated 
511 Insanity. 
Insanity. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
with all our higher faculties, and in common with them 
seeks expression through functional activity of the cere- 
bral cortex. The inference is natural that functional or 
organic disturbance of this region should be attended 
by disordered inhibition. Among the earliest manifes- 
tations in insanity is impairment of the inhibitory power. 
In health the inhibitory function is exercised in a two- 
fold manner: First, in checking irrelevant trains of 
thought, repressing whatever is impertinent to the sub- 
ject engaging the attention ; and secondly, in checking 
certain muscular movements which, though they natur- 
ally follow the stimulations which have preceded them, 
still, for the time being and with other objects in view, 
are undesirable and out of place. 
It is not surprising that the inhibitory function, so in- 
timately associated with all the higher activities of the 
mind, and probably identified with cell-activity in the 
cerebral cortex, should be among the first to become dis- 
ordered in insanity. A careful analysis of the symptoms 
that arise during the premonitory and early stages of men- 
tal alienation discloses evidences of weakened inhibition. 
Among the higher faculties the attention holds a most 
prominent position. Active exercise of the inhibitory 
power is indispensable to a complete awakening of the 
attention. And the success attained by any individual in 
the various walks of life may be measured by his power 
of inhibiting whatever is irrelevant, that is, by his ability 
to concentrate his attention upon the work before him. 
Obersteiner has well said : "We can will that a certain 
action to which there exists a powerful stimulus should 
be repressed and carry out another. By inhibition of the 
former we concentrate our attention on the latter. . . 
" Ideas tend to call up other ideas by association, and 
naturally along the most easy channels. But we can 
check the current of ideation along the easiest paths and 
divert it into paths which are more difficult. We think 
attentively and inhibit continuously. The more power- 
ful this inhibitory working of the attention, the more in- 
tense the thought, the more numerous the paths opened 
up, and the more productive in its consequences. It ap- 
pears therefore from these considerations, that in every 
mental act, whether it be in the domain of sensation, voli- 
tion, or intellect, there is seen an inhibitory power essen- 
tially the same in all cases " (" Experimental Researches 
on Attention," by H. Obersteiner, in Brain for January, 
1879). 
In the early development of insanity one of the first 
symptoms to attract the notice of the friends, and to arouse 
their suspicions of mental disturbance, is a manifest in- 
ability on the part of the patient to concentrate his atten- 
tion. This will declare itself in various ways. The 
patient becomes inaccurate. If a mechanic he either 
accomplishes less work or is careless; if in business he 
makes frequent mistakes and fails to fulfil important 
obligations. All this inaccuracy and omission of detail 
is due to varying degrees of self-abstraction. The patient 
has lost the power of successfully inhibiting the fleeting 
thoughts or suspicions which crowd his mind and which 
supplant the ideas that immediately concern his daily 
work and life. 
In health the individual possesses the power to turn his 
thoughts in the direction of his work or whatever may 
interest him at the time. Irrelevant ideas and sensations 
can be inhibited, and only those regarded which will as- 
sist the work in hand. But in the earlier stages of in- 
sanity, and in the more firmly established conditions of 
the disease, every morbid idea, and often every communi- 
cation to the sensorium through the avenues of the special 
senses, acts as a diversion. The patient's power of atten- 
tion is so easily distracted, he places such a morbid con- 
struction upon every new sight or sound, and his inhib- 
itory power is so weak that healthy concentration upon 
affairs of real importance is an actual impossibility. 
The asylum workshop affords an excellent illustration. 
Here you may study inhibitory incapacity in every stage 
of development. A stranger enters the room and probably 
half of the patients will cease working, some will arise 
from their seats, and possibly one or more will walk about 
the new-comer, looking him over inquisitively and either 
talking to themselves or to the visitor. And in what a 
scattered and desultory way is much of the work per- 
formed ! Evidently ideas irrelevant to the occupation in 
hand absorb and divert the attention of these diseased 
minds into other channels. In just the proportion that 
the individual possesses inhibitory capacity, to just that 
extent does he seem capable of performing successful and 
intelligent work. 
Bearing in mind, then, that weakening of healthy inhi- 
bition is one of the first results of insanity, we find this 
impairment of the inhibitory capacity manifested in the 
physical, and particularly the facial, expression of the in- 
sane in two ways : 
1. There is inability to control the movements of the 
facial muscles. The insane make few attempts at con- 
cealing the facial expression of their feelings. With 
them impaired inhibitory power interferes with that slight 
volitional control which we possess over those facial 
movements that habitually follow certain emotions. In 
the familiar language of daily life the insane look very 
much as they/eeZ, and their attempts at concealing their 
real emotions are few and unsuccessful. 
2. For the same reason there is impaired inhibition, 
there is inability to concentrate the attention, the result 
of which is an expression of self-absorption quite peculiar 
and characteristic of the disease. 
These two elements in the facial expression of the in- 
sane merit more discussion in detail. First, as to inability 
to control the well-known facial expressions of certain 
emotions. We must remember that the muscular move- 
ments producing facial expression are essentially reflex, 
and largely involuntary. When displeased we do not 
will our facial muscles to assume certain positions char- 
acteristic of displeasure ; neither when amused do we 
will that they should contract in the way peculiar to the 
expression of amusement. As has been previously stated, 
the muscles, without any seemingly volitional effort of 
our own, assume these positions themselves in obedience 
to the special force transmitted to them from the cerebral 
cells along the intermediate conducting nerve-fibres. 
Although the ordinary muscular movements concerned 
in facial expression are involuntary, still man does pos- 
sess a limited control over them. This inhibitory influ- 
ence over muscular contractions that are commonly re- 
flex and involuntary is developed by education and 
experience ; and is often carried to a high degree of per- 
fection by persistent self-training in this particular direc- 
tion. The emotions are more unreservedly expressed in 
the face of the child than in that of the adult ; the igno- 
rant and uneducated betray their feelings in their facial 
expression more frequently than do the intelligent ; in- 
deed, this power of controlling the expression of one's 
innermost sentiments may be the evidence of a healthy 
and well-balanced mind. This attempt at concealing 
these deeper feelings is practised to a certain extent and 
with varying success by every one. Sometimes a senti- 
ment of pride, again criminal reasons influence an indi- 
vidual to inhibit the ordinary movements of facial ex- 
pression. Thus a man may be bowed down with grief, 
and yet when he appears in public will, from a secret 
feeling of pride that leads him to avoid betraying his 
emotions to others, conceal every expression of sorrow. 
He will smooth out the wrinkles of pain on his forehead 
and appear calm and unmoved until by himself again. 
Or the criminal, who harbors motives of hatred and 
revenge, or who has committed some great crime, will 
conceal, or at least attempt to conceal, the malignant and 
guilty expression which would otherwise betray him. 
To a certain extent, therefore, the normal involuntary 
and reflex movements of facial expression are inhibited 
in health. In insanity, however, the inhibitory power is 
so weakened by the disease that successful control of 
these movements is difficult. 
The insane patient makes few and ineffectual attempts 
at disguising the feelings which oppress him. The con- 
flicting emotions by which he is disturbed are reflected 
through the various motor-tracts to the face, and as a re- 
sult we may often read the character of the delusions 
which preoccupy the mind. Thus the expression of the 
512 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Insanity. 
Insanity. 
countenance in acute melancholia is generally quite char- 
acteristic of a depressed state of the feelings ; and what 
is especially noteworthy is the fact that this diseased ex- 
pression is far more intense than would be the expression 
of similar emotions in the same individual in health. Im- 
paired inhibition does not exercise any restraining influ- 
ence upon the countenance, and, whether alone or in the 
presence of others, the melancholic presents the furrowed 
brow, the anxious and distressed expression about the 
eyes and month that are characteristic of these especial 
emotions, whether they proceed from natural or morbid 
causes. The only difference is that the normal manifes- 
tation of grief is modified by healthy inhibition, while 
morbid sorrow is persistent, intense, and not subject to 
outward restraint. 
Indeed, the most marked illustrations of impaired inhi- 
bition are found among the faces of the melancholic in- 
sane. There is oftentimes in these cases a complete 
abandonment to the predominant emotion-the patient 
making no effort whatever to control the expression of 
the feelings. Darwin's remarks upon the facial expres- 
sion of sorrow are particularly interesting, and, un- 
doubtedly, are physiologically correct. As his explana- 
tion of the physical expression of grief is corroborated 
by the physiognomy of melancholia we will briefly refer 
to what he says upon the subject. 
The muscles which are brought into play during the 
expression of painful emotions are the corrugators, orbic- 
ulars, pyramidalis of the nose, and the frontalis. These 
are what Darwin has called the " grief muscles" when 
they are placed in " conjoint yet opposed action," which 
action he thus describes : " When a person elevates his 
eyebrows by the contraction of the whole frontal muscle, 
transverse wrinkles extend across the whole breadth of 
the forehead ; but in the present case (expression of grief) 
the middle fasciae are alone contracted; consequently, 
transverse furrows are formed across the middle part 
alone of the forehead. The skin over the exterior parts 
the skin of the forehead from the central and raised part. 
The reunion of these vertical furrow's with the central and 
transverse furrows produces a mark on the forehead which 
has been compared to a horseshoe ; but the furrows more 
strictly form three sides of a quadrangle. They are often 
conspicuous on the foreheads of adults, or nearly adult 
persons, when their eyebrows are made oblique ; but with 
young children, owing to their skin not easily wrinkling, 
Fig. 317.-Case LV., Acute Melancholia. Marked and characteristic 
innervation of Darwin's "grief muscles." Intense motor disturbance. 
(From photogiaph taken by author.) 
they are rarely seen, or mere traces of them can be de- 
tected " (" Expression of the Emotions in Man and Ani- 
mals," by Charles Darwin, Am. ed., 1873, p. 181). 
This peculiar contraction of the "grief muscles'' re- 
ceives its best illustration in states of mental depression, 
but irregular and morbid activity of the brain-cells in 
different forms of insanity may produce nearly the same 
action, even though the state of mind is one of complete 
confusion or even exhilaration. In Case XXVII., chron- 
ic melancholia, we see the action of Darwin's " grief 
muscles " producing in a striking degree obliquity of the 
eyebrows and the vertical lines between them which 
Darwin says is so characteristic of emotions of depres- 
sion. In this same case the naso-labial furrow, extending 
from the wing of the nose to the angle of the mouth, and 
which Darwin says is of so frequent occurrence in blub- 
bering children, is strongly marked. In Case LV. this 
peculiar action of the corrugators and central fasciae of 
the frontalis muscle is strikingly illustrated. The corru- 
gators in their contraction draw the eyebrows inward, 
producing the vertical furrows seen at the inner edge of 
each eyebrow ; the frontalis in its contraction produces 
the transverse furrows across the centre of the forehead, 
while the orbiculars in their contraction smooth out these 
transverse wrinkles on the outer borders of the forehead. 
As in the previous case, the naso-labial furrow and the 
depression of the corners of the mouth, due to the contrac- 
tion of the depresswes anguli oris, are very pronounced. 
Indeed both Cases XXVII. and LV. afford most strik- 
Fig. 316.-Case XXVII.. Chronic Melancholia. Morbid and uninhib- 
ited expression of grief. Darwin's "grief muscles" in contraction 
producing "horseshoe mark." (From photograph taken by author.) 
of both eyebrows is at the same time drawn downward 
and smoothed by the contractions of the outer portions 
of the orbicular muscles. The eyebrows are likewise 
brought together through the simultaneous contraction 
ot the corrugators ; and this latter action generates ver- 
tical furrows, separating the exterior and lower part of 
513 Insanity. 
Insanity. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
ing representations of prolonged concentrated grief and 
mental suffering. These are typical cases of melancholia, 
and while it is evident that emotions of depression have 
produced their normal and legitimate expression in their 
faces, it is 
equally plain 
that no person 
in a state of 
mental health 
would present 
this remarkable 
appearance for 
several consec- 
utive hours, 
and in the pres- 
ence of others. 
Such action as 
is represented 
in the photo- 
graphs of Cases 
XXVII. and 
LV. could only 
proceed from 
persistent and 
u n i n terrupted 
morbid cell ac- 
t i v i t y . In 
health, the nor- 
mal inhibitory 
action of the 
cortical centres 
would render 
such extreme 
man ifestations 
impossible. In these cases of melancholia no amount of 
persuasion or distraction, not even the fact of sitting for 
a portrait, when most people make an effort to smooth 
out their features, produces the slightest change in these 
disturbed and painful countenances. It is quite obvious 
that healthy inhibition has ceased to be a factor in the 
facial expressions of these unhappy subjects, and that the 
various muscu- 
lar contractions 
of their faces 
are so many per- 
sistent signals 
of the psychic 
pain which fills 
their minds. 
The photo- 
graphs figured 
in Plate IX. of 
Kirchoff's work 
(Figs. 318, 319, 
and 320 of the 
present article) 
illustrate the 
uninhibited ex- 
pression of dis- 
tress in the fa- 
cial region of a 
case of pa r a - 
lytic dementia, 
upon an imper- 
fect attempt to 
articulate a dif- 
ficult word, and 
the smoothi n g 
of all themuscu- 
lar folds when 
the patient is in 
repose. 
In the portraits of cases of acute mania it is very plain 
that inhibition exercises no restraining influence what- 
ever over the constant nerve-muscular activity which so 
transforms the physiognomy. Case XLII. (see p. 519) 
illustrates how completely has intelligent control over 
the features been swept away by the storm raging within 
the cerebral centres. 
(SUPPLEMENT.) 
Ilie iaces or tne cnronic delusional insane snow quite 
clearly the absence of healthy inhibition. Thus the 
sly, distrustful glance, the bitter, lowering look of hatred 
and enmity, the self-satisfied air of exaltation, or the de- 
jected countenance of self-abasement, are expressions 
quite frequently noted among this class of insane, and 
are another evidence of the inability of the patient, 
through im- 
paired inhibi- 
tion, to control 
the outward 
m a n i festation 
of the inner 
feelings. These 
same feelings 
exist in health, 
oftentimes with 
great intensity, 
and yet how 
perfectly are 
they concealed! 
In this connec- 
tion it is inter- 
esting to note 
that in the 
weaker mental 
conditions o f 
childhood these 
same feelings 
and emotions 
are frequently 
and as clearly 
represented in 
changes of fa- 
cial expression 
as are the corresponding emotional states in the faces of 
the adult insane. The main difference lies in this fact, 
however, that in childhood inhibition through the will 
has not been developed, while among the adult insane 
it has been weakened bv disease. 
Fig. 318.-Paralytic Dementia. Face in repose. 
(From Kirchoff's Handbook.) 
Fig. 320.-Paralytic Dementia. (Same case; con- 
ditions the same as in Fig. 319.) (From Kirchoff's 
Handbook.) 
Fig. 319.-Paralytic Dementia. (Same case.) Un- 
inhibited expression of distress as shown in the 
contraction of the ''grief muscles" upon at- 
tempting to articulate a difficult word. (From 
Kirchoffi's Handbook.) 
Fig. 321.-Case III., Chronic Delusional Insanity. Persistent, unin- 
hibited ideas of suspicion and hostility. (From photograph taken by 
author.) 
Case III., characterized by chronic delusions of en- 
mity and suspicion, and also homicidal, quite clearly ex- 
presses in the countenance the dissatisfaction with, and 
the opposition to, those about him, as well as fierce deter- 
mination to gratify his impulses on the first favorable 
opportunity. 
514 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Insanity. 
Insanity. 
Case XII. quite plainly manifests in his countenance 
his all-absorbing egotism. In sitting for his portrait he 
chose his own position, arranging with great care his 
decorations, consisting of old buttons, bits of glass, 
(SUPPLEMENT.) 
ments that characterize their individual cases. Fig. 329 
is especially interesting, in that the same individual is 
shown under more normal conditions. Impaired inhibi- 
tion explains all this distortion of feature. 
A peculiar appearance of self-abstraction is the second 
way in which weakening of the inhibitory power among 
the insane manifests itself. 
This self-absorption results from inability of the pa- 
tient to inhibit trains of morbid and irrelevant thought. 
He looks preoccupied, and often entirely disregards his 
environment. So absorbed does he become that it is with 
the greatest difficulty that he concentrates his attention 
on persons or things about him. Hence results an ex- 
pression of indifference, a fixed intent gaze, but with no 
particu 1 a r ob- 
ject within the 
range of vision. 
In discussing the 
position and 
condition of the 
eyes in the coun- 
tenances of the 
insane more ex- 
tended allusion 
to this subject 
will be made. 
At present it is 
only necessary 
to call attention 
to the fact that 
the peculiar ab- 
sorbed, absent- 
minded expres- 
sion, so fre- 
q u e n 11 y met 
with in the in- 
sane, is due to 
impairment of 
the faculty of 
attention caused 
by weakening of 
the power of in- 
hibition. In Figs. 333 and 334, taken from Kirchoff's 
work, this absorbed expression, indicating complete disre- 
gard of the environment, is well preserved. 
III.-The third manner in which the physical expres- 
sion of health is modified by insanity is through excessive, 
deficient, or automatic nerve-muscular activity of an involun- 
tary character, dependent upon morbid irritation or degener- 
ation of the cerebral cell-structure. Allusion has been pre- 
viously made to that regular transmission of nerve-force 
which, in conditions of health, is constantly passing from 
the cerebral cen- 
tres to the mus- 
cular periphery. 
The results of 
this elimination 
of nerve energy 
are seen in that 
permanent and 
normal tension 
of the muscular 
system called 
muscular tonic- 
ity, and also in 
the ordinary fa- 
cial expression 
of every individ- 
ual when the 
features are in 
repose. It is 
proposed in the 
present section 
to consider how 
this normal and 
regular trans- 
mission of nerve 
energy in health 
is modified by 
Fig. 324.-Case of Paranoia, Showing Disap- 
pearance of all Healthy and Natural Expres- 
sion, Due to Absence of Cortical Inhibition. 
(From Kirchoff's Handbook.) 
Fig. 322.-Case XII., Paranoia. Morbid egotism and fondness for dis- 
play. (From photograph taken by author.) . 
brass wash-bowl chains, tin, etc., which he imagined to 
possess great value. The violin, which he made himself 
out of limited materials, and with an old knife and awl, 
he was anxious to display as a Cremona instrument of 
rare worth. The 
inconsistency of 
his real position 
(that of confine- 
ment for life in 
an asylum), the 
utter worthless- 
ness of his jewel- 
ry and impro- 
vised insignia do 
not in the least 
lead to the inhi- 
bition of the ex- 
p r e s s i o n s of 
morbid vanity 
and self-impor- 
tance which per- 
vade his counte- 
nance. Indeed, 
in n e a r 1 y all 
forms of acute or 
chronic insanity, 
characterized by 
active persistent 
ideas, there will 
be noticed in the 
facial expression 
a complete aban- 
donment to the prevailing morbid emotions, with scarcely 
any attempt at inhibition. 
Kirchoff's views of insane patients in Fig. 331, Fig. 
332, Fig. 325, and Fig. 326 illustrate how completely the 
insane abandon themselves to the predominant senti- 
Fig. 323.-Case of Paranoia. Uninhibited 
expression of opposition and resentment. 
(From Kirchoff's Handbook.) 
Fig. 325.-Case of Mania, Showing Uninhibited 
Muscular Movement. (From Kirchoff's Hand- 
book.) 
515 Insanity. 
Insanity. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
the functional and organic disturbance of the brain in in- 
sanity. In doing this we enter the larger field of Physical 
Expression, where we study not only the changes observed 
in the face, but every abnormal manifestation taking place 
in the entire muscular system, including gesticulations, 
attitudes, manner of holding the head, carrying the hands, 
and every possible irregular and abnormal muscular 
movement. 
All these 
movements, 
which are caus- 
ed by irregular 
cell activity of 
the cerebral cen- 
tres, have one 
ch a rac teristic 
d i s t i nguishing 
them from theor- 
dinary changes 
of facial expres- 
sion ; they are 
entirely mean- 
ingless, subserve 
no purpose, and 
do not conform 
to any of the 
well-known ex- 
pressions of the 
emotions, as 
grief, joy, etc. 
In health the ex- 
pression of these 
emotions is al- 
ways recognized 
by certain well-known muscular contractions which ob- 
servation has taught us are characteristic of correspond- 
ing mental states. We know, for instance, that laughter 
will be manifested by contraction of the corrugators, of 
the malaris, and of the great zygomatic ; in grief we know 
that the eyeballs will be rolled a little upward and inward, 
and that the con- 
traction of the 
central fibres of 
the frontalis act- 
ing upon the cor- 
rugators will 
produce a pecu- 
liar and very 
characteristic 
wrinkling of the 
forehead above 
and between the 
eyes, and that 
the depressores 
anguli oris will 
draw down the 
corners of the 
mouth. These 
muscular c o n - 
tractions follow 
in a certain defi- 
nite m a n n e r 
their causative 
mental states. 
So regularly and 
constantly do 
they succeed 
their antecedent 
mental conditions, that, given the state of mind, the re- 
sulting movements of expression can be foretold even be- 
fore their appearance. Hence the expressions of the emo- 
tions can be easily separated into groups : thus we have 
the expression of joy, grief, disgust, and all the others. 
On the other hand, the movements under discussion are 
not regular, do not indicate any particular state of mind, 
but represent rather that irregular and interrupted action 
of the brain-cells which often takes place in acute insan- 
ity, and is of very frequent occurrence in the degenerative 
brain conditions of chronic alienation. 
To avoid confusion we may study this phase of the 
Physical Expression of the insane under three heads : 
I. As representing states of excessive nerve-muscular 
activity due to central irritation. 
II. As representing states of deficient nerve-muscular 
activity due to central degeneration. 
III. As representing states of automatic cell-activity in 
the cerebrum occurring not infrequently in acute insanity, 
and quite constantly in the chronic form of the disease. 
I. Physical Expression of the Insane Caused by Ex- 
cessice Nerve-muscular Activity.-That mysterious prop- 
erty which, for want of a better name, we call nerve- 
force, is undoubtedly being constantly stored up within 
the brain - cells, 
and as regularly 
discharged from 
them. The in- 
timate relation- 
ship between 
this elimination 
of nerve - force 
and muscular 
movement has 
been clearly 
stated by Dr. 
Carpenter, in the 
following para- 
graph : 
"We shall 
hereafter see 
that each kind 
of mental activ- 
ity-sensational, 
instinctive, emo- 
tional, ideation- 
al, volitional - 
may express it- 
self in bodily 
movement; and 
it is clear that 
every such 
movement is called forth by an active state of a cer- 
tain part of the brain, which excites a corresponding 
activity in the motor nerves issuing from it, where- 
by particular muscles are called into contraction. No 
physiologist can doubt that the mechanical force ex- 
erted by the muscles is the expression of certain chemi- 
cal changes which take place between their own sub- 
stance and the oxygenated blood that circulates through 
them; or that the nerve-force which calls forth those 
changes is intimately related to electricity and other 
physical forces. 
But this ner- 
vous activity 
has its source 
in molecular 
changes in the 
nerve - centres ; 
the transmis- 
sion of nerve- 
force along the 
motor nerve be- 
ing just as de- 
pendent upon 
chemical 
changes taking 
place between 
the substance 
of the gan- 
glionic centre 
from which it 
proceeds, and 
the oxygenated 
blood that cir- 
culates through 
it, as is the 
transmission of 
an electric cur- 
rent along the 
Fig. 326.-Case of Mania. Uninhibited egotism 
and exhilaration. (From Kirchoff's Handbook.) 
Fig. 328.-Case of Mania ; showing nnrepressed 
expression of exhilaration. (From Kirchoff's 
Handbook.) 
Fig. 327.-Case of Mania ; showing unrepressed 
expression of exhilaration. (From Kirchoff's 
Handbook.) 
Fig. 329.-Folie Circnlaire. J, Depressed stage, 
with expression of uninhibited grief. (From 
Kirchoff's Handbook.) 
516 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Insanity. 
Insanity. 
telegraph wire upon the chemical changes taking place 
between the metals and the exciting liquid of the gal- 
vanic battery" ("Mental Physiology," Am. Ed., 1874). 
The laws which govern this elimination of nerve-force 
are similar to the laws governing force in general. The 
great law of conservation of force or energy prevails in 
the field of cerebral activity as elsewhere. When chem- 
ical changes take place within the delicate nerve-centres 
of the brain as a consequence of external stimulation 
through the senses, or internal stimulation following 
mental activity, the result conforms to the requirements 
of this universal law. Either the force generated by 
these chemical 
changes remains 
stored up in the 
cerebral cells as 
potential energy 
to be called forth 
at some future 
time by stimula- 
t i o n , or it is 
transferred from 
the cells along 
the proper tracts 
to the muscu- 
lar system, and 
appears as mo- 
tion. This is the 
physiological 
deli n i t i o n of 
Physi cal E x - 
pression. 
Now, a certain 
constant and 
regular trans- 
mission of this 
nerve-force from 
the central cells 
to the muscular 
periphery is, as 
we have seen, 
natural and in accordance with health. Indeed, a state 
of general good health demands this outward relief 
for the potential energy constantly accumulating with- 
in the brain-cells. Thus the excessive muscular activity 
of all young and growing animals, the playfulness of 
young dogs and kittens, the pranks and follies of boy- 
hood, are oftentimes merely the expression of this great 
natural law. In adult life the potential energy of cere- 
bral cells is manifested in more practical and useful 
ways, but still in the most tangible results of a success- 
ful b u s i n ess, 
mechanical or 
professional 
life, we recog- 
nize the out- 
ward manifes- 
tation of the po- 
tential energy 
which has been 
stored up with- 
in the brain- 
cells until the 
proper stimula- 
tion called forth 
its discharge. 
This intimate 
relationship be- 
tween muscu- 
lar movement 
and central cell- 
activity withifl 
the cerebrum, 
has been dis- 
cussed in Dr. 
Francis War- 
ner's interest- 
ing volume on 
"Physical Ex- 
pression," and in a recent article by the same author 
in the Journal of Mental Science for April, 1889. This 
author calls attention to the fact that these outward 
manifestations of central cell-activity begin at birth, 
and are witnessed in the countless random and mean- 
ingless move- 
ments of in- 
fancy, to which 
he has given 
the name of mi- 
crokinesis. Un- 
doubtedly at a 
very early age 
healthy inhibi- 
tion of muscular 
movement b e - 
gins. One by 
one useless and 
superfluous 
movements are 
checked, elimi- 
nated, or co-ordi- 
nated in such a 
way that when 
adult life is 
reached, the in- 
dividual, if in 
health, mani- 
fests those mus- 
cular activities 
which subserve 
the general pur- 
poses of the will 
and intelligence. 
Even at this period of life many movements remain, ful- 
filling no particular purpose, but representing mere auto- 
matic cell-activity which has either been acquired by the 
individual or transmitted to him by heredity. The vari- 
ous movements of the facial muscles, including the tonic 
contractions already referred to, and which, in their to- 
tality, form the individual physiognomy, belong to this 
automatic and acquired class. 
In diseased conditions of the brain, however, the 
pathological irritation of these delicate nerve - cen- 
tres may be so 
great as to over- 
come any ac- 
quired i n h i b i- 
tory resistance, 
and thus liberate 
an e x c e s s of 
nerve-force 
which will seek 
an outlet in the 
usual way by 
passing along 
the efferent 
motor tracts to 
the muscles, and 
there appearing 
as muscular 
movement. 
Thus it is that in 
the functional or 
organic brain 
disturbances of 
insanity, abnor- 
mal motor activ- 
ities are a fre- 
q u e n t accom- 
paniment of dis- 
turbed states of 
mind. 
Pathological motor activity is, as we have seen, spas- 
modic, irregular, and purposeless. The most striking 
illustration of this fact is afforded by cases of chorea and 
epilepsy. There seem to be good reasons for supposing 
that in these diseases the brain-cells are in an unstable 
condition, owing to hereditary, traumatic, or nutritive 
Fig. 332.-Case of Periodical Melancholia. (From 
Kirchoff's Handbook.) 
Fig. 330.-Folie Circulaire. B, Exhilarated 
stage, when countenance has returned to a 
more normal condition. (From Kirchoff's 
Handbook.) 
Fig. 333.-Case of Dementia. Oculardiverger.ee 
due to suspension of the attention and lack of 
ideation. (From Kirchoff's Handbook.) 
Fig. 331.-Case of Periodical Melancholia. 
(From Kirchoff's Handbook.) 
517 Insanity. 
Insanity. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
disturbances, and that, as Gowers says, the discharge of 
these same cells " may depend on the production of force 
within being increased in excess of the resistance, or on 
the resistance being duly lessened" (''Epilepsy and 
other Chronic Convulsive Diseases," p. 213). 
In the active stages of mania and melancholia, in the 
acute excite- 
m e n t w h i c h 
sometimes oc- 
curs in paresis 
and other or- 
ganic diseases 
of the brain, 
this same dis- 
charge of 
nerve•force 
takes place. 
The unceasing 
jactitation of 
acute mania, 
the restlessness 
of melancholia, 
are familiar il- 
lustrations. 
Such patients 
are apt to be ina 
state of constant 
muscular activ- 
ity, pacing the 
floor, tearing 
their clothing, 
and destroying 
whatever comes 
in their way. 
These irregular and motiveless movements of the in- 
sane are earliest manifested in the facial muscles. The 
extreme sensitiveness of this region to cerebral condi- 
tions, and the weaker inhibitory control which the brain 
possesses over these delicately poised muscles, are rea- 
sons why the face so often presents the first physical 
manifestations of the advancing mental disease. Very 
frequently the mus- 
c u 1 a r disturbance 
does not extend be- 
yond the face ; but it 
is quite rare that this 
region does not show 
some evidence of the 
morbid irritation of 
the brain-cells. 
When the face alone 
is disturbed in this 
way, the resulting ex- 
pression is quite pe- 
culiar, and resembles 
those meaningless 
contractions that are 
produced when a 
mild galvanic current 
is passed through 
these muscles. The 
muscles are gently 
but continuously con- 
tracted, particularly 
those about the fore- 
head, at the root of 
the nose, and about 
the mouth, giving to 
the patient a pecul- 
iar kind of troubled or anxious expression. It is often 
noticed by the friends at a very early stage of the 
disease, and they will tell you that the patient does not 
look natural, that his countenance has a strained, intense 
look, quite different from his normal expression, but 
still very difficult to describe. 
This particular region about the forehead, above and 
between the eyes, and at the root of the nose, is the first 
to bear evidence of psychic pain or distress, and, indeed, 
of mental excitement of any kind. Nearly all writers on 
physiognomy speak of the important role sustained by 
the frontal region in the development of facial expres- 
sion. Some attribute this fact to the nearness of the part 
to the regions of thought and mental activity in the brain, 
and cite as one evidence of this the fact that we all in- 
voluntarily rub or press this space above and between 
the eyes when we are perplexed. The act of rubbing re- 
lieves, in some way, the unpleasant tension which we 
feel at such times. It is not at all improbable that the 
nerve-force, liberated by the increased activity of the an- 
terior convolutions of the brain during active thought, is 
transmitted from the cortical centres to these muscles and 
occasions that slight feeling of tension, which is undoubt- 
edly relieved by rubbing. 
The peculiar action of the "grief-muscles" in melan- 
cholia has already been discussed. It is somewhat sin- 
gular that these same muscles are called into action in 
other states of mind than those of morbid depression. 
States of mental confusion, of mania, with exhilaration, 
often stimulate the grief-muscles into activity. Illustra- 
tions of this are afforded by Cases XXXIX. (Fig. 
335, A) and XLII. (Fig. 337, A). In these last cases 
Fig. 334.-Case of Melancholia. Self-absorption, 
ocular divergence, and contraction of "grief 
muscles." (From Kirchoff's Handbook.) 
Fig. 336.-Case XXXIX. B. Taken at time of discharge and recovery. 
Disappearance of morbid innervation, improved nutrition. (From 
photograph taken by author.) 
we may believe that the cell irritation of the cortex 
transmits nerve-force in the direction of the so-called 
grief-muscles, since, through repeated use, that channel 
affords the readiest outlet. Or, it may be that this 
disturbed and anxious look so often seen in different 
phases of insanity is due to a feeling of displeasure awak- 
ened in the mind of the patient by the opposition to his 
plans and delusions, which he so frequently encounters 
in those about him ; and this sense of displeasure and dis- 
appointment has its usual manifestation in the muscles 
that reflect these emotions. However this may be, the 
frontal region, including the eyes and space between them, 
is, through contiguity to the brain, the most expressive 
part of tiie face, and the nerve-muscular activity of insan- 
ity finds there its earliest and most persistent reflection. 
Returning to the illustrations, we find that the por- 
traits of Cases XXXIX. and XLII. illustrate the pecul- 
iar muscular contractions already referred to, and which 
proceed from the brain irritation of mania in different 
degrees of intensity. Case XXXIX. was transferred to 
the asylum from the prison. Six weeks before his re- 
moval to the asylum he began to be careless in his work, 
Fig. 335.-Case XXXIX. Acute Mania. 
A. As he appeared on arrival at asylum 
from prison. Morbid innervation of fa- 
cial muscles. (From photograph taken 
by author.) 
518 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Insanity. 
Insanity. 
and was supposed to be refractory. He was placed in 
solitary confinement, but while in this situation he began 
to develop hallucinations of sight and delusions of exalta- 
tion, thinking he was Christ. On his arrival at the asy- 
lum he was quite deluded, slightly incoherent, and ex- 
hilarated. Fig. 335, A, shows his appearance at this time. 
The compressed lips, the almost bristling hair, deep fur- 
at a distance of thirty or forty feet. Warner thus alludes 
to this symptom : " Tooth-grinding is produced by the 
action of the deeply situated pterygoid muscles ; champ- 
ing of the jaws is produced by the masseter and temporal 
muscles; all these muscles are supplied by the fifth 
nerve, and it is to their condition that we must look for 
information as to the condition of the central origin of 
the nerve." By means of the Casserian ganglion and 
small nerve-filaments branching from it, the fifth nerve 
is brought into intimate connection with the dura mater 
and adjacent membranes. In chronic insanity associated 
with dementia these membranes are nearly always found 
to be in a pathological condition. It is quite natural, 
therefore, that morbid sensations should be transmitted 
from these diseased membranes, through the sensory 
branches of this portion of the fifth nerve, back to its 
origin in the pons varolii and medulla, and thence be re- 
flected outward along its motor tract to the pterygoid 
and masseter muscles. 
In many cases of maniacal excitement attention has 
been called to the dry, rough, and almost bristling condi- 
tion of the hair. In those patients who have recovered 
from mania the hair resumes its normal condition, is 
softer, and more easily kept in place. Illustrations of this 
are seen in Cases XXXIX. (Fig. 335) and XLII. (Fig. 
337). In chronic, or in recurrent mania the dry and brist- 
ling state of the hair is of common occurrence. One case 
under the writer's observation, a woman, was character- 
ized by exacerbations of excitement, and at these times 
her hair was exceedingly dry and stood out in a striking 
way all about her head and face. In two cases the hair 
was naturally curly but, as one result of the active mental 
excitement, there seemed to be imparted to it a stiffness 
quite different from that produced by the curliness; 
each individual hair, during the period of excitement 
appeared to have a special prominence of its own. 
This singular condition of the hair, in states of active 
mental excitement, has been alluded to by Darwin in 
his " Expression of the Emotions in Man and Animals." 
His explanation, which is undoubtedly correct, affords 
another illustration of excessive nerve-muscular activity 
following cerebral cell irritation Every hair-sac is pro- 
Fig. 337.-Case XLII., Acute Mania. A. Taken during active stage. 
Morbid innervation, trophic alterations, neglect of personal appear- 
ance. (From photograph taken by author.) 
rows in the skin extending from the alae nasi to the 
corners of the mouth, the lowered eyebrow's, and deep 
wrinkling between the eyebrows at the root of the nose 
and on the forehead, illustrate what has been referred to 
as a "troubled " expression, and show how the centric ir- 
ritation has been communicated to the muscles of the 
face. Fig, 336, B, giving the face of the same individual 
at time of recovery, presents a most marked contrast. 
The smooth brow and forehead, the clear, open eye, and 
natural position of the mouth, all indicate, more clearly 
than words can express, the subsidence of the storm with- 
in the cerebral centres. 
In Case XLII. (Fig. 337), the patient was entirely inco- 
herent, and in a state of constant muscular agitation. 
He was destructive, and almost too confused to eat his 
meals, so that frequent feeding with the nasal tube be- 
came necessary. The staring eyes, wrinkled forehead, 
dry, dishevelled hair, and torn coat are in striking con- 
trast with Fig. 338, B, in which the hair has assumed its 
natural condition, the face is smooth, and the eyes are 
calm and quiet. 
In cases of melancholia with motor disturbance we see 
the effects of central irritation reflected in muscular agi- 
tation. Sometimes the patient will pace the floor wring- 
ing the hands, groaning and moaning, or the excitement 
will become so intense as to lead to an impulse to tear or 
destroy whatever comes within reach. 
In many cases of chronic insanity almost constant tooth- 
grinding is a noticeable feature, and another illustration 
of morbid transmission of nerve-force from the central 
cells to the muscular periphery. Tooth-grinding is not 
uncommon in nervous children, and is of very frequent 
occurrence in the insanity proceeding from structural 
brain disease. It is noticed oftener in connection with 
paresis than with any other disease. In passing through 
wards for demented patients it is a familiar sound, and 
sometimes is made with such force that it can be heard 
Fig. 338.-Case XLII., B. Taken at time of recovery. (From photo- 
graph taken by author.) 
vided with delicate unstriped muscular fibres-arrectores 
pili. These minute involuntary muscles are exceedingly 
liable to contract under the influence of strong emotions, 
such as fear and anger, as wTell as from the effects of 
cold. The contraction of these muscles causes a more or 
less complete erection of the hair shaft. Darwin con- 
cludes that " the erection of the dermal appendages is 
519 Insanity. 
Insanity. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
a reflex action, independent of the will ; and this action 
must be looked at when occurring under the influence of 
anger or fear, not as a power acquired for the sake of 
some advantage, but as an incidental result, at least to a 
large extent, of the sensorium being affected " (Op. cit., 
p. 102). 
In the active mental excitement of mania, acute or 
chronic, persistent irritation of the cerebral cell-structure 
leads to the transmission of nerve-force along this chan- 
nel to the arrectores pili-all the more readily because the 
natural emotions of fear and anger have made this a cus- 
tomary route. Hence in those forms of insanity which 
are accompanied by excessive nerve-muscular activity 
this erection of the hair is an almost inevitable result. 
This condition of the hair is only seen in those forms of 
mental disease characterized by active excitement, or 
marked emotional disturbance. The bristling and erec- 
tion is intensified by the dryness and roughness of the 
hair due to the impaired action of the subcutaneous 
glands. Darwin also informs us " that with man the 
hairs on the front of the head which slope forward, and 
those on the back of the head which slope backward, are 
raised in opposite directions by the contraction of the oc- 
cipito-fronlalis or scalp muscle " (Ibid., p. 297). This mus- 
cle is, as we have seen, often kept in a state of unnatural 
tension in conditions of pathological cerebral excitement, 
and hence its action would assist the arrectores pili in 
maintaining an erect and bristling state of the hair. 
The study of the portraits calls for a slight digression 
on the significance of the wearing apparel of the insanei 
When we consider its neglected, disarranged state, its 
unique and oftentimes bizarre arrangement; when we 
contrast the general appearance of the clothing of many 
of the acute and chronic insane with what we know is 
characteristic of mental health, then we become impressed 
with the fact that this matter of the condition and ar- 
rangement of a patient's clothing may be of diagnostic or 
even prognostic value to the alienist. Even in health 
our estimates of individual character are assisted by ob- 
servation of the condition and general style of a person's 
clothing, so closely related to our inner selves have these 
outer vestments become. Carlyle, in " Sartor Resartus," 
made no mere imaginative allusion when he asked the 
question : 
" How, then, comes it, may the reflective mind repeat, 
that the grand tissue of all tissues, the only real tissue, 
should have been quite overlooked by science, the vest- 
ural tissue, namely of woollen or other cloth ; which 
man's soul wears as its outmost wrappage and overall; 
wherein his whole other tissues are included and screened, 
his whole faculties work, his whole self lives, moves, and 
has its being ? " 
In observing the condition of the clothing of the in- 
sane we shall have additional evidence for believing 
that this " outmost wrappage " may partially reflect the 
mental and moral state of the individual. For this reason 
no especial attempt was made in the taking of the various 
portraits to arrange the wearing apparel for appearance' 
sake. Many of the views reproduced in this article were 
taken in the ward, so as to secure a true likeness of the 
individuals as they appeared at that particular moment. 
In all forms of mental disease accompanied by motor 
disturbance due to excessive and irregular transmission 
of nerve-force from the brain-cells, we find that the re- 
sulting muscular agitation causes the clothing to be dis- 
arranged and disorderly, oftener it is torn and partially 
destroyed. In acute mania, and in the melancholia ac- 
companied by restlessness, the cases to which we have 
already referred illustrate what has been said about the 
condition of the clothing. One of the great difficulties 
encountered by asylum officers is the tendency manifested 
by the active insane to tear and disarrange their cloth- 
ing. This is only one way in which nerve-force, gener- 
ated in excess of inhibitory resistance, seeks an outlet. 
In cases of mental failure, such as dementia proceed- 
ing from chronic insanity and organic brain disease, the 
clothing shows neglect, is often untidy unless personally 
cleansed by another, and seems to hang from the person 
rather than fit his form. A party of demented patients 
may be recognized at a distance by the very hanging of 
their clothing. The absence of healthy muscular resist- 
ance, the sluggish gait, drooping shoulders, pendent 
arms and hands, give to the outer garments a peculiar and 
almost indescribable appearance, which once recognized 
cannot be forgotten. It would seem as though the gen- 
eral lack of healthy muscular tonicity, the flabby state of 
the entire muscular system, characteristic of this form of 
mental disturbance, had been communicated to the cloth- 
ing. 
The subject of personal attire among the insane should 
not be dismissed without a passing allusion to the pen- 
chant which many of this class exhibit for fantastic dress. 
In some forms of subacute mania, of the active stage of 
recurrent mania, or in some cases of mild chronic mania, 
and noticeably among many of the chronic delusional in- 
sane, there is quite frequently exhibited a passion for 
bright colors, and for personal decoration of a fantastic 
character. 
Artists and dramatists, from the earliest times, have 
always heightened the effect of their portrayal of insanity 
by representing the insane as peculiarly decorated with 
straw, flowers, feathers, or rags. Thus Shakespeare 
makes Ophelia enter " fantastically dressed with straws 
and flowers." And in King Lear, Cordelia, when reflect- 
ing upon her poor insane father, says : 
"Alack 'tis he ; why. he was met even now 
As mad as the vex'd sea, singing aloud ; 
Crown'd with rank fumiter. and furrow weeds, 
With hardocks. hemlock, nettles, cuckoo-flowers, 
Darnel, and all the idle weeds that grow 
In our sustaining corn." 
Aside from all exaggeration due to the license univers- 
ally granted the poet and painter, there is an actual scien- 
tific foundation for this time-sanctioned portrayal of in- 
sanity. It is a matter of common occurrence in asylums 
for the insane to see patients, suffering from the above- 
mentioned types of the disease, pick up shining bits of 
tin, brass, or glass, or brightly colored cloth, and use the 
same as a decoration for the hair or clothing. Such pa- 
tients often attach a great value to these worthless ma- 
terials. While it cannot be said that this tendency for 
fantastic decoration is always an indication of chronic 
insanity, it is frequently associated with that form of 
mental disease. Nearly every asylum contains, among 
its old residents, some who have made themselves con- 
spicuous for years by the odd and fantastic decoration of 
their dress ; and were it not deemed inadvisable to allow 
this passion for odd display to be carried too far, such 
cases would be far more numerous and their costumes 
much more striking than is usually the case. 
Cases XII. (see page 515) and LIV. illustrate the ten- 
dency for striking and fantastic display, notwithstanding 
that in each of these patients an attempt was made to re- 
duce it to a minimum. Case XII., one of chronic mania 
or paranoiac insanity, manifested a marked fondness for 
sensational display. In sitting for his portrait he ar- 
ranged his regalia with the greatest care, wishing that his 
various pins, "precious stones and diamonds," as he 
called them, should all be included in the photograph. 
Case LIV., chronic mania with marked delusional exal- 
tation, always decorated herself in some fantastic manner. 
At the time the portrait was taken she had evidently 
taken the greatest pains to produce an effect with her 
hair and also with the handkerchief which is elaborately 
displayed on her dress. The peculiar cap was made out 
of worsted and cotton cloth ravellings, and was considered 
by her to be a very choice ornament, and in some way a 
badge of her superiority. She entertained the delusion 
that she was Christ, the Virgin Mary, and that she had un- 
limited power. The portrait of this patient is also inter- 
esting as showing the marked inhibitory control that ex- 
ists in the midst of great incoherence of idea and language. 
No sane person could prove a better poser for her photo- 
graph than this very excitable insane woman. 
The variety of fantastic decoration that one meets in an 
asylum is almost endless. The interesting query sug- 
gests itself whether this singular fondness for adornment 
520 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Insanity. 
Insanity. 
noticed among the insane is anything more than an 
exaggeration of a natural proclivity common to mankind 
generally. In health the desire for personal decoration 
has certain well-defined limits prescribed by fashion and 
common sense ; but as a result of mental disease this 
same natural desire is no longer controlled by a healthy 
judgment and inhibition, and hence this fantastic, gro- 
tesque, and odd display. 
II. Physical Expression of the Insane Caused by Deficient 
Nerve-muscular Activity Due to Central Degeneration.- 
Deficient nerve-muscular activity plays a prominent part 
Some of these varying degrees of mental weakness are 
noticeable in nearly all cases of persistent and long-con- 
tinued insanity, and many cases of acute insanity do not 
recover so perfectly but that a slight amount of mental 
damage may be detected. Unfortunately, our knowl- 
edge of the pathological anatomy of the brain is so lim- 
ited that we cannot with precision locate the specific 
lesion corresponding to the various forms of mental dis- 
ease. It is generally assumed that the pathological con- 
dition is one of degeneration consequent upon hyperae- 
mic and inflammatory processes, or upon inflammatory 
changes succeeding malnutrition of that delicate organ. 
Whatever the pathological alterations in the brain-cells 
may be, varying degrees of motor impairment constitute 
one very constant result in all cases of chronic insanity 
attended with mental weakness. We have already no- 
ticed how excessive nerve-muscular activity character- 
izes nearly all attacks of acute mania, as well as the 
excited stage of paresis, and the temporary exacerbations 
of excitement occurring in dementia. In these cases the 
nerve-force is discharged in excess of the power of resist- 
ance, either because the inhibitory power itself is dimin- 
ished, or because there is an excess of nerve-force gener- 
ated within the nerve-centres. On the other hand, in cases 
of persistent and long-continued acute insanity, as well 
as in chronic insanity associated with the varying de- 
grees of dementia above mentioned, deficient nerve- 
muscular activity is a prominent symptom. And the 
inference seems a legitimate one, that this deficient nerve- 
muscular activity represents or corresponds to certain 
degenerative processes occurring within the brain-cells. 
This deficient nerve-muscular activity varies from the 
slightest motor impairment in a few of the delicate facial 
muscular strands, to an extreme degree of general mus- 
cular paresis. 
Griesinger says : " The most important circumstance 
in regard to anatomical diagnosis and to prognosis is the 
existence or non-existence of severe motory disorders, in 
particular, of general progressive paralysis." We might 
add that the slighter motor impairments have a very im- 
portant bearing upon the diagnosis and prognosis of the 
patient's mental condition. In nearly all cases of demen- 
tia secondary to acute or chronic mental disease, there 
are evidences of this motor impairment. It is not unlikely 
that if we possessed instruments for accurately gauging 
the degree of intensity of motor force in individual mus- 
cles in patients suffering from dementia, we should find a 
much larger deficiency than we realize by our present 
methods of observation. 
This deficient nerve-muscular activity represents im- 
perfect or weakened innervation on the part of the 
central organ-the brain. All nervous tissue is en- 
dowed with one peculiar property, that of sensibility. By 
means of it, " the nerve-cells feel excitation from with- 
out, and react in consequence, by virtue of the excite- 
ment of their natural affinities" (Luys, "The Brain 
and its Functions," p. 81). Impaired sensibility of the 
nerve-cells is a frequent result of protracted" attacks 
of acute insanity, and a constant accompaniment of the 
various forms of dementia. And in such cases there is 
imperfect reaction to the various sensory stimulations 
which, in health, are being constantly transmitted from 
the periphery to the higher nerve-centres of the brain. 
Dementia is characterized by imperfect responsiveness 
to external impressions. It is difficult to arouse and 
interest such patients. They care little for their sur- 
roundings ; they eat and sleep, but their energy seems 
lost. They lie or stand around in a listless way, and 
oftentimes it is necessary to speak to them in a louder 
voice in order to attract their attention. 
Impaired nervous sensibility is attended with imperfect 
motor reaction, probably for the reason that the afferent * 
and efferent tracts do not transmit impulses to and from 
the brain as readily as in health, and also because the 
brain-cells themselves are less sensitive. Those regions 
which, in health are most responsive to this excitation 
are very apt to be the first to become affected in diseases 
of the central nervous system. For this reason the face, 
in the earliest stages of dementia, begins to show evi- 
Fig. 339.-Case LIV. Chronic Mania. Showing exaltation, fantastic 
decoration, etc. (From photograph taken by author.) 
in the etiology of the physical expression of insanity. 
A recognition of its existence in any case frequently en- 
ables the physician to make a correct diagnosis and 
prognosis of the mental disease affecting the patient. In 
nearly all forms of chronic insanity accompanied by 
mental enfeeblement, deficient nerve-muscular activity 
corresponds to the degree of mental impairment. 
Dementia is the sad termination of all chronic, as well 
as of many of the acute, insanities. The degree of the 
dementia varies with individuals, and no definite rule 
can be given which will indicate just how rapidly or to 
what extent mental weakness will advance in any par- 
ticular case. 
Sometimes the impairment of mind is very slight, the 
individual not being incapacitated from living at home 
and enjoying a fair amount of personal liberty, and per- 
forming many acts of life fairly well. Again, the deteri- 
oration of mind is such that the patient is incapable of sus- 
taining the responsibilities of life outside an asylum, and 
yet is made very comfortable by the regularity, intelli- 
gence, supervision, and mild restraint of the hospital. 
Indeed, under careful direction, such patients come to 
be capable of performing a certain amount of fairly 
skilled labor. In still other cases, however, the mental 
impairment has advanced so far that not only is the hos- 
pital the only proper and safe residence for the patient, 
but his entire life in such an institution is helpless and 
unproductive. He becomes a veritable wreck in which 
only the slightest semblances of mind can be detected, 
nearly all the acts of whose life have become purely 
automatic and vegetative. 
521 Insanity. 
Insanity. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
deuces of impaired innervation. The lines about the eyes, 
the forehead, and the mouth, which were formerly well 
defined and which represented the healthy muscular to- 
nicity already referred to, begin to lose their precision 
and appear to be smoothed out. The peculiar pose of 
the features, due, as we have seen, to the continuous 
transmission of nervous force along the various efferent 
nerve-tracts to the muscular periphery, and which gives 
what we call character to each individual countenance, 
seems to have lost its definiteness. As a result the face 
begins to lose its expression, and in the very earliest 
stages of the disease constitutes a painful symptom for 
the friends to behold, and leads the physician to make a 
grave diagnosis and prognosis. 
This defective nerve-muscular activity, which is first 
manifested in the faces of demented patients, in time ex- 
tends to the larger muscles of the extremities. Demented 
patients become clumsy, and if good mechanics, gradually 
lose the muscular precision whicii formerly characterized 
their work. Quite frequently such individuals are obliged 
to give up a certain line of skilled labor in which they 
formerly excelled, and undertake a less exacting branch 
of the work, or renounce it entirely before it becomes 
fully apparent that their mental health is being serious- 
ly undermined. At a still later stage of the disease the 
muscles of locomotion become impaired, and the patient 
grows clumsy in gait. 
In the wards for demented patients in a large asylum, 
one is struck with the slow, lumbering gait of the patients, 
with their lifeless attitudes and the general absence of 
healthy muscular activity which is evident on every 
side. A party of demented persons is easily recogniza- 
ble at a distance. Their muscles, like their clothing, 
seem to hang, and there is none of that elasticity of move- 
ment characteristic of health. 
This progressive muscular failure is quite noticeable 
in the cases of terminal dementia, which constitute so 
large a proportion of the population of public hospitals 
for the insane. Oftentimes these patients are under ob- 
servation for years. In the earlier stages of their asylum 
residence they are capable of performing much manual 
labor. Gradually, as their dementia advances, they be- 
come less capable of sustained work ; they may grow 
fleshy, but their muscles become weaker and more unre- 
liable ; and finally they cease to be efficient workers, and 
spend their time in the ward or on the grounds, lying 
and lounging about in a listless way. In these cases 
there is a real failure in nerve-muscular force, which is 
represented by an inability to enter into mechanical em- 
ployment, as was formerly their wont. 
In cases of structural brain disease the order in which 
failure of muscular innervation occurs is quite interest- 
ing, and has already been referred to. First the muscles 
about the mouth begin to show weakness; then those 
about the forehead and between the eyes ; later, the ar- 
ticulation begins to fail and to grow more thick and 
indistinct; and the muscles of deglutition respond so 
feebly to innervation that the act of swallowing is ren- 
dered clumsy and difficult, and the patient is in danger 
of choking. Finally, the larger muscles of the extremi- 
ties begin to weaken ; the drooping head, shoulders, and 
arms, and the shuffling, clumsy gait indicate the steady 
progress of the brain disease. 
Warner says : " In a strong and healthy man the head 
is held erect and symmetrical, unless some central con- 
dition or external agent changes the posture. In a strong 
man the centre of the forehead is in the mid-plane of the 
body, the antero-posterior and the transverse axes are 
horizontal, with both eyes on the same level; this is a 
normal position of quiescence " ("Physical Expression," 
International Scientific Series, p. 185). 
In cases of progressive dementia, in the advancing 
stages of paresis, this failure of innervation is quite com- 
monly seen in the drooping of the head. 
In many cases the lower jaw drops on account of re- 
laxation in those muscles which support it ; this gives to 
the face an elongated expression, and quite frequently oc- 
casions the open, stupid-looking mouth so often seen in 
dementia (Fig. 340). 
(SUPPLEMENT.) 
Defective innervation, as we have seen, finally extends 
to all the muscles, and produces that peculiar drooping of 
the body, shoulders, arms, and even fingers, and that 
almost indescribable, but when once seen never-to-be-for- 
gotten, clumsiness of gait and attitude so characteristic 
of demented patients. 
III. Physical Expression of the Insane, Caused by or 
Representing States of Automatic Cell-activity in the Cere- 
brum, Occurring not Infrequently in Acute Insanity, and 
Quite Constantly in the Chronic Forms of the Disease.- 
The subject of automatic nerve-activity is so well under- 
stopd that any extended allusion to it would be super- 
fluous. It has been a matter of frequent physiologi- 
cal observation, that all nerve-structure manifests a 
tendency toward automatic activity. This attribute in- 
herent in nerve- 
tissue is notice- 
able in the low- 
est forms of 
animal life pos- 
sessing only the 
simplest and 
most rudiment- 
ary suggest ion 
of a nervous sys- 
tem. The ascid- 
i a n illustrates 
the peculiar me- 
dian ical and 
automatic 
action of a very 
simple organism 
that is wholly 
unprovided 
with anything 
like conscious- 
ness. In this 
animal crude, 
imperfect sensa- 
tions are trans- 
mitted from its 
periphery 
through afferent 
nerve-fibres to a 
solitary ganglion ; a motor impulse is thus originated in 
the ganglion, and, being reflected outward to the muscu- 
lar fibres of the animal's outer sac and orifices, produces 
in these parts a simple contractile movement. This sim- 
ple movement is entirely involuntary and reflex, and, 
upon the presentation of the proper stimulus, is always 
repeated in identically the same way, during the life of 
the ascidian. 
As we ascend the scale of animal life the nervous sys- 
tem becomes more complicated ; entire regions are spec- 
ialized, one part becoming subordinate to another until 
we reach man, in whom the completest subdivision and 
specialization has been attained. In him the higher cen- 
tres in the anterior cerebral region preside over the nerve- 
structures below, both in the brain and cord. But these 
more highly specialized centres of the human brain man- 
ifest the same tendency to automatic and mechanical 
activity. 
In one respect, however, man differs from other forms 
of animal life. His will-power presides over and directs 
those various processes which in the lower animals are 
not only automatic and instinctive, but are largely invol- 
untary. In man a few of the activities of organic life- 
such as respiration, the beating of the heart, and the 
like-are transmitted at birth fully established and are 
entirely independent of the will. Other processes, such 
as walking, writing, etc., are acquired after a most care- 
ful direction of the will and laborious practice, and then 
become automatic. Still other higher processes, such as 
the psycho-intellectual activities of the individual, while 
under the guidance of the will, conform to the universal 
law of automaticity. Thought runs in certain well-es- 
tablished channels, and "mechanism in thought and 
morals " is as susceptible of proof as the mechanical 
action of the heart or the lungs during the processes of 
Fig. 340.-Case of Progressive Dementia. Drop- 
ping of lower jaw on account of relaxation 
of the muscles which support it. (From 
KirchofFs Handbook.) 
522 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Insanity. 
Insanity. 
circulation and respiration-the only difference being that 
volition directs these intellectual and acquired activities. 
A high volitional power, therefore, distinguishes man 
from the lower animals. Even the most highly devel- 
oped of these lower orders possess limited volitional 
powers. In them life is largely automatic, and distinct 
purposive direction of their actions is slight. Many of 
their acts that seem to display a high degree of intelli- 
gence and to suggest the power of voluntary selection, 
prove, on close examination, to be merely the result of 
an unreasoning instinct which would not have admitted 
of any other course. In man, on the contrary, while his 
daily life is largely made up of various automatic activ- 
ities, still the range of purposive selection is large, so that 
the " mechanism of thought and feeling '' is made to serve 
the best interest of the individual through the guidance 
of the will. 
In some way, at present obscurely understood, will- 
power and functional activity of the cortex are mutually 
interdependent. Hence disturbance of these centres in 
insanity, caused by impaired nutrition, defective func- 
tional activity, or more gross structural lesions, weakens 
the will-pow'er of the individual. The functional activity 
of the cortical centres may be completely disarranged by 
insanity, and, as a result, the normal exercise of the will 
may be disturbed, if not entirely suspended. At the same 
time, however, the activities of the basal ganglia, no lon- 
ger under the guiding and controlling influences of the 
cortical centres, continue automatically. As a result, 
purposeless thought and action of an automatic character 
is quite apt to follow those serious disturbances of the 
higher cerebral centres during attacks of severe acute and 
chronic insanity. 
Automatic activity of the cerebral centres in health is 
subject to the direction of the will, and its results display 
purpose. Automatic activity of these same centres in 
disease of the mind seems to be less under the guidance 
of the will, and the resulting action appears purposeless. 
In proportion as the will-power is weakened by the brain 
disease, do meaningless automatic activities of thought 
and action prevail. 
In passing through the wards for the chronic and de- 
mented insane, one is struck with the evidences on every 
side of automatic activity. Here you will notice a man 
walking backward and forward in a mechanical way for 
hours together, until he has worn a beaten path in the 
floor ; there will stand one who picks away at a certain 
place on his clothing for an indefinite period, until he has 
worn the garment through to the skin. Quite frequently 
one will hear curious meaningless noises repeated in a 
mechanical way-singular repetitions of certain words or 
sentences wholly meaningless. It is not an uncommon 
thing for chronic patients to have some peculiar word or 
phrase, or even a single articulate sound, and to repeat it 
in an irrelevant way for years. In like manner you will 
meet with patients who make strange motions with the 
arras and hands, and take singular attitudes in a mechan- 
ical way. It is difficult to arouse the attention of such 
patients ; their monotonous repetition of words and move- 
ments continues just the same, regardless of the presence 
of others, and with little reference to any attempts made 
for their diversion. All this variety of automatic action 
and speech would seem to indicate that the healthy func- 
tional activity of the higher cerebral centres has been 
disturbed anil partially suspended, and that the lower 
centres are acting mechanically and without the normal 
volitional control. 
Prolonged automatic activity in thought, speech, and 
action, among the insane, suggests a serious lesion in the 
higher brain. The more mechanical and purposeless the 
words and acts of the patient, the graver is the prognosis. 
The nervous system manifests a striking tendency to 
mechanical repetition of any process once initiated within 
its centres. One epileptic attack is likely to be followed 
by another, and a number of seizures renders the pros- 
pect of still others quite certain, until in a short time the 
disease becomes firmly established. Both mania and 
melancholia manifest tendencies to repetitions of the 
attack, and each new attack renders the probability of 
(SUPPLEMENT.) 
another quite certain, until recurrency or permanent in- 
sanity is established. 
In the advanced stages of fevers, such as typhoid and 
scarlatina, the higher functions of the mind are often 
suspended, either from exhaustion, or because the cortical 
centres have been disturbed by the severity of the febrile 
action. In these grave physical conditions the automatic 
and purposeless repetition of words and muscular move- 
ments becomes quite noticeable. Subsultus tendinum, 
carphologia, tiresome utterance of some particular sound 
or word, indicate that the higher cerebral functions have 
been suspended, and that the lower centres are acting at 
random and without the direction of the former. In this 
case the prognosis is grave because the vital forces them- 
selves are waning and volitional activity is suspended 
through exhaustion of the cortical centres. 
In chronic insanity the prognosis as to mental recovery 
of the patient may be equally grave, for the reason that 
healthy functional activity of the cortex has been per- 
manently disturbed by the disease, which, though not 
necessarily fatal to life, is most assuredly so to mental res- 
toration. 
For the reasons just outlined the chronic insane are 
very likely to develop objectionable habits. The study 
of the physiological origin of many of the habits of this 
class of the insane would be most interesting and instruc- 
tive. Two laws underlie every form of nervous activity, 
and furnish a physiological reason for the constant ten- 
dency toward automatic and habit action exhibited by 
the chronic insane in whom inhibitory impairment al- 
ways exists. 1. The discharge of the nerve-centres oc- 
curs along those tracts which offer the least resistance. 
2. The more frequently the discharge occurs along a 
given line, and the weaker the inhibitory resistance, the 
easier does a repetition of the discharge become, and the 
more certain its permanent automatic establishment. 
If, for any reason, in those conditions of mental dis- 
ease characterized by a weakening of the will-power, one 
especial route is established either by reason of delusion, 
or mere fortuitous circumstance, the probability is that 
this particular route will continue to be the one most 
frequently traversed by nervous force in its passage from 
the brain to the periphery. A delusion, an hallucina- 
tion of sight or hearing, some peculiar condition in the 
patient's environment may have first initiated certain ac- 
tions which, by being unresisted, and hence repeated, lead 
to the establishment of a habit. Probably in some such 
simple and purely fortuitous way are developed the pull- 
ing out of the hair, tearing the clothing, walking in a 
beaten path, making singular motions or uttering mean- 
ingless sounds-in fact any of the countless strange habits 
of the insane. It matters little whether the performance 
of these habits is painful or disagreeable, no other alterna- 
tive seems open to the patient when, through weakness 
of will and intelligence, the morbid route has once been 
established. Some morbid sensation in the scalp or chin 
to act as an excitor, or merely the absence of anything of 
an intelligent character to engage the attention, may lead 
to the plucking out of the hair or beard, which impulse, 
meeting with no resistance, soon develops into a per- 
sistent habit. A delusion about the bed may lead the 
patient into the habit of standing up all night, and if not 
interrupted, nothing short of restraint will prevent ex- 
haustion, so persistent will the impulse become to remain 
on the feet. 
The importance of the early breaking up of bad habits 
among the insane will be readily understood. Fortu- 
nately the same tendency to automaticity of action may 
be utilized in a good as well as a bad direction. By care- 
ful supervision we may succeed in breaking up many 
useless and vicious habits by supplying some simple me- 
chanical occupation for the hands, thereby utilizing the 
automatic nerve - activity characteristic of the disease. 
And in doing this we may even seem to retard mental 
deterioration. Judiciously selected, mechanical employ- 
ment among the insane has become therefore a valuable 
means of treatment. 
It is quite obvious that photographic illustration of the 
entire subject of automatic nerve-activity is impossible, 
523 Insanity. 
Insanity. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
and yet enough in this direction may be shown to de- 
monstrate the important part played by morbid automatic 
cell-activity in the physical expression of chronic insanity, 
and, to a certain extent, in some forms of acute aliena- 
tion. It is evident that illustration of this part of the 
subject must be limited to postures. The significance of 
postures in health has been referred to by Dr. Francis 
Warner in an article on " Muscular Movements in Man," 
in the April number, 1889, of the Journal of Mental 
Science. He says : " Postures depend upon the ratios of 
nerve-muscular action, and to some extent they indicate 
the present ratios of static efferent force proceeding from 
the centres concerned. Observations show that the post- 
ures, when not due to a present stimulus, or when pro- 
duced by a weak stimulus from without, such as a sound 
or sight, correspond to and are signs of the general con- 
dition of the central nerve-system." 
The postures maintained, oftentimes for long periods, 
by the insane possess a special interest because they are a 
pretty sure index of the morbid condition of the central 
organ of innervation. 
Cases LI., LVIII., and LX., illustrate peculiar and 
somewhat painful attitudes which were taken by patients 
suffering from secondary or terminal dementia. And in 
Case LXV. is seen a singular position maintained by a 
patient in a condition of stuporous melancholia. In these 
(SUPPLEMENT.) 
terial for physiological and psychological study. The 
careful investigation into the early development of me- 
chanical movements, attitudes, and meaningless habits 
among this class of patients, would amply repay the time 
and labor expended in this direction, and throw some 
Fig. 342.-Case LVIII. Chronic Dementia. Peculiar and uncomfort- 
able attitude maintained daily for years. Automatic nerve-muscular 
activity. (From photograph taken by author.) 
light on the processes of cerebration and their connection 
with muscular movements. 
The singular postures shown in the photographs of 
Cases LI., LVIIL, and LX., were gradually assumed by 
the patients while under the writer's care, and yet so very 
slowly were they initiated that they became fixed and 
habitual positions before any especial attention was called 
to the fact. In this way the real causes that led up to 
the final establishment of the habitual posture were lost 
sight of. From what was known of the patients, the im- 
pression would be readily formed that in Cases LVIIL 
and LX. delusions of suspicion or a dislike to seeing per- 
sons about, led to a habit of hiding the face, as is often 
witnessed among bashful and diffident children. As 
these particular patients became more demented, a posi- 
tion which was at first assumed as the result of an active 
delusion finally developed into a permanent habit, simply 
because nervous force, flowing along this route from 
centre to periphery for so long a time in obedience to 
impulses derived from morbid ideas, and meeting with 
little inhibition, continued to take this route long after 
active thinking had ceased. 
Fig. 341.-Case LXV. Melancholia with Stupor. Showing persistent 
morbid attitude maintained for hours. (From photograph taken by 
author.) 
and similar cases the intensely interesting question is al- 
ways suggested, how came such peculiar habits to be 
initiated? The wards for demented patients will present 
numerous cases of this character which will afford ma- 
524 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
I nsanity, 
Insanity. 
Another interesting fact concerning these strange atti- 
tudes assumed by these patients is, that they seem utterly 
oblivious to the discomfort and even the painfulness of 
these constrained positions. Cases LI. and LX. would 
maintain the posture for hours ; and Case LVIIL, from 
(SUPPLEMENT.) 
Schack, with earnest enthusiasm, says : "The eye is 
the most immediate and most delicate point of transition 
between body and soul; it is the most interesting and 
most spiritueUe part of the physiognomy, and has been 
rightly called the mirror of the mind. Brilliant or dull, 
it contains remembrances of the past and enables us to 
prophesy of the future. Joy gives it clearness, sadness 
and grief fill it with shadow ; it speaks a language which 
sympathy understands at once without the aid of words 
or a dictionary" (" The Physiognomy in Man and Ani- 
mals," p. 76). 
In speaking of the expression of the eye physiogno- 
mists generally allude to the eyebrows, the eyelids, and 
those parts immediately surrounding the organ as well 
as the eyeball itself. Indeed, it would be difficult to do 
otherwise, so intimately associated are the muscular 
movements of these various parts, and so actively do they 
all enter into what is commonly called the expression of 
the eye. Schack, in an interesting chapter on the eye, 
gives several pictorial illustrations which are intended to 
represent that organ in the varions states of joy, anger, 
revenge, shame, and so forth. In these sketches it is 
noticeable, however, that the expression owes its indi- 
viduality, in nearly every instance, to the position of the 
Fig. 343.-Case LI. Chronic Dementia. Showing peculiar and uncomfort- 
able attitude assumed by demented person as a result of morbid and per- 
sistent nerve-muscular activity. (From photograph taken by author.) 
the hour of rising until bed-time, was continually in the 
attitude shown in the photograph. The muscles con- 
cerned in the maintenance of these postures were in a 
high state of tension, showing that a certain amount of 
" static efferent force " was being transmitted continuously 
from the centres within the sensorium to the periphery 
over these morbidly pre-established routes. Nearly all 
the other healthy activities of mind seemed in these cases 
to have ceased with the exception of the mere processes 
of organic life, and the entire energy of the sensorium 
was expended in keeping up these automatic and useless 
positions. Any attempt to move the arms into a more 
easy position was met by firm resistance, which was not 
spasmodic but persistent in character. That these atti- 
tudes would be painful to a person in health, anyone can 
demonstrate by attempting to maintain similar positions 
for even a few minutes at a time. 
There remain for consideration the various positions 
and expressions of the eye as modified by insanity. 
These, though largely dependent upon the different 
pathological conditions already discussed, still are de- 
serving of separate mention. 
Every writer upon physiognomy gives great prominence 
to the eye as an agent in expression. Bell, in his "Anat- 
omy of Expression,'' has said : "The eye is the most 
lively feature in the countenance ; the first of our senses 
to awake, and the last to cease motion. It is indicative 
of the higher and holier emotions, of all those feelings 
which distinguish man from the brutes" (Ibid., p. 94). 
Fig. 344.-Case LX. Chronic Dementia. Uncomfortable attitude main- 
tained for a long period. Automatic nerve-muscular activity. (From 
photograph taken by author.) 
parts about the eye as much as to any particular change 
in the organ itself. 
In a limited way, however, the eye itself entirely dis- 
sociated from surrounding parts, is subject to certain 
525 Insanity. 
Insanity. 
DEFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
changes which modify its expression. In studying the 
eyes of the insane it is proposed to limit our observation 
to these very changes, the muscular movements of ad- 
jacent parts having already received discussion in pre- 
vious sections. 
Three conditions modify the expression of the eye : 
I. The state of the iris. 
II. The degree of brilliancy of the organ. 
III. The position of the eyeball in its socket and its 
mobility. 
I. The state of the iris may be either one of contrac- 
tion or dilatation. Neither of these, however, plays any 
prominent part in modifying the expression of the indi- 
vidual. 
II. The degree of brilliancy of the organ exerts a 
wider influence upon expression, and variations from ex- 
treme dulness to remarkable lustre are of frequent oc- 
currence in the different phases of insanity. This qual- 
ity of brilliancy is quite characteristic of the eye in states 
of health, and has been alluded to by Darwin, Mante- 
gazza, Schack, and others. Its physiological causation 
is of much interest and has been variouly explained by 
different authors. Darwin says : "A bright and spark- 
ing eye is as characteristic of a placid or amused state of 
mind, as is the retraction of the corners of the mouth 
and upper lip with the wrinkles thus produced. Even 
the eyes of microcephalous idiots, who are so degraded 
that they never learn to speak, brighten slightly when 
they are pleased. Under extreme laughter the eyes are 
too much suffused with tears to sparkle ; but the moisture 
squeezed out of the glands during moderate laughter or 
smiling may aid in giving them lustre ; though this must 
be of altogether subordinate importance, as they become 
dull from grief, though they are then often moist. Their 
brightness seems to be chiefly due to their tenseness, owing 
to the contraction of the orbicular muscles and to the 
pressure of the raised cheeks. But according to Dr. 
Piderit, who has discussed this point more fully than any 
other writer, the tenseness may be largely attributed to 
the eyeballs becoming filled with blood and other fluids, 
from the acceleration of the circulation consequent on 
excitement of pleasure. He remarks on the contrast in 
the appearance of the eyes of a hectic patient with a 
rapid circulation, and of a man suffering from cholera 
with almost all the fluids of his body drained from him. 
Any cause which lowers the circulation deadens the eye. 
I remember seeing a man utterly prostrated by prolonged 
and severe exertion during a very hot day, and a by- 
stander compared his eyes to those of a boiled codfish " 
(Darwin, " Expression of the Emotions in Man and Ani- 
mals," Am. Ed., p. 206). 
Schack, in describing the physiognomy of laughter, 
says : " The glance of the eye at the same time becomes 
shining and brilliant, a fact which is in part due to the 
increased secretion of the lachrymal gland, and probably 
also to the inner tension of the eyeball which is the re- 
sult of the increase of circulation under the influence of 
pleasure" (Schack, ibid., p. 126). 
Mantegazza says with great truth: " The eyes have a 
remarkable brilliancy which goes far toward modifying 
the expression. The eye of one who laughs, of one who 
thinks or speaks with energy, is very brilliant; the eye of 
a stupid, feeble, or sick man has little brilliancy ; while 
the eye of one who is moribund seems to be almost ex- 
tinguished. This brilliancy deserves an attentive exam- 
ination, for it is one of the most important and obscure 
elements that enter into the study of the eye. For the 
moment we ought to content ourselves with saying that 
this condition depends in part upon the structure of the 
cornea, upon its variable convexity under the influence 
of the ocular muscles, upon the humors secreted by the 
eye, and especially upon the veil of tears which bathes 
its entire outer surface" (Mantegazza, ibid., p. 36). 
And again the same author says : " Popular opinion 
attributes a lively eye to the man of genius, and a dull 
eye to the stupid man. In fact, in the former a continu- 
ous discharge of nerve-energy is being liberated from the 
central nervous system which finds an abundant outlet 
in the numerous muscles of the eye; hence the move- 
ments and oscillations of these muscles, hence also the 
veil of tears which renders the eye brilliant" (Mante- 
gazza, ibid., p. 245). 
These different physiological reasons for varying brill- 
iancy of the eye under corresponding emotional and in- 
tellectual states, find interesting illustration and confir- 
mation in the eyes of the insane. Among the insane, as 
in no other class, there exist in full force the very condi- 
tions noted by the physiognomists whose views have just 
been quoted. Prominent among the factors that enter 
into the causation of a brilliant eye, none are more im- 
portant than the varying tenseness of the ocular muscles, 
due, as Mantegazza says, to the continuous discharge of 
nerve-energy along the efferent routes to these particular 
muscles. Varying degrees of convexity of the eyeball, 
caused by the alternate contraction and relaxation of the 
ocular muscles, produce variations in the refraction of 
light from its smooth surfaces, a fact which may in large 
measure account for the changes in brilliancy, assisted 
as it must be by the squeezing out of a greater or less 
amount of fluid from the lachrymal glands. 
These different degrees of muscle tension, varying as 
they do from the ordinary tonicity of health to extreme 
contraction and relaxation, are, as has been seen, of com- 
mon occurrence in the different types and stages of 
mental disease. Variations in the brilliancy of the eye 
among the insane would seem, therefore, to find one very 
natural explanation in the different degrees of efferent 
nerve-muscular activity, so commonly witnessed in this 
disease, and which is distributed to the ocular in common 
with all other muscles, causing thereby varying degrees 
of tension and convexity of the eyeball, and correspond- 
ing variations in the refraction of light from its surface. 
Another cause assigned for increased brilliancy of the 
eye is that given by Piderit, and referred to by Darwin 
in the quotation given above, namely, an acceleration of 
the circulation consequent upon emotional excitement. 
Nearly all conditions of increased cerebral circulation are 
followed by a peculiar brilliancy of the eye. On the con- 
trary, a slow and depressed circulation is followed by a 
dull and lustreless eye. Even in conditions of depraved 
physical health, provided the circulation is more rapid, 
the eye assumes a brighter aspect. We see this in the 
later stages of phthisis, where, as a compensation for the 
loss of aerating surface within the lung, the heart is 
urged on to greater frequency and impels the blood more 
rapidly through the arteries ; and by reason of this 
heightened circulation, the eyes of such patients assume 
oftentimes an almost unnatural brilliancy. By reason of 
increased cerebral circulation it may also be quite likely 
that the eye of acute mania assumes its brilliancy, while 
in the slow circulation of melancholia and dementia just 
the reverse obtains. 
We may conclude, then, that changes in the brilliancy 
of the eye may be due to either one or both of the two 
causes mentioned : varying tension of the eyeball caused 
by the transmission of nerve-muscular force from the 
nervous centres to the ocular muscles, or the presence of 
a greater or less amount of fluid within the transparent 
media of the eye as a result of increased flow of blood 
in that region. Either or both of these causes may ac- 
count for variations in brilliancy noticeable in different 
forms of mental disease. 
Unfortunately, this important element in the expression 
of the insane does not admit of satisfactory illustration, 
the flash of light from the eye being of too fleeting and 
evanescent a character to be caught and retained by the 
sensitive plate in the camera. In a general way, every 
form of insanity which is attended by increased nervous 
activity, with or without more rapid heart-action, is 
characterized by brilliancy of the eye. The eye of de- 
mentia, of melancholia, of the depressed stage of folie cir- 
culaire, is dull and lacking in brilliancy ; the eye of acute 
mania, of the exhilarated stage of folie circulaire, and of 
those acutely maniacal conditions frequently witnessed 
in paresis, is brilliant and glistening. 
Striking illustrations of a change from brilliancy to 
dulness are often very noticeable in different stages of 
the disease in the same individual, although it is ex- 
526 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Insanity. 
Insanity. 
tremely difficult to get a satisfactory portrait illustrating 
such change. 
III. The position of the eyeball in its orbit, and its mo- 
bility. The position of the eyeball in the orbit is a very 
prominent factor in facial expression. Six small muscles 
guide the eye in various directions. Four of these mus- 
cles, the recti, are under the influence of the will, and 
during our waking hours are in almost constant activity. 
They conjointly balance each other and maintain that 
slight convergence of the eyes which Darwin says is nec- 
essary in binocular vision. The two oblique muscles are 
involuntary in character and apparently serve a double 
purpose. They rotate the eyeball on its antero-poste- 
rior axis-"this kind of movement being required," as 
Gray says, "for the correct viewing of an object when 
the head is moved laterally, as from shoulder to shoul- 
der, in order that the picture may fall in all respects on 
the same part of the retina of each eye." The oblique 
muscles also serve the purpose of rolling the eyeball up- 
ward under the lid. The recti being voluntary muscles, 
their action ceases during sleep and in states of deep un- 
consciousness, and then the oblique muscles, meeting with 
no counteracting influences, roll the eyeball upward. Sir 
Charles Bell called attention to this interesting action of 
the oblique muscles, which is undoubtedly intended to 
protect the delicate surface of the cornea from being ex- 
posed, in case the lids remained partially opened during 
states of unconsciousness. 
Between the extreme condition of entire relaxation, oc- 
curring in states of sleep and unconsciousness, and the 
varying degrees of tension necessary to the direction of 
the eyes during the waking hours, the recti undergo a 
certain relaxation corresponding to the state of the faculty 
of attention. 
In health the faculty of attention is in nearly continu- 
ous activity. During the waking hours some person or 
some thing near or remote is, by this act of attention, be- 
ing made an object of vision. Except in moments of in- 
trospection or reverie the sensorium is, by the guidance 
of tlie attention, being brought in contact with the en- 
vironment through the sense of sight. For this reason 
the eyes are kept in a state of gentle convergence-such 
a position being necessary to binocular vision. The 
least withdrawal of the attention from any object in the 
immediate or remote environment is at once followed by 
a partial relaxation of the recti muscles, and as a result 
the eyes slightly depart from their condition of conver- 
gence and appear to be directed forward, or in nearly 
parallel or slightly divergent lines. This is the position 
of the eyes in states of reflection or absent-mindedness, 
which gives to the face a characteristic expression that 
receives a familiar and sometimes annoying illustration 
in every-day conversation. While conversing with a 
friend we are suddenly made aware, by a change in the 
position of his eyes, that be is not any longer looking at 
us, but apparently through or beyond us; and by this 
same parallelism of the eyes we are conscious that his at- 
tention has ceased to be interested in what we are saying 
and has become occupied with other things. 
As before remarked, impairment of this faculty of at- 
tention is one of the first results of insanity. Disordered 
inhibition associated with enfeeblement of the will-power 
leads to a positive weakening of the faculty. The mind 
of the insane patient is often entirely preoccupied. Mor- 
bid trains of thought, delusions of suspicion, fears, in- 
tense subjective ideation fill his mind, and, by reason of 
the inhibitory incapacity consequent upon the disease, 
these morbid psychic processes continue unchecked. As 
a result the recti muscles undergo relaxation, allowing the 
eyes to depart from that state of convergence which is 
the usual result of the normal exercise of the faculty of 
attention. 
Ocular parallelism or divergence, therefore, which fol- 
lows absent-mindedness in health and is then of mere tem- 
porary character, may become in many forms of insanity 
a prevailing condition, thereby forming a very striking 
feature in the facial expression of the disease. In such a 
condition of the eyes the person does not seem to take 
any interest in his environment. Oftentimes the eyes 
have a staring look, and in many forms of insanity all 
attempts at diversion are futile, the patient continuing to 
manifest that painfully stony and glaring aspect which 
show how intense is the mental absorption. Indeed, one 
of the first symptoms of insanity observed by the friends 
is this peculiar expression due to ocular parallelism. 
They often refer to a certain strange, unnatural, or wild 
appearance about the eyes which is undoubtedly brought 
about by the divergence due to almost constant morbid 
preoccupation of the attention. 
In the late John McCullough's masterly representation 
of the insanity of Virginius, or the feigned insanity of 
Brutus, one of the most striking features of his portrayal 
of the morbid mental condition was the apparent cen- 
tring of the eyes upon vacant space, rather than upon 
near objects. The idea was at once conveyed to the 
Fig. 345.-Case XLIX. Senile Dementia. Showing ocular divergence, 
neglect of personal appearance, general absence of healthy muscular 
tonicity. (From photograph taken by author.) 
spectator that the mind of the character represented was 
preoccupied with ideas entirely outside his environment. 
In the early stages of delusional insanity, in melancho- 
lia, in many conditions of mania, and in dementia, ocular 
parallelism is of frequent occurrence, either on account of 
the intense preoccupation of the mind with subjective 
ideas, or on account of absence of ideation, or, lastly, 
because ideas are so hurriedly brought up before the 
mind that the individual is unable to direct his atten- 
tion upon anything or anybody about him, and conver- 
gence, if it does occur, is merely momentary. In conclu- 
sion, it may be said that ocular parallelism or convergence 
among the insane represents, if persistent, the extent to 
which the faculty of attention is weakened by the disease. 
Thus the demented, in whom the power of attention has 
been almost entirely destroyed, nearly alw'ays presents a 
527 Insanity. 
Insanity. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
vacant, staring appearance of the eyes, and in extreme 
cases it becomes absolutely impossible to induce that con- 
vergence of the eyes characteristic of the healthy binoc- 
ular vision. The same is true of cases afflicted with 
melancholia attonita. From the extreme and persistent 
ocular parallelism noticeable in terminal and organic de- 
mentia and melancholia attonita there may occur all 
tention can be aroused momentarily. In Fig. 348, C and 
Fig. 349, D the change has become complete and the pa- 
tient takes an intelligent interest in his environment. 
This case recovered and retained perfect recollection of 
the fearful mental torture through which he passed. He 
was able to give an intelligent account of his ideas, and 
the reason for his vacant, preoccupied, divergent stare 
lay in the entire suspension of the faculty of attention to 
anything but his own morbid ideas, and a complete lack 
of interest in anything in his environment. 
Case XLII. (see page 519) shows ocular divergence in 
a state of acute mania. Here the cerebral activity is so 
persistent that ideas are hurried through the mind more 
rapidly than they can be grasped by the attention. The 
condition is exactly the reverse of what occurs in demen- 
tia. In dementia there is absence of ideas, while in 
mania there is such an excess of ideas that the attention 
is bewildered and paralyzed. So great is the mental 
confusion that the patient is incapacitated from taking 
any interest in his environment. The eyes of such pa- 
tients are rarely centred upon anything, and complete in- 
coherence of thought is manifested by the position of the 
eyes almost as much as by disordered speech and action. 
Cases of mild mania and delusional insanity very fre- 
quently present this condition of ocular divergence. 
Either the mind is confused with a number of irrelevant 
ideas and the attention is thus diverted, or some one per- 
sistent idea or series of ideas so completely absorbs the 
patient's attention that that faculty seems to be incapa- 
ble of being aroused by anything in the immediate en- 
vironment. 
The mobility of the eye in the orbit is quite a promi- 
nent factor in facial expression, and is subject to great 
variation in the different phases of insanity. The ner- 
vous supply to the muscles of the eye is abundant and is 
Fig. 346. Case XXXIII. Acute Suicidal Melancholia. A. Taken at 
height of attack. Trophic alterations, ocular divergence, and self-ab- 
sorption well marked. (From photograph taken by author.) 
varieties of the condition to those cases in which the fac- 
ulty of attention is so slightly disturbed by the mental 
disease that' the position of the eyes does not vary from 
that which is characteristic of health. 
Case XLIX. illustrates the fact that deficient ideation, 
accompanied with actual impairment of the faculty of 
attention, is attended with parallelism of the eyes or 
slight divergence. If one should stand directly in front 
of this individual he would find it almost impossible to 
place himself directly in the line of his vision. This pa- 
tient's position is very characteristic. He appears to be 
staring into vacancy, not because his mind is preoccupied 
with any particular line of thought, but rather on ac- 
count of absence of active thought of any kind. 
Cases XXXI. (see page 510) and XXXIII. (see page 
528) present ocular divergence in states of active melan- 
cholia. In these individuals the eyes depart from the 
normal convergence of health because the mind is so 
intensely preoccupied with some one dominant idea or 
class of ideas as to be actually incapable of being aroused 
or attracted. It is impossible to interest these unhappy 
minds in any subject. Either1 some one idea of painful 
character has excluded every other thought, or the corti- 
cal centres themselves have been so overwhelmed by 
the force and intensity of the morbid ideation as to be 
incapable of farther functional activity. These same 
cases are particularly interesting because in each of them 
we have excellent views both at the time of greatest mor- 
bid intensity and during perfect health. 
In XXXIII. the series show the gradual but steady 
progress of the mind toward recovery. In Fig. 346, A 
the eyes are fixed in a state of divergence. No amount of 
urging can prevail upon the person to awaken from bis 
intense painful preoccupation of mind. In Fig. 347, B 
there is evidently the beginning of an awakening-the at- 
Fig. 347.-Case XXXIII. B. Taken three monthslater. Self-absorption 
less marked. Delusions beginning to weaken. Health improving. 
(From photograph taken by author.) 
distributed through three main tracts : the motor oculi, 
the fourth nerve, and the sixth, or abducens. The dis- 
charge of nervous energy which is constantly taking 
place along the various efferent tracts during periods of 
cerebral activity, undoubtedly follows these three nerve- 
tracts to the muscles of the eye. Such an elimination of 
nerve-force is, as we have already noticed, one cause of 
the brilliant and glistening eye of mental activity. In 
528 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Insanity. 
Insanity. 
the active cerebral excitement consequent on attacks of 
mania a similar discharge of nervous energy passes along 
these same routes to the various eye-muscles. Not only 
are the eyes of the actively insane quite brilliant, they 
For this reason any collection of photographs of the insane 
presents a bizarre appearance. In acute mania, for in- 
stance, irregular and spasmodic action of the cortical 
centres produces meaningless expressions and asymmet- 
rical contractions of the facial muscles, noticeable in 
Case XLII. Fig. 337, A (see page 519). Here it may be 
supposed that the centres in the motor area act indepen- 
dently of each other, or that there is imperfect co-ordin- 
ation. One group of muscles are contracted, while the 
corresponding group upon the other side are relaxed. 
The usual bilateral contractions that occur in the normal 
facial expression of the emotions are absent in these 
cases (see Fig. 350). 
Among the demented insane organic degeneration of 
cortical areas produces a very similar result. This is il- 
lustrated in the strange attitudes and persistent meaning- 
less position of groups of muscles. In dementia it may 
be supposed that one group of cortical cells may have 
been destroyed by degenerative processes, and that co- 
ordinate action between cortical areas ordinarily associ- 
ated has thus become physically impossible. Again, in 
acute alcoholism the same kind of irregular and one- 
sided action of muscles occurs. And in this case there is 
good reason for sup- 
posing that the 
toxic influence of 
the drug has im- 
paired the normal 
activity of the cell 
to such a degree 
that there is a with- 
drawal of the sup- 
ply of nerve-force 
necessary to 
healthy muscular 
action. The alcohol 
in the cerebral cir- 
culation affects one 
group of cells more 
than another, or so 
impairs normal co- 
ordination that 
muscular move- 
ments are jerky and 
uncertain. Both 
the face and the 
gait of the intoxi- 
cated man disclose 
the asymmetrical 
and irregular action 
of the centres of the 
motor area. In the 
paretic, the organic 
changes that have 
occurred in the cor- 
tical cells are clear- 
ly revealed in the 
imperfect co-ordination of different groups of muscles, 
particularly those of the mouth, tongue, and throat. 
In studying the physical expression of insanity, one 
thing is worthy of note. Departure from normal expres- 
^ionkeeps pace with functional and organic disturbance 
in the cortex. The distortion and agitation of mania, the 
dissolution of expression witnessed in organic dementia, 
or in melancholia with stupor, correspond to extreme 
functional or structural disturbance in the cortical cen- 
tres. As inhibition, the power of attention, and intellec- 
tual activity depend upon the integrity of the cells in 
the cortical area, we may conclude that the changes in 
the physical expression of the insane are associated with 
certain" inhibitory and intellectual disturbances, accom- 
panied in the later stages with motor enfeeblement. 
These psychological concomitants of the physical expres- 
sion of insanity represent the pathological changes that 
have occurred in the cortex. Hence it happens that the 
expression differs in different cases of mental disease 
according to the degree of functional or structural im- 
pairment of the cortical area. Slight departure from 
normal expression is evident in Cases XII. (see page 515) 
Fig. 348.-Case XXXIII. C. taken two months after B. Convalescence 
established. Healthy ideation and restoration of physical health. 
(From photograph taken by author.-) 
also possess great mobility ; and rapid movements of the 
eye, giving to that organ a character of restlessness, are 
important factors in the facial expression of nearly every 
case of active insanity. 
This pathological transmission of nerve-force from the 
Fig. 350.-Onesided Contraction of the 
Facial Muscles of Expression. (From 
Kirchoff's Handbook.) 
Fig. 349.-Case XXXIII. D. Recovery. Taken at time ot discharge. 
(From photograph taken by author.) 
cerebral centres to the muscular periphery, which has 
been referred to in the previous pages as excessive, defi- 
cient, or automatic in character, leads to a certain asymme- 
try of the muscles, particularly noticeable in the face. 
529 Insanity. 
Intestinal Diseases. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
and LIV. (see page 521), notwithstanding that the patients 
are affected with marked delusional insanity ; on the 
other hand, in Cases XLII. A (see page 519), LXV. (see 
page 524), XXXIX. (see page 518), and in the woman 
shown in Fig. 351, there is great disturbance, and even 
distortion of expression in some instances. The ex- 
planation of the difference in the character of the ex- 
pression in the two classes of cases may be found in 
the varying 
character of the 
functional d i s - 
turbance in the 
cerebrum. I n 
Cases XLII. A, 
LXV., etc., nor- 
mal intellectual 
activity is inter- 
fered with, inhi- 
bition is dimin- 
ished, and the 
power of atten- 
tion so tempo- 
rarily or perma- 
nently damaged 
as to be nearly 
useless; while in 
Cases XII. and 
LIV. the inhib- 
itory and intel- 
lectual processes 
are quite well 
preserved, not- 
withstanding 
the fact that 
there is marked 
delusional in- 
sanity. Case XII. could sit for his photograph with 
as much ease and confidence as any sane person, ow- 
ing to the preservation of inhibitory power and the 
ability to concentrate his attention upon his immediate 
environment. Case XLII., on the other hand, owing 
to his motor restlessness and his intellectual incoher- 
ence, was entirely unable to sit intelligently for his por- 
trait, and a likeness was only secured by the aid of in- 
stantaneous pho- 
tography. The 
greatest diver- 
sity of physical 
expression is 
encountered, 
therefore, 
among the in- 
sane. Many 
very natural and 
intelligent coun- 
tenances are no- 
ticeable in the 
extremely d e - 
hided, simply 
because the 
functional corti- 
cal activities un- 
derlying inhibi- 
tion, attention, 
and ordinary 
intellection have 
not been im- 
paired. 
In conclusion, 
it may be said 
that the study 
of the physical 
expression of the insane by the aid of instantaneous 
photography is a matter of much interest to the psychol- 
ogist, indeed may become a valuable aid to diagnosis 
and prognosis. A series of photographs illustrating an 
individual in different stages of mental alienation gives 
a good illustration of changes that have taken place in 
the central nervous system. Every hospital for the in- 
(SUPPLEMENT.) 
sane should possess a photographic outfit and preserve 
pictures illustrating the individual in various stages of 
his disease. The slow but steady disintegration of ex- 
pression preserved in the photograph will become an 
accurate index of the organic failure that has occurred 
in the brain. On the other hand, the return of normal 
muscular tonicity, of natural expression as evidenced in 
the trophic condition and normal motor activities of the 
muscles of the face and extremities, is an equally sure in- 
dex of the reparative processes that have occurred in the 
central nervous system. It may not be too visionary to 
suppose that a careful study of photographs, taken at dif- 
ferent periods in the life of an individual whose case has 
come before the courts, may prove to be of medico-legal 
importance, and give the medical expert valuable assist- 
ance in comparing the past with the present mental and 
moral status of the case. Charles P. Bancroft. 
INTESTINAL DISEASES: DYSENTERY. In the light 
of recent investigation the word "Dysentery'' has but 
little right to occupy a place at the head of this article. 
Originally used to express a certain set of symptoms, 
which differed entirely from those included under the 
term " Diarrhoea," it now covers pathological states which 
differ very much in nature and extent, and does not de- 
fine varieties which are unlike anatomically and etiologi- 
cally. The so-called dysenteric lesions may have diar- 
rhoea as a symptom, and simple catarrhal changes in the 
mucous membrane may be attended by tormina, tenes- 
mus, and dysenteric stools. 
The symptoms vary to such an extent that they can- 
not be made a basis for study; pathological changes 
and etiology will alone help us to define the nature of 
the different forms, and a new nomenclature must be 
based upon new methods of investigation. 
Nevertheless the w'ord dysentery is still used to indi- 
cate certain pathological changes which occur in the in- 
testine from various causes ; it even includes a condition 
proven to be due to a specific cause with characteristic 
anatomical changes, as well as other special ulcerative 
changes which may be dependent upon bacilli not yet 
isolated. 
In the present state of our knowledge the conditions 
formerly included under our term "Dysentery" can be 
differentiated into-a, simple catarrhal dysentery ; b, 
diphtheritic dysentery ; c, amoebic dysentery. 
Catarrhal Dysentery.-In the milder cases of this 
form there may be no change beyond a more or less in- 
tense hyperaemia of the mucous membrane occupying 
areas of varying extent. Punctiform hemorrhages may 
be seen in the mucosa or submucosa. The mucous 
coat may be swollen and covered with much mucus and 
pus cells. The surface epithelium may be absent, and 
the exfoliation of epithelium may involve the glands. 
There may be destruction of the tissue of the mucous 
membrane ; shallow ulcers are seen, and are formed by 
extension of the superficial softening. Sometimes the 
ulcers extend to the muscular coat. In the submucosa, 
which is much thickened, there are masses of granula- 
tion and pus cells, and the connective - tissue cells are 
enormously swollen. The solitary follicles are swollen 
from hyperplasia of lymphatic tissue ; from distention 
they burst and an ulcer is formed. This form may un- 
dergo cure by an arrest of the disease and healing of the 
spots of ulceration, or the ulcers remain and show no 
tendency to heal. 
This form is frequently a complication of other and 
generally chronic diseases. It constitutes the most fre- 
quent form outside of the tropics, and is the one which 
we most frequently see as sporadic dysentery. 
The symptoms usually begin suddenly, sometimes 
with diarrhoeal discharges, or with "dysenteric" stools 
from the start. These consist of blood and mucus ; 
later, pus may be seen and the discharges may become 
more fluid and abundant. Tormina, rectal tenesmus, 
vesical tenesmus, prolapsus ani, with continued fever, 
constitute the chief symptoms. Improvement begins 
with a diminution in the number of the stools, the dis- 
appearance of blood and mucus, and the reappearance of 
Fig. 351.-Delusional Melancholia, with Ideas 
of Fear. (From Kirchoff's Handbook.) 
Fig. 352.-Delusional Melancholia, with Ideas 
of Fear. (From Kirchoff's Handbook.) 
530 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Insanity. 
Intestinal Diseases. 
fecal matter. The fever subsides and there is a return 
of appetite and strength. Relapses may occur. The 
duration is from one to two weeks in mild cases, but the 
attack may be prolonged to four weeks. 
Diphtheritic Dysentery. - Diphtheritic dysentery 
is so called because of the presence of a membrane on 
the surface of the mucous membrane of the large in- 
testine, and sometimes of the small intestine as well. 
This is composed partly of a fibrinous exudation, but is 
•chiefly necrotic tissue. 
The process is as follows : On the surface of the hy- 
persemic mucous membrane small, whitish-gray patches 
appear, which cannot be removed without causing a loss 
of substance. By coalescence large membranous areas 
are formed, which may completely line portions of the 
tubes, or the patches may continue distinct, small mem- 
branous patches being scattered over the surface. These 
•changes are most marked at the bends of the intestine. 
The intervening mucous membrane may be intensely 
hypersemic in the most acute cases ; in others it is un- 
changed. 
Microscopic examination shows the membrane to be 
composed of necrotic cells, nuclear detritus, and masses 
of fibrine, which involve the mucosa to varying depths. 
Between it and the healthy tissue there is a line of de- 
marcation formed of pus cells. In the submucous tissue 
there is intense injection. The vessels are dilated and 
surrounded by a zone of small-cell infiltration. Fibrine 
is sometimes exuded in the submucous tissue, having no 
•connection with the surface membrane. The pseudo- 
membrane is subsequently separated from the tissue be- 
low by suppuration, and is thrown off, leaving an ulcer- 
ated surface. The ulcers vary in size with the extent 
and depth of the necrosed tissue ; they may heal, or ex- 
udation and necrosis may go on, destroying deeper and 
larger areas and causing large and irregular ulcers. By 
healing, large and irregular cicatrices may form, and the 
wall of the intestine may be thickened and its lumen 
narrowed. Inflammation may extend to the peritoneum 
or perforation may result. 
This form of dysentery is the one usually found in epi- 
demics. The symptoms are more pronounced, and con- 
stitutional disturbance is more marked than in the 
preceding form. Fever of varying intensity is observed, 
with great prostration, abdominal pain, and frequent 
discharges. The stools at first may present the same 
characters as those in the catarrhal form, but later they 
become more watery, with membranous fragments, and 
at times large necrotic masses of putrid odor are passed, 
with or without tenesmus, depending upon the location 
of the ulceration. 
The bacteriological research in both catarrhal and 
diphtheritic dysentery is full of interest, though nothing 
positive can be stated as to any specific bacillus. In 
1869 Hallier observed a number of micrococci in dysen- 
teric discharges, which he claimed to have differentiated 
from the discharges of diarrhoea and healthy faeces. 
There are two species of bacteria present in the healthy 
intestine, viz., bacteriumlactis aerogeneus, which is usually 
found in the upper, and bacterium coli commune, found 
normally in the lower intestine. Councilman suggests 
that the part the bacterium coli commune plays in dysen- 
tery may be an important one. It is pathogenic in a 
number of the lower animals, and if the normal resist- 
ance of the tissues of the intestine is lessened from any 
of many causes, it may act in man as a pathogenic germ. 
It is found not only in the ulcerations, but it is also 
found to have penetrated the tissues. 
Booker, in a series of careful examinations upon a 
child which had died of dysentery, claims to have iso- 
lated a germ not found in the normal intestine or in 
diarrhoeal discharges. It resembles in morphology the 
bacterium lactis aerogeneus, but is smaller, and differs 
from it by producing fermentation in milk. The new 
bacterium was found in large quantities in the diseased 
part of the intestine, and was absent in the healthy part. 
In 1876 Normand, having made a microscopic exami- 
nation of the stools of soldiers returned from China with 
severe dysentery, discovered a parasite which he named 
"bacillus stercoralis." It is a fusiform germ of the ne- 
matode family, and very similar in appearance and size 
to the filaria of the human blood. This germ measured 
about one millimetre in length, and was thirty to forty 
micro millimetres broad, a little pointed in front and 
tapering to a point in the back. Normand, having first 
proven the constant presence of the germ in nearly all 
the cases of severe dysentery, did not hesitate to call it 
the specific agent of the disease ; but this idea was soon 
abandoned. 
Amiebic Dysentery.-The intestine is always con- 
siderably thickened, the submucous coat being consider- 
ably affected, though the other coats are involved to 
varying extents. This thickening is due not only to the 
oedematous condition, but there are sharply circum- 
scribed projecting nodules, in which are small cavities 
filled with a viscid gelatinous pus. The mucous mem- 
brane covering these cavities becomes necrosed and 
sloughs off, leaving irregular ulcers, which may connect 
with others by a sinuous tract, burrowed under appar- 
ently healthy mucous membrane. 
The submucous coat is generally infiltrated and oedem- 
atous ; it softens, and by necrosis of overhanging tissue 
ulcers, with undermined and ragged edges, are formed, 
which have the muscular coat for their base. The cel- 
lular infiltration extends through the upper layers of 
necrosed muscular tissue into the septa of the intermus- 
cular connective tissue and into the submucous coat. 
Destructive necrosis goes on in the tissues of the circu- 
lar muscular coat, and masses of it slough off and are 
passed by stool. The next step is great thickening of the 
adjacent peritoneum, which next becomes the seat of dis- 
integration ; adhesions form with neighboring viscera 
and with contiguous links of intestine. 
The mucous membrane at a distance from the seat of 
the acute process is not altered ; lower down, some of the 
glands are dilated and filled with mucus and pus cells, 
the epithelial cells are distended with mucus, and the 
epithelium everywhere contains an increased amount of 
mucus. By confluence of neighboring glands cysts are 
formed. Near the ulcers the glandular epithelium pro- 
liferates with bud-like projections into the tissue below. 
Lambl first saw amoebae in the intestinal contents in 
1849. In 1875 Losch, in examining microscopically the 
stools of a patient, twenty-four years of age, who was 
suffering wdth an ulcerative affection of the large intes- 
tine, discovered amoebae in great numbers, which he 
called " amibe du colon," or amoeba coli. Next, he in- 
jected these stools into the intestines of four dogs, one of 
which had vomiting and diarrhoea. The animals were 
then killed, the intestines were found to be inflamed, 
were covered with bloody mucus, and showed many 
ulcerations. The amoebae were found in the mucous 
membrane and in the ulcers. The parasite appeared as a 
protoplasmic mass and measured on an average twenty 
to fifty fi ; in motion and with their greatest elongation 
they reached over sixty f>. Their protoplasm is very 
granular and encloses six or eight round vacuoles. 
Koch, in 1883, found the amoeba in the intestines of 
those dying from dysentery. Kartulis attempted to prove 
that the amoebae played the principal role in the patho- 
genesis of dysentery. He also found them in other ulcer- 
ative affections of the intestine, viz., typhoid fever and 
tuberculosis. In certain complications of dysentery, and 
especially in abscess of the liver, Kartulis found the 
amoebae in the pus, associated nearly always with the 
ordinary microbes of suppuration. He did not believe 
that the parasite was pyogenic in itself, but that it only 
prepared the way for the microbes of suppuration. 
Osler, first in America, reported a case of abscess of the 
liver in the course of dysentery, in which he found the 
amoebae in large numbers. Much that we know of this 
form of dysentery is due to the work done in Johns Hop- 
kins Hospital by Osler, Councilman, and Lafleur, and we 
are indebted chiefly to the paper of Councilman (" Trans- 
actions of the American Association of Physicians, 
1892 ") for our knowledge of the pathological anatomy of 
amoebic dysentery. Dock afterward demonstrated the 
amoebae in a case of dysentery contracted in Texas. Vassi 
531 Intestinal Diseases. 
Intestinal Suture. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
has since found them in a case of abscess of liver; he 
found only a small number in the pus, but they were 
present in great numbers on the side of the abscess, also 
in some of the small branches of the portal vein. 
The constancy of the presence of the amoeba in the 
various manifestations of dysentery adds weight to their 
probable pathogenic influence. Massiutin has found 
these same parasites, with characters absolutely identical 
with those described by Kartulis, in other affections than 
dysentery (chronic intestinal catarrh, mucous diarrhoea, 
and acute enteritis), and on the strength of his researches 
he repudiates the idea held by Kartulis as to the speci- 
ficity of the amoeba as the parasite of that disease. In 
the meanwhile Kartulis is still experimenting, and his 
researches rather confirm his idea, though the results are 
not sufficiently proven to be assured. He has been able 
to produce a mucous and bloody diarrhoea by injecting 
the amceba cultures into the rectum of a cat. 
The amoebae are found in the submucous tissue around 
the ulcers; apparently they themselves produce few 
lesions in the mucous membrane, but they first attack 
the submucosa and the mucous membrane is affected 
from below. 
They are also found in the lymphatics and sometimes 
in the blood-vessels. The tissues in which they are seen 
are infiltrated with cells. There is no necrosis, and the 
neighboring connective-tissue cells sometimes lose their 
nuclei and the nuclei split. Most numerous in the 
smallest ulcers, when the process is most rapid and 
where there is no suppuration, they are scattered through 
the tissue or lead the advance of cell infiltration. 
Abscess of the liver was found in six out of eight autop- 
sies of amoebic dysentery (Councilman) ; in four cases, 
there was more than one abscess, and in two cases they 
were very numerous and small; in every case the right 
lobe was the seat of this change, and in two cases there 
were abscesses in the left lobe. In the smaller abscesses 
there was a small amount of glairy, semi-transparent 
fluid ; in the larger ones the contents were more fluid, of 
a grayish color, sometimes brownish-red, from admixt- 
ure with blood. A distinct limiting wall, sometimes 
dense and hard, is found in the larger abscesses, but it 
has not been seen in the smaller ones. 
The fluid of the smaller abscesses is composed of fatty, 
granular material, fragments of liver-cells, and pus or 
lymphoid cells ; that of the larger abscesses contained 
fat, red blood-corpuscles, fragments of liver cells, and 
very few pus cells. Amoebae were contained in both, 
but were more numerous in small and recent abscesses. 
Other changes in the liver consist in extensive necrosis 
in the centre of the lobules, the capillaries and necrotic 
cells containing numerous leucocytes ; but amoebae are 
not associated with the necrotic process ; they are only 
found in association with the abscesses. 
Abscesses are found also in the lungs ; they occurred 
in three out of eight cases, and were seated in the lower 
lobe of the right lung in every case. In two cases the 
lung abscess communicated with a liver abscess through 
a perforated diaphragm. The abscess cavity in the lung 
was surrounded by consolidated tissue of great extent, 
embracing the entire lobe. The consolidation is due to 
interstitial pneumonia. The contents of the abscesswere 
granular detritus, round lymphoid cells, red blood-cor- 
puscles, pus cells, and amoeb;e. A definite wall some- 
times included the abscess. The amceba? are more nu- 
merous in alveoli immediately adjoining the abscess, and 
in those places where the abscess is most rapidly advanc- 
ing, and where there is no limiting wall of connective 
tissue ; but all the neighboring tissues contain them. 
These appearances are different from those found in 
any other disease, and show an individuality of lesion, as- 
sociated with the presence of the amceba, which estab- 
lishes amoebic dysentery as a distinct disease. The 
amoeba is not an accompaniment but a cause of the de- 
structive changes in the liver and the lungs ; there is a 
relation between the number of the amoebae and the ac- 
tivity of the process, and where the process is more re- 
cent the amoebae are more numerous. 
The attacks begin suddenly or gradually. In the for- 
mer case a watery diarrhoea is followed by frequent stools 
of blood and mucus ; there are tormina and tenesmus. In 
some cases blood and mucus may appear in the begin- 
ning. In cases of slowT development, diarrhoeal symp- 
toms are present throughout, with intercurrent periods 
of constipation. In both forms there is no fever unless 
diphtheritic changes occur, or unless abscesses develop in 
the liver or lung. In more severe cases, with gangrenous 
destruction of the mucous membrane, the patient is pros- 
trated, and the stools are putrid and contain fragments of 
necrosed tissue. 
The symptoms are not uniform or characteristic, as in 
the catarrhal and diphtheritic forms ; intermissions and 
exacerbations occur. Convalescence is slow. The dura- 
tion is from two weeks to several weeks, but it may hist 
months or years ; it becomes a chronic disease. 
Amoebae are seen in the stools, floating in the fluid or 
clinging to fecal masses. They are more numerous in 
acute cases and in the periods of exacerbation. They 
disappear during convalescence, but may be seen in nor- 
mal stools after the patient is well. 
Treatment.-Popular favor in India still holds to the 
ipecacuanha treatment of dysentery. McDowell, after 
thirty-five years' service with the British Army, says that 
the horrors of dysentery are disappearing since this treat- 
ment has been employed. He gives a preparatory dose 
of twenty drops of laudanum an hour beforehand, and 
places a mustard-plaster over the stomach ; twenty to 
twenty-tive grains of ipecacuanha are given at bedtime. 
This treatment is to be given every evening, and no fluid 
is to be taken after it ; by the third day blood and mucus 
have usually disappeared from the stools, and they are 
free from pain. Maclean says this mode of treatment 
has reduced the former mortality to from twenty-five per 
cent, to seventy-five per cent., and that it is the most 
simple, the most successful, the most conservative, and 
the least objectionable mode of treatment of dysentery. 
Year by year under this treatment the chronic cases are 
becoming more rare and hepatic abscesses less frequent. 
Other observers, while not losing faith in the efficacy 
of this mode of treatment, urge its use in smaller doses. 
Its use in this country has been disappointing, and it has 
never come into especial favor, though many advocate its 
use in small doses (| grain to 3 grains) every half-hour to 
an hour. 
The experience of those who have had most to do with 
epidemic dysentery in this country, has led to a division 
of favor between the specific treatment by ipecacuanha 
alone and purgation by salines. A supposed portal con- 
gestion furnishes the theory for the purgative plan of 
treatment, although its good effects are confirmed by ex- 
perience. The fact that the supporters of purgation ad- 
vise the constant use of opiates afterward, and those who 
recommend ipecacuanha do not find it necessary to have 
recourse to them, gives ground for belief that the latter 
is the more successful method. 
The removal of scybalae in the early part of the attack, 
and toward the end of the more acute symptoms, is of 
unquestionable advantage in influencing favorably the 
condition of the inflamed mucous membrane. Daily 
purgation is not found so beneficial as was at one time 
believed, and when to give a purgative becomes one of 
the most perplexing questions, requiring much judgment 
and experience in its decision. The salines and castor-oil 
are the best. In those cases where the discharges are 
fluid, containing shreds of tissue and small clots, point- 
ing to extensive colitis, purgatives are unsuitable ; their 
use is confined to cases of catarrhal dysentery with small 
bloody and mucous stools. In amoebic and diphtheritic 
dysentery they are of less use. 
Opium, so largely used in this country in the treatment 
of dysentery, has its place among proper medicaments, 
but its use is only to ease pain and quiet the patient ; 
when used for any other purpose, or in large doses, its 
use is to be deplored. 
Bichloride of mercury and salol have been favorably 
mentioned on account of their antiseptic properties. 
Ringer recommends the former in doses of Tj(T to of a 
grain hourly. Salol is supposed to pass unaltered through 
532 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, 
Intestinal Diseases. 
Intestinal Suture. 
(SUPPLEMENT.) 
the rectum ; the smaller one admits the fluid, which es- 
capes through the larger one. The irrigating liquid is 
injected rapidly and escapes at once; in this way the 
rectum can be emptied and cleansed in a few moments. 
There is an important point in connection with this 
method which shows its advantages. In the worst 
forms of dysentery, where the colon is chiefly involved, 
the rectum is more or less constantly filled with a decom- 
posing fluid filled with shreds ; with each effort at stool 
the rectum is only partly emptied ; the sphincter con- 
tracts and closes, retaining a certain amount of the con- 
tents. Irrigation secures a complete emptying of the 
rectum, washes it out thoroughly, and makes it antisep- 
tic as far as can be done. Frequent repetitions of the 
procedure will sometimes arrest, at once, the frequent 
stools, and the patient may be made to have his evacua- 
tions only at the time of irrigation, the intervals being 
lengthened as he improves. In this way great suffering 
is relieved and the danger of general infection is avoided. 
The experience of the writer has convinced him of the 
great value of this method, as applied especially in cases 
with abundant fluid putrescent discharges. 
Rectal irrigation may be used in this manner, at first, at 
intervals of two to three hours ; as tenesmus diminishes 
and the desire for stool lessens, the intervals are in- 
creased to four or six hours ; they are then gradually 
stopped, a relapse often following a too early interruption 
of the treatment. Even after all the dysenteric features 
of the dejecta have disappeared it is well to continue ir- 
rigation for several days. 
If the tenesmus is great and the stools very frequent, 
an opiate suppository introduced into the rectum imme- 
diately after irrigation gives added comfort. But for in- 
tense tenesmus, combined with wakefulness, nothing an- 
swers so w'ell as the subcutaneous injection of morphia. 
In this article the attempt has been made to present the 
more recent views of dysenteric processes, and not to give 
a full exposition of the subject. Reference to the article 
on Dysentery in a former volume of the Handbook will 
show that many parts of the subject have not been 
touched upon here, because very little has been added to 
our knowledge except in the differentiation of amoebic 
dysentery from forms already known and fully described, 
and in the improved treatment by irrigation. 
William W. Johnston. 
INTESTINAL SUTURE AND ANASTOMOSIS. The 
advance in the treatment of wounds of the intestine, 
whether they be made by accident or by the surgeon in 
resecting or incising the bowel, is coincident with great 
surgical activity in the field of abdominal work. The 
possibilities of safe and perfect work have increased. 
The details of methods devised by many operators 
have multiplied until the practical surgeon is bewildered 
in choosing a method suitable to each emergency he en- 
counters. The technique of some of the methods pro- 
posed is elaborate, of others comparatively simple. It 
may be said that in the hands of each author the method 
advocated by him has resulted in a measure of success, 
seeming to warrant him in launching it upon the ocean of 
surgical endeavor, strewn already with more wrecks than 
sailing craft. It is to be assumed that, unless a method 
meets with a goodly share of success in the hands of 
general surgeons everywhere, the appeal of any one ad- 
vocate will not entitle it to a permanent position in the 
armamentarium of the well-equipped surgeon. Many 
methods are highly ingenious and appeal to the fancy of 
the student rather than to the utilitarian mind of the 
operator. 
It is difficult, with the improved statistics of abdominal 
surgery, to know howr much value to place on the help 
obtained in saving life by the novel methods of intestinal 
repair, and how much on the general knowledge of the 
treatment of all abdominal wounds per se. 
Statistics of the past cannot be compared with those of 
recent years, because of the marked causes of former 
mortality from peritonitis due to infection of erysipelas, 
sponge and hand contamination, and sepsis, now happily 
so largely eliminated from our hospital operating-rooms. 
the stomach, and in the intestine to be broken up into 
salicylic acid and phenol ; it is given in ten-grain doses 
every two hours. 
Calomel, so long in favor in this affection, has of late 
fallen into practical disuse, though some few still hold 
that it is worthy of a place among the specifics and pur- 
gatives. 
Treatment by Suppositories and by llectal and Colon In- 
jection and Irrigation.-The use of suppositories contain- 
ing opiates and astringents, although at one time a com- 
mon practice, is much less in favor than formerly. It is 
not desirable to destroy, or to limit to too great an ex- 
tent, the tendency of the rectum to expel its contents. 
The retention of a decomposing fluid in the colon and 
rectum cannot but be a source of danger, and fatal gen- 
eral infection may follow. The disease cannot be cured 
by putting a stop to dysenteric discharges, and therefore 
suppositories used for this purpose are not to be recom- 
mended. After the action of a purgative an opiate sup- 
pository may arrest too free purgation and keep the bowel 
at rest with benefit, and after irrigation, also, advantages 
may follow upon the same principle, but the doses of 
opium should never be large. In attempting to control 
tenesmus the temptation is frequently to give too large 
doses, which induce narcotism and which involve great 
danger. 
These same rules hold against following the once pop- 
ular method of using injections of starch-water and laud- 
anum, which may be of service with the limitations just 
mentioned, but as a routine treatment the plan is not 
without danger. 
The injection into the bowels of large quantities of 
warm or cold water has many advocates. The sedative 
effect of water of a high or low temperature upon an 
inflamed mucous membrane is of undoubted service in 
dysentery. The only objection is to be found in the dan- 
ger of over-distending the inflamed gut, and of adding 
to its irritability. Irrigation, by cleansing the ulcerated 
surfaces, by washing away the decomposing contents of 
the bowel, and by destroying bacterial life, gives promise 
of accomplishing a great deal more than by the mere in- 
jection of fluids into the bowel. 
Cool or hot water may be used for irrigation, but if an 
antiseptic agent be added to the water there is an ad- 
ditional benefit. 
Antiseptic irrigation may be practised with solutions of 
mercuric chloride 1 to 5,000, quinine 1 to 5,000 or 1 to 
2,000, salicylic acid, thymol, carbolic acid, sulpho-carbo- 
late of zinc, boracic acid, etc. The use of bichloride 
solution must always be attended with a certain amount 
of danger ; precautions should always be taken so as to 
have a free exit. 
Irrigation can be practised in the rectum or colon ; in 
either case a soft rubber tube is passed into the rectum or 
is gently and gradually forced upward through the sig- 
moid flexure. This is by no means an easy task, as the 
instrument so readily turns on itself; an occasional ex- 
amination ought to be made with the finger to see if this 
has happened. Experiments in the cadaver show that the 
smaller-sized rectal and colon tubes do not make their 
way as readily as those of larger size. The habit of in- 
jecting water, as the tube progresses, favors tw'isting; 
progression is more easily made if the bowel is empty, as 
the mucous-covered wall guides the instrument in the 
proper direction. In many cases the colon cannot be 
reached, and there is danger of perforating the ulcerated 
bowel if too continued efforts are made. One must be 
content, therefore, to pass the tube as far into the sig- 
moid as possible. The fluid is then allowed to flow in 
from a fountain syringe, or is thrown in by a Davidson ; 
when six to eight ounces have entered, it is allowed to es- 
cape through the same tube. This process is repeated 
until a quart or more has been used, or until the water 
escapes perfectly clear. If the patient is in the dorsal 
position or on the left side, with the hips raised, gravity 
favors the entrance of the fluid. In most cases, and es- 
pecially in bad cases, with putrescent fluid discharges, it 
is safer never to attempt to push the instrument beyond 
the rectum. Two tubes of different sizes are passed into 
533 Intestinal Suture. 
Intestinal Suture. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
The mechanical part of intestinal suturing will, there- 
fore, concern us rather than the results as judged by the 
scant statistical records. The really important part of 
this work is a matter of contemporary surgery. 
Prior to the past twenty years, recovery from injury 
of the bowel bordered on the marvellous, even to the 
mind of the older surgeons. True, an occasional re- 
covery is recorded of successful treatment as far back as 
1521, when an unknown surgeon sewed up a stab wound 
of the stomach and the patient recovered. 
Now, we know that with strictly clean work a surgeon 
can, for all practical purposes, insure perfect healing of 
sutured wounds of the alimentary tract. His duty is 
first to know the simplest technique of the few useful 
methods of stitching, and then the application of them to 
more complicated methods. 
His first concern is with the material used-the needle 
and thread. I believe nothing more perfect than the or- 
dinary cambric needle can be used. Yet a small Haga- 
dorn or a glover's needle may be employed in the absence 
of the other. The cutting edges of the latter wound the 
many veins of the bowel, and are pretty sure to make 
troublesome interstitial hemorrhages which dissect the 
coats for some distance from the puncture points. The 
round cambric needle, on the other hand, enters the ten- 
der intestinal coats readily and stops at the resisting sub- 
mucosa, which, as Halsted has shown, has a definite 
fibrous quality which can be detected and picked up on 
the point of this needle, thus giving a more secure pur- 
chase for the thread. The needle should be long enough 
to be readily handled-one and three-quarters or two 
inches is the best length. 
The thread should be of fine silk; No. 00 embroidery 
silk, iron-dyed, is best. 
In emergency, however, 
one may use common 
linen thread perfectly 
well, though it is not so 
smooth nor so readily 
drawn through the tis- 
sues as is silk. It has 
the advantage of being 
obtained of proper 
strength and size in an 
emergency, in any 
household, as is the 
needle also. 
Catgut is not to be 
used in intestinal sutur- 
ing. It is not enduring 
enough, its knots slip, 
and its sterilization is 
not to be trusted as per- 
fectly as is that of silk or 
linen. The needle should 
be sterilized by passing 
it through the flame of a 
lamp three times. The 
thread is perfectly steril- 
ized by boiling, after 
winding it on a small 
glass rod. Boiling for a 
half-hour and immers- 
ing in alcohol until 
needed, is the best 
method for preparation. 
It may, however, be 
sterilized by dry heat 
for three hours (oven- 
baking temperature, 
300° F.) and kept in 
cotto n-stoppered test- 
tubes without fluid, 
thus making it light and portable. 
Safe and accurate apposition of the edges of the in- 
testinal wound depends on the variety of stitch employed, 
and it is well to fix in one's mind two or three varieties 
of suture that have stood the test of experience, and dis- 
card all others as unnecessary. 
The principle underlying the inducing of sound adhe- 
sion of the wound is that fixation of two peritoneal sur- 
faces in contact, by means of some slight traumatism or 
the presence of a foreign body, such as the suture, im- 
mediately causes the copious exudation of plastic lymph, 
which seals the layers in from two to six hours, so that 
leakage is impossible 
without violence. To 
further add to the solid- 
ity of the lymph, it has 
been shown by Senn that 
gentle abrasion of the 
surfaces before sewing 
causes additional firm- 
ness to result. 
The suture must take 
hold only on the peri- 
toneum, the muscular 
coat, and an attenuated 
but firm and readily 
recognizable submucous 
fibrous reticulum, with- 
out penetrating the mu- 
cous coat. 
The action of the cir- 
cular and longitudinal 
muscular fibres causes a 
double movement of the 
part involved by the 
stitches, so that absolute 
fixation is a matter of 
skill in the use of the 
stitches. The stitches to 
be considered are the 
Lembert or "interrupt- 
ed," the "continuous," 
and the quilt stitch. 
The "Czerny-Lem- 
bert " is characterized 
by the use of a separate 
suture of the mucous 
coat within the bowel, 
combined with the Lem- 
bert externally. 
The continuous sut- 
ure, as modified by 
Cushing, of Boston (Fig. 354), gives a method by which 
excellent apposition is obtained and the thread more 
thoroughly buried in the intestinal coats than in the sim- 
ple running suture of Dupuytren (Fig. 353). When we 
consider the fact, however, that all these sutures turn in, 
and keep in contact two lips of intestinal edge which act 
as a valve when pressed from within, allowing nothing to 
escape so long as the suture holds, it seems that one has 
no advantage over the other from a mechanical point of 
view. It is argued that the lengthening and shortening 
of the wound by reason of the double peristaltic muscu- 
lar action might allow such relaxation of the continuous 
suture as would cause a gap for leakage between succes- 
sive stitches. Practically, this would be quite as likely 
to happen after the use of the interrupted suture. But 
in reality it never does happen after either one. What 
does happen occasionally, when one row is used alone, is, 
that some single stitch in the line gives way, owing to its 
insufficient hold, allowing it to cut out, and then an ever- 
sion of the mucous membrane and leakage occur. This 
is a uniformly fatal mishap,-hence all experience shows 
that a double row is needed to secure perfect union. 
Each row should have about six stitches to the inch and 
the rows should be parallel to the cut edge-one-sixth of 
an inch apart. With this double row carefully applied, 
no sutured opening can leak. 
The time occupied in making a running suture is one- 
third that of the interrupted, and it is therefore coming 
into vogue as the most desirable. 
The choice of sutures for the different rows lies 
with the operator. The interrupted Lembert has had 
preference in the past. It is acknowledged to take 
three times as long to apply as the continuous, and 
Fig. 354. 
Fig. 353. 
534 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Intestinal Suture, 
Intestinal Suture. 
is therefore being displaced by the latter in suitable 
cases. 
After an extensive use of all methods in living sub- 
jects, having regard both to security and time, I prefer 
to apply a quick-running Lembert suture (Fig. 353) near- 
est the cut edge of bowel, and outside that the Halsted 
"quilt" suture or its 
modification (Fig. 356). 
In my observation 
the " quilt " suture has 
an advantage over all 
others, in that it in- 
cludes and ties up a 
certain length of the 
longitudinal muscular 
fibres within the grasp 
. of each knot, thus fix- 
ing the definite length 
of the wound beyond 
the power of 
its elongation 
or shortening 
during repair. 
This point has 
not heretofore 
been empha- 
sized, but it is 
one of impor- 
tance. 
There are 
times when a 
continuous 
suture "over- 
hand " may be 
taken, of the 
edge of a stomach 
wound, for example- 
the needle penetrating 
both mucous and peri- 
t o n e a 1 coats. This 
may be utilized, for in- 
stance, in a case w'here 
one cuts out an ellipti- 
cal piece of the entire 
wall of the organ to 
include an ulcer, or 
a neoplasm. It is found that the wounded edge, being 
thick and vascular, requires many points of clamping. 
It is here safe and advantageous to suture the edge as 
above to check hemorrhage and secure the edges. This 
thread then becomes turned entirely into the stomach 
when the outside sutures are applied. 
It is of interest to observe what becomes of the threads. 
They all, even the continuous sutures, seem to work 
toward the cavity of the viscus by natural law. One 
end having become free, the remainder is soon cast off 
into the bowel. From two to six or eight weeks is 
usually enough time for them to work free. 
Experience goes to show that if the thread, needle, 
and operator's finger are sterilized, there is not much to 
be feared from sepsis due to intestinal contents. At 
least, careful rinsing of the parts sutured during the 
operation-with plain boiled water-gives non-suppurat- 
ing results, and stitch-hole abscesses must occur infinitely 
less often than in the case of the skin, unless the mucous 
membrane be involved. Where the thread penetrates 
and secures two edges from mucous membrane to mu- 
cous membrane, it acts as a seton, and as the inflamma- 
tory fluids exude they drain into the bowel-thus doing 
no damage,-provided the adjacent peritoneum is well 
secured by the outside row of stitches catching up only 
peritoneum. 
To Dr. Nicholas Senn is due the credit of a thorough 
and exhaustive experimental study of the subject of in- 
testinal repair, and to him will ever be credited the addi- 
tion of certain aids to operative work. Abrasion of the 
approximated surfaces has been mentioned. Omental 
grafting, so called, will stand as a useful adjunct. 
It has been shown by Schede and others that the peri- 
(SUPPLEMENT.) 
toneal cavity will tolerate the presence of considerable 
masses of living tissue, such as pieces of muscles, or even 
cancer tissue, deposited in an aseptic state, free within it. 
Such pieces, quickly blanketed by a layer of lymph, are 
soon vascularized and 
digested, as it were. 
If a strip of omen- 
tum two inches wide, 
and as long as needed, 
be torn from the edge 
of the patient's omen- 
tum, wrapped round 
the sutured bowel, 
and tacked in 
place by three or 
four sutures, it 
quickly becomes 
adherent to the 
parts under- 
neath and acts as 
a reinforcement 
to the junction. 
This is the so-called 
" omental graft." 
It has been showm 
to be useful, and is un- 
questionably a prac- 
tical pr o c e d u r e. 
Whenever greater 
security is needed in 
cases where the oper- 
ator is not quite satis- 
fied with his sutur- 
ing, it should be used. 
In most operations, 
however, it is un- 
necessary. If used, 
it must be entirely de- 
tached from its omen- 
tum, otherwise it will 
leave a band to cause 
internal strangula- 
tion. Senn found ex- 
peri men tally that 
such grafts of omen- 
tum became firmly 
adherent in from twelve to eighteen hours, and were 
freely supplied with blood-vessels in from one and a half 
to two days. 
Having settled in our minds the best methods of sut- 
uring simple wounds of the intestine, we turn to the 
variously complicated conditions which the surgeon is 
called upon to meet. They consist of either gunshot 
wounds, perforating ulcers, obstructions, tumors, stenoses 
from contractions, kinks or twists, or resections for de- 
stroyed portions of bowel, as in hernias, or old fecal fistulse. 
Fig. 355. 
Fig. 356. 
Fig. 357. 
In considering these maladies we may, for the purposes 
of this article, regard the intestine as either the subject 
of a lacerated wound or ulcer, or as resected after one of 
the diseases named, and study the best methods of re- 
pairing the lesion. 
535 Intestinal Suture. 
Intestinal Suture. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
For a lacerated wound or a gangrenous perforation 
one may split the intestinal wall an inch and a quarter 
in each direction from the perforation, lengthwise, and, 
bending the bowel, make an elbow at this point, turning 
the ulcer in and bringing the cuts together where they 
are stitched about, so as to restore the continuity of the 
bowel. 
I have done this in a case of gangrenous ulcer trans- 
verse to the bowel, where it had been held under the 
sharp inguinal ring (Figs. 357, 358, and 359). The alter- 
(SUPPLEMENT.) 
iodoform gauze for thirty-six hours. At the bottom 
of the-wound is the wounded bowel. If when the tam- 
ponade is removed the lymph has sealed the wound, 
nothing need be feared, no replacement of the tampon is 
needed - at most, a small drain may be established 
through the abdominal wall; and to insure prompt muon 
between the parts displaced by the tamponade, all that 
is required is to bring them into close contact. On the 
other hand, if leakage from the bowel occurs, it will form 
a fecal fistula which will, in nine out of ten cases, spon- 
taneously close in a few weeks. 
If, after a fecal fistula has formed, the edges of the 
abdominal wound and the surface of adjacent skin be- 
come quickly excoriated from the intestinal juices, it is 
an evidence that the portion of bowel which is wounded 
is situated high up toward the stomach, even though the 
loop seemed to be anatomically as low as the supra pubic 
region. The seemingly acrid secretions, though really of 
alkaline reaction, have so powerful a digestive capacity, 
that they do not spare the horny non-vascular layer of 
skin, and only stop at the papillary. The most exquisite 
pain follows from exposure of the nerve-ends in the skin. 
I have tried everything to relieve this distress and tide 
the patient over the few weeks during which the stenosis 
goes on so surely, and I have found no remedy as good 
as zinc ointment smeared on the cleansed skin, over which 
is laid coarse surgical gauze, in small compresses so dis- 
posed as to confine the discharge well. Simple spread- 
ing of salve cloths is useless, but the superimposed com- 
presses draw away from the skin the discharging intes- 
tinal juices, and only the lowest layer, which soon be- 
comes neutral, touches the tender skin. All other meth- 
ods than the above I have found to fail. 
I will not consider here why, when, or where the sur- 
geon has to resect portions of intestine, but will review 
his resources for restoring the continuity of the canal, 
after he has resected a complete piece of the intestinal 
tube. 
For the history of the earlier adventurers in this field 
one may refer to works on general surgery, such as 
Treves's " Manual of Operative Surgery." 
Practically, at present, we have a choice of three 
methods to accomplish our purpose :- 
First. End-to-end union. 
Second. Lateral implantation. 
Third. Lateral anastomosis. 
Each method is capable of being done by sutures 
alone, or we may use artificial mechanical devices aided 
by sutures. 
The ideal result would undoubtedly be attained by end- 
to-end union, if possible, without narrowing the canal. 
Practically, however, the operator has to consider the 
security of his suturing and the time consumed by this 
method. 
When intestine is cut across there is a part lying be- 
neath the mesenteric attachment which has no peritoneal 
coat. When this is sewed to the corresponding part of 
the other end, the reparative lymph thrown out from the 
peritoneal surface is wanting here, and it is therefore the 
point at which fatal leakage of fecal matter often takes 
place. 
This can be avoided by extreme care, as follows: 
Place an independent stitch at the cut edge of the mesen- 
tery close to the bowel, uniting its two layers. This 
practically makes the peritoneal coat continuous around 
the circumference. 
Two layers of sutures are essential: one of the mucous 
edges only, which must be knotted on the inside ; the 
second, limited to the peritoneum. 
In tins, the so-called Czerny-Lembert suture, the con- 
tinuous suture is not available, because, if tightened se- 
curely enough, it acts like a purse-string, and leaves an 
annular stricture. The time consumed in making the 
circuit of the bowel by interrupted sutures, a double 
row, is very great, amounting to from an hour and a 
half to two hours, in thoroughly perfect work. The re- 
sult, however, when complete, leaves nothing to be de- 
sired. 
One risk must be borne in mind, namely, that if the 
Fig. 358. 
native of resection or artificial anus was avoided, and the 
patient was restored immediately to perfect health, which 
she has maintained for four years past. 
For impending perforation, instead of resecting or sut- 
uring, one may adopt Chaput's suggestion of stitching a 
convenient piece of adjacent intestine to the ulcerating 
surface, thus protecting the peritoneal cavity and insur- 
ing its safety in case the perforation follows. In such an 
event the attempted discharge through the ulcer would 
be thrown back into the bowel from whence it came, or 
if it perforated through the piece of bowel plastered up 
against it, there would be only a fistula between bowels 
which would soon close spontaneously.* 
If a portion of intestine is torn in dissecting it from 
Fig. 359. 
an inflammatory association with a tumor, the abdom- 
inal wall, or another piece of bowel, the degree of tearing 
will determine whether to suture or to resect, or to form 
an artificial anus temporarily. A small tear should al- 
ways be sutured at once, if feasible. If the tissues are 
in a bad state and it is doubtful whether the sutures can 
be relied on, the wound should be tamponed with 
* This method of Chapul (Gazette des Hopitanx, 1892, No. 138) ap- 
plies as well to torn or gunshot wounds of the bowel, ami may on occa- 
sions prevent a resection. It requires nice judgment, however, on the 
part of the operating surgeon to choose between these methods. In 
badly torn wounds, especially if a bullet traversed the gut. I would pre- 
fer the resection and lateral anastomosis, as described later on. 
536 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Intestinal Suture. 
Intestinal Suture. 
arterial supply coming to the cut edge from the mesen- 
tery is interfered with by too close suturing there, where 
it is most demanded, there is danger of gangrene of the 
sutured edge, with late extravasation of faeces. This is 
due to the anatomical fact that the arterial circulation in 
the intestinal coats courses around the bowel and not 
lengthwise of it. 
With fifty per cent, of deaths from this method in the 
A modification of this method consists in stripping the 
mucous membrane from the inside of the distal end for a 
half-inch or more by curette, and stitching the proximal 
end into it so that the serous membrane of the latter is 
stitched to the freshened interior of the distal end. 
This has been found to work well in dogs' intestines, 
but it seems a perilous method to use in the relatively 
thinner human bowel, where much depends on the main- 
tenance of perfect circulation in the edge. 
Where resection of a stricture has been performed, or 
a malignant growth has been excised and the tube of 
bowel above is dilated to a much larger size than that 
below, Wehr has suggested that the smaller be trimmed 
obliquely, so as to match the second in diameter, and 
then the stitching of two equal openings, one circular, 
the other oblique, can be accomplished by double suture. 
This jointure will make a wide angle elbow in the course 
of the bowel, but not one that would be disposed to kink. 
The oblique cut being made at the expense of the side op- 
posite to the attached mesentery, there would be no dan- 
ger of a sloughing edge from interrupted blood-supply. 
The second method, of " lateral implantation," is in 
Fig. 360. 
hands of good operators, it is not surprising that we have 
to turn to less tedious and dangerous methods. 
End-to-end invagination has been advised by many- 
in imitation of the accident of intussusception. The dis- 
tal divided end is first inverted, and the proximal drawn 
into it by two sutures fixed to its peritoneal edge, thrust 
into the lower end, and brought out on its surface where 
it is temporarily secured, while a series of circumference 
sutures is applied to the edge where the inverted cuff of 
the lower lies against the surface of the upper end. 
Fia. 362.-Senn's Decalcified Bone Plate. 
imitation of the normal anatomical relation of the ileum 
to the caput coli. 
If we have a free end of the ileum left after a resection 
near the colon, we may resort to this simple procedure 
after the method first devised by Jobert, but best modified 
by Senn, as illustrated herewith (Figs. 360 and 361). 
This method may be described as follows :- 
A fiat band of rubber is stitched by the edge on the 
inside of the proximal gut to hold this firmly open. A 
slit is made in the colon, and by two stitches, one on either 
side, taken like large quilt stitches, the small end is drawn 
into the large bowel, whose edges are inverted thereby. 
A continuous suture is made around the line of meeting, 
thus shutting it off perfectly. This method is not tedi- 
ous and deserves attention. Whether the aperture would 
tend unduly to close later, or whether intussusception 
would take place from peristalsis, and blocking ensue, 
cannot be said. To this method may be applied some of 
the aids mentioned later, such as bone buttons, etc. 
In lateral anastomosis we have a method that has a 
great field of usefulness in the future. The operation 
essentially consists in establishing an opening between 
two adjacent portions of bowel tightly secured together, 
thereby switching off the intestinal contents to another 
channel. 
Fig. 361. 
This method has been very successful in canine experi- 
mentation, and may be used successfully in men. It is 
likely to get blocked by the obstruction of the thickened 
coats plus the food products, and thus be pushed on by 
peristalsis and beget a severe and genuine intussuscep- 
tion. 
537 Intestinal Suture. 
Intestinal Suture. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
The proposition of thus making a short circuit for the 
intestinal fluids originated with Maisonneuve, who prac- 
tised the method on two patients, who died. This dis- 
couraged further efforts to perform the operation. It 
was not resorted to again until 1881, when Billroth and 
Wollfler each operated on a case of pyloric stenosis from 
cancer, by establishing an opening between the stomach 
and small intestine, calling the operation gastro-enteros- 
where the edges of the plates press them together. The 
plates are then laid together, and the edges of both open- 
ings are thereby tightly sandwiched between them, 
when the four strings are tied in strong, square knots. 
These knots are cut short and tucked in between the 
plates. The intestinal edge being so slippery, will often 
be squeezed out between the plates ; hence a few outside 
Lembert sutures, or one continuous suture, are needed to 
complete the operation. Senn advises a light abrading 
of the peritoneum between the plates before tying. 
The excellence of the method has been proven by 
many successful cases, I have myself used it with per- 
fect satisfaction in the case of a carcinomatous stricture 
of the hepatic flexure of the colon, in which, after 
twenty-five or thirty pounds of soft faeces had been evac- 
uated by inguinal colotomy, and ten days had been 
allowed for recuperation, I united the ascending and 
transverse colon by lateral anastomosis, by means of 
Senn's plates, with perfect success. Six months later, 
the man died of cancer, and I found the opening I had 
made had contracted to a small orifice only large enough 
to allow fluid faeces to pass, hence requiring him to use 
laxatives for three months before death. The original 
aperture was an inch and a half in diameter. I felt the 
need of making larger apertures than the plates allowed, 
and devised the catgut rings, which have since been used 
with great success by many operators. This was the 
first modification of Senn's device, and has the double 
advantage of being made large (the opening measuring 
two inches in length) and of not interfering with the 
course of faeces through the aperture from the moment 
of operation. This device has been used many times 
with perfect success in grave cases of lateral anastomosis, 
and has usually required twenty-five minutes for com- 
plete adjustment. Sejata^ethod can be satisfactorily 
done, when everyth^j^j3epared, in fifteen minutes ; 
but I consider the si:MyLN^'ture obtained, the blocking 
by bulky plates, th^^^^ing of complicated knotted 
threads attached to the wound, the imposition, upon the 
sensitive intestine, of a mass of comparatively indigesti- 
ble foreign substance, the removal of which is to be 
effected by peristaltic action, which causes a tugging at 
the wound, as a menace to perfect security that is illy 
compensated for by a gain of five or ten minutes' time 
over another method by suture alone, to be described 
further on. 
Among many modifications of Senn's bone plates 
published later, I may mention Brokaw's segmented rub- 
ber rings (" Trans. Southern Surgical and Gynecological 
Fig. 363.-Ileo-colostomy with Decalcified Bone Plates, showing plates 
in position, one in the ileum, the other in the colon. 
tomy. Since then it ha^ been widely used. To obviate 
the tedious suturing of the openings, Senn, of Milwau- 
kee, used disks of decalcified bone (after trying all other 
absorbable but firm substances) for the purpose of ap- 
proximating the serous margins about the anastomotic 
openings. His two objects were, first to save time, 
second, to make safe apposition. 
That the principle of lateral anastomosis has been uni- 
versally accepted by surgeons as worthy of adoption, is 
proved by the energy and ingenuity shown by operators 
everywhere to modify and simplify the technique. The 
two objects aimed at have been to save time and add se- 
curity. Up to the present writing, no device has shown 
itself better than Senn's bone plates in saving time. 
These aids are made from the hard bone of an ox thigh 
sawed in a plane so as to make a bone plate three inches 
long, an inch wide, and a quarter-inch thick. This is 
soaked twenty-four hours in ten per cent, hydrochloric 
acid, to decalcify it. A brief washing in alkali removes 
the acid. The pliable bone can be cut with a penknife. 
A hole is made in the centre an inch and a half long, and 
four small holes are drilled beside it. Threads are now 
secured in it as shown in the diagram (Fig. 862), and the 
plate is kept in a solution of equal parts glycerine, alco- 
hol, and water, ready for use. 
The mechanical part of its application is extremely 
simple. The two parts of bowel to be joined are drawn 
up into view and confined by compresses of gauze or 
damp towels. An incision is made lengthwise of each 
bowel an inch and a half long, opposing each other, and 
into each opening a bone plate is slipped. A needle hav- 
ing been threaded with each of the two side-threads, is to 
be carried through the plate and the edge of the cut from 
within outward. This secures the plate against slipping. 
The two end-threads lie in the angle of the cut. The same 
is done to the other plate. The two, plates being then 
in position, a half-dozen Lembert stitches are placed be- 
hind the plates to secure the coats of the bowel together 
Fig. 364.-Ileo-colostomy without Resection of the Csecum, showing 
plates in position, one in the ileum, the other in the colon. 
Ass., November, 1889 "); also Robinson's rawhide plates, 
made of a long disk of beef's hide, shaved, macerated one 
day in saturated salt solution, then dried, cut into shape, 
threaded, and kept in alcohol until used. This material 
has been found serviceable. 
Davis's catgut mats (Virginia Med. Monthly, Septem- 
ber, 1889) were devised later, and have been used, but 
the author of them has abandoned their use. 
538 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Intestinal Suture* 
Intestinal Suture. 
Dawbarn advises oval rings, cut from raw potato, to 
be used much as Senn's plates are, and claims that they 
ought to remain firm twelve hours, which would give 
time for plastic adhesion to be fairly secure. He adds 
to the usual technique two features that seem unneces- 
sary and unwise, namely, the use of hydrostatic pressure 
through one of the open ends of bowel, to test the se- 
curity against leakage after the plates are tied in ; and, 
second, the introduction and fixation of the plates through 
the open ends of bowel, and cutting of the anastomotic 
opening through both walls of the bowel at once by a 
knife passed into one open end (Annals of Surgery, Feb- 
ruary, 1893). 
Jessett, of London, has devised a bone plate like Senn's, 
with a cylinder of bone fitted into the central hole. This 
pushes into the opposite plate hole and secures the exact 
fixation of the plates, with the addition, of course, of 
some suturing. 
Baracz has devised plates of raw turnip, which he has 
used successfully on the human subject, the anastomosis 
occupying three-quarters of an hour. They are like the 
potato, hard, easily prepared, and do not tear (Central- 
blat. f. Chirurgie, July 9, 1892). 
Mayo Robson has devised a spool of bone, or " bone 
bobbin," as he calls it, having a diameter of an inch, 
over which he sutures the bowel ends in end-to-end union, 
or inserts it in lateral implantation. 
Murphy has devised metallic buttons of oval shape, 
whose stems clinch each other when pressed together 
after the button part has been passed into the lateral 
opening in the bowel, and thus pinch the involved walls 
Thus the devices multiply, and in the hands of each 
inventor success is reported. 
The writer has tried many of the devicesupon animals 
and the human subject, and with what is commonly 
called brilliant results. Yet it seems to him that per- 
fect work, after all, follows the use of the suture alone. 
Fig. 36G.-After a Four-inch Incision and Sewing the Edges. 
Improved technique of lateral anastomosis by suture- 
gives a marked shortening in time. Twenty minutes 
have sufficed on several occasions to complete thorough 
anastomosis in human subjects. 
The operation should be conducted as follows : Let us 
suppose resection to be called for. If the bowel has faeces- 
in it, a ribbon of iodoform gauze is drawn through a 
small wound of the mesentery at the bowel edge, some 
inches above the trouble, and tied about the bowel so as 
just to stay the flow of faeces. The resection is quickly 
done with scissors, and the cut ends inverted by a double 
row of continuous fine black silk suture. 
The two ends are then overlapped four inches or more,, 
or laid side by side with ends together, as may be most 
convenient. I have tried both methods on the human, 
subject, and cannot see that the results are less perfect 
either way. 
Several needles are prepared, armed with fine black 
silk twenty inches long, tied with a double knot at the 
eye of the needle, and with one end cut off one inch from 
the eye. 
Two rows of continuous suture of the peritoneal and 
muscular coats are made, about four inches long and 
one-quarter inch apart (Fig. 365). An opening is now 
made with blunt-pointed scissors parallel to the sutures, 
and an eighth of an inch from them, leaving both rows 
on one side the cut. The latter should be between three 
and four inches long. Some bleeding points may now 
need clamping. 
Fig. 365.-Suturing Intestines in Apposition before Incision. 
so that adhesive inflammation is engendered at the mar- 
gin of pressure, and this sloughs when the united but- 
tons come away. This device be has used to produce 
quick anastomosis between the gall-bladder and intes- 
tine, as well as between two different portions of the 
bowel (N. Y. Med. Rec., December 10, 1892). 
539 Intestinal Suture. 
Intestine Wounds. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
A fresh thread and needle are now' made to secure both 
the cut edges next the sutures together ; a simple over- 
hand suture is best (Fig. 366). It arrests all hemorrhage, 
and the clamps are removed as the needle reaches them. 
The stitch is now made to quickly overhand each free 
edge by itself. 
We have thus far made two long button-holes, secured 
on one side by three rows of sutures. It remains only to 
rinse the parts with pure water and continue the two 
outer rows around the still unsecured edge. This is 
easily and rapidly accomplished (Fig. 367). 
On one side of the opening are three row's of stitches, 
which give great stability to the union, especially as the 
The absence of all paraphernalia but scissors, thread, 
and needle, makes the procedure most attractive. 
There is one feature of the lateral anastomosis opera- 
tion which has been largely overlooked, but which the 
author believes to be of the greatest moment in determin- 
ing the lasting benefit of the operation ; that is, the ques- 
tion of stenosis of the newly made orifice. 
The law of cicatricial contraction, which operates so 
effectually in closing accidentally made fistulae into the 
intestinal tract, or comparatively large ulcerations be- 
tween the gall-bladder and the intestines, is here the 
direct antagonist of the surgeon in his endeavor to create 
a permanent and adequate anastomotic opening. 
The incised opening for Senn's plates is about an inch 
and a half in length, for others it is still smaller, and the 
contraction of such an opening, sometimes with great 
rapidity, has in some cases rendered it entirely inade- 
quate to its service. Not many autopsies remote from 
date of operation are recorded. * 
Three of my own cases of lateral anastomosis illustrate 
my point admirably. In the first, done in 1888, where I 
united the transverse and ascending colon by Senn's 
plates, the patient lived six months. The aperture had 
contracted from an inch and a half down to three-quar- 
ters of an inch, and the man required constantly to use 
laxatives. In the second, where I united ileum to ileum 
by catgut rings, the patient lived six months. The con- 
traction reduced the opening from an inch and a half to 
one-half inch. In the third, eight months after lateral 
anastomosis of the sigmoid flexure following resection, 
the aperture of three inches contracted to one and a half. 
This was perfectly competent to do the functional work 
of the bowel. 
These results were relatively good, but two cases done 
after the suturing method above described, around open- 
ings of between three and four inches in length, have main- 
tained perfect functional action for over a year and a half. 
I believe the future utility of lateral anastomosis lies in 
making these long openings. This, I think, is almost 
impossible with bone plates, and only to be done with 
very long rings or vegetable plates, and then only with 
less security and with the consumption of as much time. 
The contrast is enormous between dropping back into 
the abdominal cavity a beautifully sutured, absolutely 
tight and flexible anastomosed end of intestine to any 
position in the abdomen which its natural surroundings 
demand, and returning a huge, stiff bunch of bowel, in- 
side which there is a pair of big plates of bone or raw 
potato, to remain as irritating foreign bodies, stimulating 
peristalsis, and tugging at the wound until they become 
softened enough to be swept on by the current; or, as in 
one of Dr. Senn's cases, to be vomited up after danger- 
ous retching. 
As regards time, even were it proven that a hand 
equally expert at each method could do that by plates a 
few minutes quicker, the relative advantage of the two 
procedures for safety would still lie with suturing. 
But, as a matter of fact, I have found that to do thor- 
oughly a lateral operation in the living subject, by either 
plates or rings, takes twenty or twenty-five minutes, and 
the same operation by simple suturing, done with the 
greatest nicety and perfect security, has taken me twenty 
minutes. 
In conclusion, the author still feels that what gain has 
been made in intestinal anastomosis and suturing is due 
to improved understanding of the needs of aseptic work 
and intelligent handling of the viscera ; that the attempt 
to simplify the technique of lateral anastomosis by plates, 
rings, and the many devices extant has not improved it; 
that lateral anastomosis is, in most cases, the speediest, 
safest, and best method of restoring the canal ; that sim- 
ple and thorough suturing with fine silk continuous sut- 
ure, after the manner detailed, is the most satisfactory ; 
that, in order to allow for the inevitable tendency to ste- 
nosis, an aperture nearly four inches long should be 
made between bowels ; that, while it may assist in forti- 
fying the lymph union, abrasion of the opposed sur- 
faces of peritoneum is not necessary to quick and solid 
repair. Robert Abbe. 
Fig. 367. 
innermost includes the entire thickness of both edges. 
This is especially a strong point in uniting bowel to 
stomach (gastro-enterostomy), inasmuch as the disposi- 
tion of both viscera to sag away from each other brings 
a little added strain on the back of the union. 
Anastomosis thus done may be tested by water press- 
ure, and will be found never to leak. 
The question of time gained, during what is usually a 
prolonged operation-perhaps five or ten minutes' gain, 
at most, in the face of the uncertain advantage of plates, 
rings, buttons, and bobbins--is one that in the author's 
opinion is greatly outweighed by the superior advantage 
of having absolute security against leakage, blocking, 
etc., by the method of simple suturing. The technique 
of the latter procedure is a matter of easier accomplish- 
ment and far greater satisfaction in its results than that 
of the newer methods. 
540 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, 
Intestinal Suture. 
Intestine Wounds. 
INTESTINES, WOUNDS OF. Intestinal wounds de- 
pend on the same causes as wounds elsewhere. The in- 
jury usually comes from without; rarely, it is due to a 
foreign body in the intestinal canal. 
Each anatomical division of the intestinal tract is lia- 
ble to injury, but those portions that are most extensive 
or most exposed are obviously in greatest danger. For 
these reasons the ileum and jejunum suffer most fre- 
quently, the colon occasionally, the duodenum least of 
all. In contusions, however, the duodenum seems to 
suffer a little more frequently than the colon. The lat- 
ter, especially its vertical portions, has but a limited 
range of motion, and is therefore poorly protected 
against traumatic influences. It possesses, however, the 
immunity afforded by a deep location, comparatively 
limited use, and dense protecting structures. 
The mobility of the intestines, due to their lax attach- 
ments and to the peculiar nature of their investing mem- 
branes, their elasticity, and the yielding nature of the 
tissues about them, affords the greatest possible natural 
immunity from violence that is consistent with the proper 
performance of the functions of the human body. 
While in normally developed adults the divisions of 
the intestine present no decided variations from each 
other in their relations to the abdominal wall, yet Treves 
has shown it to be impossible to definitely localize any 
certain portion of the jejunum or ileum by external ex- 
amination. In Treves's own words, "there is no sys- 
tematic arrangement of the coils of the small intestine. 
There is a disposition for the bowel to follow an irregu-. 
larly curved course from left to right, but this disposi- 
tion can never be relied on. Such as it is, it may be ex- 
pressed a3 follows : The gut starting from the duodenum, 
will first occupy the contiguous parts of the left side of 
the epigastric and umbilical regions. The coils then 
fill some part of the left hypochondriac and lumbar re- 
gions. They now commonly descend into the pelvis, re- 
appear in the left iliac quarter, and then occupy in or- 
der the hypogastric, low'er umbilical, right lumbar, and 
right iliac regions. Before reaching the latter situation, 
they commonly descend again into the pelvis. The coils 
found in the pelvis belong usually to the lower ileum 
and to the bowel, between two points respectively six and 
twelve feet from the duodenum." 
Causation in General.-The violence coming from 
without, or arising within the canal, may be called the 
exciting, while the habits, occupation, idiosyncrasy, a,nd 
surroundings of the patient are the predisposing causes. 
The nature of all intestinal wounds usually indicates 
the cause, though a single form of violence may pro- 
duce a wound of multiform characteristics. The di- 
rection and degree of the force, the magnitude and char- 
acter of the agent transmitting it, determine the extent, 
and largely also the number and variety of the wounds 
inflictea. The direction of a wound of the intestines, as 
well as the size, exerts an important influence on its lo- 
cal physical phenomena. 
Causation of Contused and Lacerated Wounds. 
-Contused and lacerated wounds differ only in degree. 
In contusions the intestinal walls are bruised, in lacera- 
tions they are torn. These forms are commonly due to 
external violence, and when thus caused both varieties 
may be well marked at or near the same situation. A 
considerable degree of external violence is required to 
cause a laceration or a severe contusion of the intestines, 
owing to their mobility and flexibility, and also to the 
nature of their investing tissues. Despite this fact, how- 
ever, cases of laceration occur from blows so slight, or 
through agents of such a character, that no injury is 
done to the abdominal walls. MacCormac has reported 
several such cases. Usually the agents transmitting the 
force have a blunt outline. The passage of the wheel of 
a loaded vehicle over the abdomen offers a frequent il- 
lustration of the manner in which the violence is in- 
flicted ; also a blow from the clenched hand or from the 
kick of a horse or a man, especially if the intestine be 
forced against the spinal column, or if the violence be 
received at a point where dense fecal impaction exists. 
Partial distention, according to Curtis, who made an 
(SUPPLEMENT.) 
analysis of 116 cases, diminishes the danger of rupture, 
while great distention of an isolated loop increases it, 
even for a loop not in contact with bony parts. The in- 
testines may-be bruised and even lacerated by imprudent 
manipulations for the reduction of hernise, and the colon 
has been torn by the incautious introduction of the hand 
or an instrument into the sigmoid flexure. Contusions 
with or without lacerations have been caused by knead- 
ing the abdomen to overcome intestinal obstructions de- 
pendent on fecal impaction, and rupture has occurred 
from the force exerted by circumscribed collections of 
gas generated in morbid obstructive conditions. The 
force of spent pieces of shell has caused laceration of the 
small intestine. In 113 of the cases analyzed by Curtis, 
the duodenum was injured in 6 instances, the jejunum 
in 44, the ileum in 38, other portions of the intestine in 
21, and the colon in 4. 
Non-penetrating gunshot wounds of the intestine are 
essentially contused injuries of that structure. However, 
in penetrating gunshot injuries, the character of the in- 
testinal wound assumes a different aspect, due, of course, 
to the penetration of the intestine by the missile causing 
the abdominal injury. Still, in these instances one fre- 
quently meets with both contused and lacerated wounds, 
independent of those due io direct penetration, since the 
mobility of the intestine or a mere impingement upon it 
of the missile fails to cause direct penetration. It is 
proper to say, however, that the borders of a penetrating 
gunshot wound of the intestine possess the character- 
istic features often of lacerated and contused wounds, 
although, for obvious reasons, in a much less degree. 
Penetrating gunshot wounds of the intestine are more 
frequent in civil than in military life, as in the latter the 
trunk is exposed as little as possible and the missiles fly 
high, while in the former the attacks are often unex- 
pected, and, therefore, the recipient is illy prepared to 
guard against them. Moreover, the range of the former 
is shorter, therefore the aim is better. It is interesting 
to note at this time that the percentage of gunshot inju- 
ries of the abdomen that are reported as resulting from 
the late war, is astonishingly small (about 0.035), while 
those of the head were 0.15. The increased percentage 
of the latter is due to the greater exposure of this part of 
the body. No definite estimate can be made prior to in- 
vestigation of the number, size, direction, or exact nature 
of the injuries of the intestine that may follow penetrat- 
ing gunshot wounds of the abdomen. The original text 
(see Vol. IV.) discusses this in greater detail. 
Abdominal Symptoms.-Pain, tenderness, tympa- 
nites, and bloody stools, with or without the protrusion 
of the viscus and the escape of the intestinal contents, 
are common symptoms of intestinal wounds. They are 
greatly modified, however, with reference to their pres- 
ence and their association with each other, by the nature 
of the wound itself. 
Pain and Tenderness.-Pain is not a reliable symp- 
tom. Soon after the occurrence of an injury, there may 
be little, or indeed none, even when perforations are 
present. Commonly, however, pain and tenderness are 
among the first of the abdominal symptoms. Located 
primarily at the seat of the wound, it is dull or lancin- 
ating in quality, the former being more characteristic of 
contused wounds. As a rule it increases rapidly, be- 
comes burning in character, and is accompanied by ex- 
quisite tenderness of the abdomen, retraction of the 
thighs, and obstinate constipation. It is increased by 
any muscular exertion, even the act of breathing. Some- 
times there are griping pains with a desire to stool. Re- 
tention of urine may occur, due to the shock, to the peri- 
tonitis, or to the treatment employed. 
Emphysema.-This sign is not associated very fre- 
quently with penetrating wounds of the abdomen, but 
when present is usually due to the escape of intestinal 
gases into the connective tissue situated between the in- 
testine and the abdominal walls ; hence it is associated 
especially with injuries of those portions of the intestinal 
tract that are not entirely surrounded by peritoneum. 
It may be limited to the immediate neighborhood of the in- 
jury, or may become general by spreading gradually into 
541 Intestines, 
Wounds of. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
the surrounding tissue, and it also may be due entirely 
or in part to a complicating wound of pulmonary tissue. 
Emphysema has been considered by some writers as a 
•certain sign of intestinal perforation, when associated 
with a suspected penetrating abdominal wound. Its di- 
agnostic value is much lessened, however, by the fact 
that it has been frequently observed in connection with 
non-penetrating wounds of the abdominal wall, one such 
instance, at least, having fallen within the observation 
of the writer. If decomposing processes occur in the 
course of a penetrating wound of the abdomen, emphy- 
sema may result even though the intestines themselves 
have not been injured. In such cases, however, the ap- 
pearance of the emphysema is delayed. 
Contused Wounds.-The diagnosis of contused and 
lacerated wounds can readily be made from that of all 
other forms, but to differentiate between these two is 
more difficult. There will be a history of abdominal 
injury received in some such way as already indicated. 
There may be external evidences of such injury, though 
in some instances there are none. If the intestinal wound 
be a contused one, there will be evidence of shock. Res- 
piration may be modified by the pain attendant on the 
act of breathing. Vomiting is a frequent but not con- 
stant symptom. Pain is usually present in the begin- 
ning, not so acute as in lacerated wounds, but dull, deep- 
seated, and burning, denoting a beginning inflammation. 
These symptoms may subside in a few days, or they may 
be quickly followed by a sudden increase in the pain and 
more urgent manifestations of peritonitis, or by collapse. 
These unfavorable symptoms may be caused by the rapid 
increase of a localized inflammation, by a sudden hemor- 
rhage from a previously contused vessel, or more com- 
monly by a sudden extravasation following sloughing of 
some portion of the intestinal wall. The constitutional 
symptoms keep pace with the local. The temperature 
rises, the pulse becomes more frequent and harder, and 
the patient soon shows evidence of collapse. 
The degree of tympanitic distention of the abdomen 
is usually proportionate to the extent and intensity of 
the inflammation. The tympanites may be due to air 
in the peritoneal cavity or in the intestine. In the former 
condition it comes from a wound in the gut, and in con- 
tused wounds it will, therefore, occur at or soon after 
the exacerbation of symptoms, while in lacerated it fol- 
lows quickly the intestinal injury. Tympanites due to 
intestinal distention comes more slowly and is less in 
degree. In lacerated wounds, fecal extravasation occurs 
as a rule. It was present in 107 out of 113 cases (Cur- 
tis). The symptoms will, therefore, appear earlier than 
in contused wounds and be more severe. In both vari- 
eties there may be vomiting of blood, particularly if the 
duodenum or jejunum be injured. Blood may also be 
passed at stool, and if the amount be small and clotted, 
it indicates injury to the ileum. If the blood has to 
traverse a considerable portion of the intestine, it will be 
darkened in color and consistency by the intestinal fluids. 
The possibility of coincident diseases of the intestines 
causing hemorrhage must not be forgotten. 
Nor must it be forgotten that a patient may have re- 
ceived either a contused or a lacerated wound of the in- 
testines, and yet present no symptoms for a few hours. 
MacCormac has reported one such case, and two others 
where vomiting was the only symptom, yet all three had 
rupture of the intestine and died within forty-eight 
hours. 
Hydrogen gas has been recommended by Senn as a 
means of determining whether or not, in a case of pene- 
trating abdominal wound, there co-exist perforations of 
the intestines. He has demonstrated that under slight 
but steady pressure, the patient being relaxed by an an- 
aesthetic, the gas may be forced from the anus past the 
ileo-caecal valve to the mouth. If perforations exist the 
gas escapes into the peritoneal cavity, its presence being 
denoted by free tympanites, loss of liver-dulness, etc., 
or it will appear at the abdominal wound, where it may 
be ignited. If the distention follows the line of the colon, 
and, after passing the valve, be confined to the umbilical 
and hypogastric regions, it indicates that the intestine is 
intact. The gas in passing the valve causes a blowing 
or gurgling sound which may easily be heard with a 
stethoscope. The method of using it is as follows : The 
gas, generated in the ordinary manner (care being taken 
to have it pure), is collected in a rubber bag holding 
about four gallons. This bag is connected with a rectal 
tip by means of a rubber tubing and stop-cock. The 
rubber bag being tilled, the rectal tip is inserted and the 
margin of the anus pressed against it to prevent the re- 
turn of the gas ; the bag is now subjected to gentle press- 
ure, the valve yielding to a force varying from one-half 
to two pounds. If the external wound points to the pos- 
sibility of stomach injury, then insufflation should be 
practised through a stomach tube. The disadvantages 
of the method are that it prolongs the operation, some- 
times makes the returning of the bowels a very difficult 
matter, and occasionally, when perforations exist, it fails 
to discover them-items which, according to the majority 
of observers, outweigh its advantages. In addition to 
this, there exists the danger of forcing a portion of the 
intestinal contents into the abdominal cavity, particularly 
if they be fluid, and be located in or at the point of per- 
foration. 
Local Treatment of Hemorrhage.-Hemorrhage through 
the abdominal wound may arise either from the wound 
itself or have an intra-abdominal origin. In either 
case the indication is to tie the bleeding vessel. This 
can be easily done if it be situated in the abdominal wall, 
although it may be necessary to enlarge the opening for 
that purpose. Bleeding from within the cavity is con- 
sidered in the great majority of cases a positive indica- 
tion for laparotomy. Its treatment by and during lapa- 
rotomy will be considered under gunshot wounds. If, in 
a given case, for any reason laparotomy may not be per- 
formed, the treatment must be palliative. The patient 
is kept quiet, and cold applications made to the abdo- 
men. The external wound must remain unobstructed, 
so as to permit the free escape of blood that might other- 
wise collect in the abdominal cavity. A dressing of 
moist antiseptic gauze will serve the double purpose of 
protecting the wound and acting as a drain. In these 
admittedly hopeless cases, it is not impossible that press- 
ure on the abdominal aorta, combined with transfusion, 
may prolong the patient's life. Should the hemorrhage 
thus be controlled, laparotomy during continuance of the 
pressure may yet offer an additional means of preserving 
life. 
Treatment of Lacerated and Contused Wounds. 
-A lacerated or contused wound of an intestine may or 
may not admit of abdominal section. There is, of course, 
less danger of fecal extravasation in such a wound than in 
one associated with abdominal penetration, as the pene- 
trating agent may carry the infection from all parts of the 
wound into the peritoneal cavity. If the symptoms are 
mild and rupture seems improbable, adopt the expectant 
plan. At all events, the performance of laparotomy 
should be deemed unwise in these cases after sufficient 
time has elapsed to permit the formation of adhesions 
contiguous to the injured portion. Severe hemorrhage, 
or serious visceral lesion, demands prompt operative inter- 
ference. Laparotomy to be serviceable must be done 
early, and not left until peritonitis sets in. In a collec- 
tion of eleven cases operated on after a few hours had 
elapsed, and as peritonitis was beginning, all died. Shock, 
usually great in these cases, is much increased by a long 
operation. For this reason many advocate the formation 
of an artificial anus. The choice between this and en- 
terorrhaphy will depend in a measure on the experience 
and preparation of the operator. A wound located at a 
point of the intestine that would lead to rapid impover- 
ishment of the patient from the formation of an artificial 
anus, should be treated by enterorrhaphy, even though 
the patient be exposed to greater immediate danger. 
Treatment of Punctured and Incised Wounds.- 
In all uncomplicated punctured wounds of the intestine 
not more than 8 mm. in length, the question of abdomi- 
nal section need not be raised. If it be thought larger 
than this, the measures adopted will be governed directly 
by the size of the wound and acuteness of the symptoms. 
542 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Intestines, 
Wounds of. 
Incised wounds of the intestines are more dangerous 
than punctured ones, because of the greater liability to 
hemorrhage and extravasation. Their general treatment 
is similar to that of other varieties. In performing lap- 
arotomy the incision is usually made in the line of the 
wound rather than in the median line, because it affords 
the most direct route to what is usually a limited injury. 
Treatment of Gun-shot Wounds.-In opening the 
peritoneal cavity, the initiatory incision should be made 
in the median line, especially when it shall appear that 
if the opening be made at the seat of injury, it will not 
offer an adequate opportunity for a proper inspection 
and treatment of the injured parts. The probable direc- 
tion taken by the missile should be considered in all such 
instances. It has been advised, and wisely, that when 
the intra-abdominal wound is probably limited to the 
more fixed portions of the intestinal tract, or to other ab- 
dominal viscera, in the absence of symptoms of hemor- 
rhage the incision be made in the line of the abdominal 
wound. After opening the peritoneal cavity, instead of 
using forceps, which bruise the tissues, to limit perito- 
neal retraction, a long suture of silk or catgut should be 
passed through the peritoneal borders for this purpose, 
and held by an assistant or otherwise properly anchored. 
The agents employed in repairs of the intestine in- 
clude materials for ligatures, sutures, etc. ; carbolized 
iron-dyed silk may be employed for both purposes. An- 
tiseptic catgut of small sizes may be used exclusively 
for ligatures, although some prefer to rely solely on 
silk. The needles required for sewing peritoneal and 
intestinal surfaces will depend on the preference of the 
operator, some using curved needles of small size and 
without sharp edges, others ordinary straight, slender 
sewing needles. The latter are particularly serviceable 
in introducing the Lembert suture. In addition, there 
are required thumb and mouse-tooth forceps to raise the 
borders of the wound, artery and needle forceps for 
obvious purposes, large catch-forceps with horseshoe- 
shaped blades to close the openings at the side of the 
intestine, of a similar shape, two or three long-bladed 
catch-forceps with the blades protected by rubber tubing 
to compress the intestine transversely, holding back its 
contents above and below the wound. (Several instru- 
ments have been devised for this, but the fingers of an 
assistant are best and safest.) Curved and straight scis- 
sors, aneurism needle, grooved director, scalpels, and 
other common surgical instruments are also necessary. 
After opening the abdominal cavity, the blood and 
fecal matter under observation should be removed with 
small sponges as soon as seen. This should be done very 
carefully, when possible by gentle pressure rather than 
by wiping movements, as the latter provoke the further 
spread of the infecting agents. In either instance, a 
sponge should be changed with each effort at removal. 
The bleeding points immediately under notice should be 
tied. It is important to remember that penetrating intesti- 
nal wounds should be closed as soon as found, otherwise 
they may escape notice, and thereby furnish an ad- 
ditional risk of still further infecting the peritoneal 
cavity. 
The repair of the intestine should be accomplished by 
one of two methods: 1, by directly closing the open- 
ings ; 2, by excision of a portion of the intestine and 
the union of the divided extremities, which union may 
be accomplished by either circular enterorrhaphy or lat- 
eral anastomosis. The former method may be done 
when the closure of the wound will not diminish the in- 
testinal calibre more than one-third. Either of the latter 
methods when the gut is extensively injured. In cer- 
tain wounds where direct closure will narrow the calibre 
more than one-third, additional room may be gained by 
closing the wound transversely. To do this it may be 
necessary to increase the length of the wound by making 
longitudinal incisions at either end of it of suitable and 
equal lengths. The intestinal wall is then grasped at 
corresponding points on opposite sides, and drawn upon ; 
the longitudinal wound is thus converted into a trans- 
verse one, and in this position its borders are united. 
By this means a certain amount of "elbowing" is pro- 
duced. While, as a rule, it is unwise to trim the borders 
of intestinal wounds, yet care should be taken to exam- 
ine the border of a wound contiguous to an important 
vessel, to ascertain if the integrity of the vessel be endan- 
gered ; otherwise the closure without this precaution may 
be follow'ed by secondary hemorrhage. 
The wound may then be closed by either the Gely, 
Lembert, or continuous sutures. A double row of the 
Lembert or continuous varieties may be made, or a single 
row of each instead, or the Czerny-Lembert. (Of the 
continuous varieties, Treves recommends the right angle 
continuous suture of Cushing.) See article on Sutures. 
The sutures, to be reliable, must go down to and em- 
brace a thread or two of the submucosa, and not be 
more than three lines apart. The best material for su- 
turing the intestine is the loose-textured carbolized iron- 
dyed silk. 
If the mesenteric border only of the intestine be in- 
jured, the injured portion of the gut should be excised, 
because gangrene is liable to follow from injury to the 
vessels of this part. 
When the intestine is completely severed, either by 
the original injury or the knife of the surgeon, the diffi- 
culty of adjusting the cut borders is much increased. 
The portion to be repaired must be drawn well out of 
the abdominal wound and carefully isolated by sponges 
and towels that completely prevent blood, faeces, etc., 
from entering the abdominal cavity. The uppermost 
extremity of the divided intestine will be known by the 
greater amount of fecal matter seen at its open end. 
The intestinal contents must be pushed aside for some 
distance from the part to be operated on, and the bowel 
occluded above and below. This may be done by using 
the clamps already referred to, or by making a hole in 
the mesentery and ligating the intestine either -with a 
cord of iodoform gauze or a flat india-rubber band. 
The fingers of an assistant serve better than anything 
else. The use of the clamps may, as shown by Parkes, 
cause sloughing if carelessly or continuously applied. 
The excision is made with sharp, straight-bladed scissors, 
at a right angle with the long axis of the intestine. The 
length of the portion removed will depend on the extent 
of the injury ; it should always be sufficient to include it, 
even though it be six or eight inches in extent, and 
where multiform perforations exist near each other, it is 
advised to include them in one resection, even if the in- 
testine removed be three feet long. The danger, how- 
ever, of removing a so large and absorbing surface, must 
be remembered. 
The vascular supply of the intestine at the seat of in- 
jury must be carefully examined, and all that portion of 
gut excised that has an impaired supply of blood, else 
gangrene of the bowel may ensue. In fact, it is a wise 
precaution in excision always to divide the gut at those 
points which will afford the best vascular supply to the 
extremities to be united-that is, close to the entrance of 
a mesenteric vessel into the unimpaired portions. The 
mesentery corresponding to the portion of gut removed 
can be cut away in the form of an isosceles triangle, the 
base of which shall correspond to its intestinal attach- 
ment, or it may be ligated en masse, or in sections at its 
point of attachment, and allowed to remain free in the 
abdominal cavity. Parkes and others consider the latter 
plan unsafe, since, owing to the feeble vitality of its tis- 
sue, gangrene of the distal extremities of the mesenteric 
stumps frequently ensues. Parkes advises that the en- 
tire mass be included in one ligature drawn tight enough 
to check the bleeding, and that after the intestine has 
been united, the stump be stitched to the seat of opera- 
tion, thereby forming again as nearly as possible a con- 
tinuous mesentery. This method was in his experiments 
followed by less mortification. Another method is to 
make two incisions, one on each side of the mesenteric 
vessels, at a distance of about half an inch from them, 
through the wall of the intestine in its long axis corres- 
ponding in length to the portion of the intestine to be re- 
moved. Tear away the mucous lining of this mesenteric 
strip, and unite its peritoneal borders by a continuous 
suture of fine catgut. After the excision is completed 
543 Intestine Wounds. 
Intra-Uter. Tampon. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
and the ends of the intestine have been united, the mesen- 
teric strip will present a looped appearance due to the 
approximation of the intestinal extremities. The open- 
ing of this loop should be united by sutures, and the op- 
posed surfaces of mesentery should also be transfixed, to 
prevent the formation of a pocket there. When the lig- 
ature en masse is employed, it is not considered safe to 
use catgut. 
As soon as all hemorrhage is checked, the extremities 
of the intestines are approximated by an assistant and 
some form of suture is introduced. The suturing is be- 
gun at the mesenteric border, care being taken to thor- 
oughly close the triangular space at this point caused by 
the reflection of the peritoneum from the walls of the 
intestine. After this, the protruding mucous membrane 
is pushed into the intestine and a suture is introduced at 
each of the three remaining aspects of the bowel, and 
then the intervening spaces are properly sewed. This is 
a better plan than to begin to sew at any given point and 
go directly around. In no instance should a suture be 
passed through the mucous membrane. If a Lembert 
or Gely be used, at least three to four lines of peritoneum 
should be included in the grasp of the suture at each ex- 
tremity of the intestine. A suture should be drawn only 
sufficiently tight to bring the severed borders in close ap- 
position, for if drawn too tightly the tissue grasped by 
it will slough. If a single row of sutures alone is to be 
made, they should be placed about five millimetres apart. 
If a double row is to be employed, those of the first can 
be deposited within six or seven millimetres of each other, 
and those of the second at intervals between the former. 
After the bowel is united, it is well to return to the mes- 
enteric border. This is the weakest portion of the wound. 
It should be covered by stitching the two peritoneal layers 
of the mesentery over it, or by an omental graft. 
A great many instruments and agents have been de- 
vised and recommended for the purpose of holding the 
divided ends of the bowel open while it is being sutured, 
but they are all or nearly all useless. 
Omental Grafting.-In certain experiments on dogs. 
Dr. Senn fixed a flap of omentum over the seam of an 
enterorrhaphy, the free or distal end being attached over 
the seam, the proximal remaining continuous with the 
omentum. These soon grew in place and thus reinforced 
the bowel. To avoid the danger of strangulation occur- 
ring through the loop thus formed, isolated grafts were 
employed and fixed round the suture. In every instance 
they retained their vitality. The intestinal peritoneum 
is lightly scarified before the flap is put in position, and 
in a few hours it is adherent. 
Senn's operation for intestinal anastomosis by means of 
bone plates, though devised to meet the requirements in 
cases of obstructive disease of the intestine, is yet ap- 
plicable to certain cases of injury, especially when time 
is a very important element. 
Recently intestinal anastomosis is being performed 
without the use of bone or any other form of approxima- 
tion-plates. The advocates of this method claim for it 
exemption from the special dangers following the use of 
approximation-plates, viz., leakage, irritation and sup- 
puration or hemorrhage, also obstruction from the plates 
themselves, or, later, from contraction of the cicatrix, etc. 
The operation, as described by Abbe, is briefly as follows : 
The resected ends of the intestine are inverted and closed 
by Lembert sutures approximating the serous surfaces. 
They are then overlapped to the extent of five inches and 
held there by two rows of continuous Lembert sutures, 
each row being an inch longer than the proposed opening. 
These rows are straight, in the long axis of the gut, par- 
allel, one quarter of an inch apart, and are both to be on 
one side of the anastomotic opening. The needle with 
its thread is to be left at the end of each row ready to be 
continued. The openings in the bowel are now made 
about four inches long, parallel with and one-quarter of 
an inch distant from the nearest row of serous sutures. 
The bleeding points are clamped and the clamps left on. 
A suture is then started at one end of the wound and 
unites by a continuous overhand stitch, which penetrates 
the entire thickness of the intestinal wall, the cut edges 
lying near to the rows of serous sutures. The free or 
more remote edges are whipped in turn by separate 
threads. This controls the bleeding without ligatures, 
the clamps being removed as they are reached, and it also 
prevents any union of the edges at the angles of the 
wound. The serous surfaces around the openings are 
now united by a continuation of the first two rows of 
sutures, their relations to each other and to the opening 
being preserved and ending where they began. 
Cleansing the Peritoneal Cavity and Closing the Abdomi- 
nal Wound.-All the bleeding points must be closed by 
ligaturing if possible, if not, then by cautery. It must 
not be forgotten that the tendency of intra-abdominal 
vessels to bleed when not exposed to the air is very 
great ; therefore a simple oozing before the closure of the 
abdominal walls is likely to become a formidable hem- 
orrhage thereafter ; and even though the secondary ooz- 
ing be not sufficient to imperil the life by loss of blood, 
it is liable to do so by causing inflammatory or septic proc- 
esses. The blood, other fluids, fecal matters, and all other 
foreign agents must be removed from the abdominal cav- 
ity and its contents and culs-de-sac thoroughly wiped by 
warm soft aseptic sponges soaked in Thiersch's fluid, a 
two per cent, solution of carbolic acid, or a solution of 
bichloride of mercury (1 to 10,000). Too great care 
cannot be taken in sponging away the foreign matter. 
As already stated, the same portion of the sponge should 
be applied to a serous surface but once, for to apply it 
repeatedly causes quite as surely the dissemination as 
the removal of the irritating agents. 
Malcolm, of London, advises flushing out the abdomi- 
nal cavity for the purpose of adjusting naturally the in- 
testinal folds. Water or antiseptic solution at the tem- 
perature of the body is poured into the cavity from a 
pitcher. The intestinal folds floated up, subside later into 
their normal positions. The fluid is poured in until it 
returns clear. That remaining in the cavity is siphoned 
off or sponged out thoroughly. This flushing with hot 
fluid also aids in cleansing the peritoneal cavity, and, 
besides, acts as a stimulant. 
The abdominal wound should be closed by two rows of 
sutures, a superficial and a deep. The latter should be a 
continuous one of strong silk, and should include the 
serous and subserous tissues and the transversalis fascia. 
The practice of making a deep row of interrupted sutures 
widely separated, or of including the whole thickness of 
the abdominal wall in one such row, is to be condemned. 
The pockets or dimples of peritoneum which are thereby 
formed between the stitches invite the occurrence of her- 
nia. The superficial row may be of silk or catgut, inter- 
rupted or continuous. If necessary, the wound may be 
drained. And last of all, an antiseptic dressing is to be 
applied. The patient should be quieted by small doses of 
an opiate ; the diet should be light at first and of a nature 
to leave little or no residue. The bladder should be 
evacuated with a catheter. 
Prognosis.-Ruptured or lacerated wounds have thus 
far proved more fatal than any of the other forms. Of 
five cases reported during the late war all were fatal. 
Curtis reports eight cases which were operated on, and all 
died. Since then several others, in which laparotomy was 
performed, have been reported, only one of which, that of 
Crofts, was successful. 
The prognosis in gunshot wounds of the intestines, 
w'hen treated by laparotomy, has of late years vastly im- 
proved. In 1887, Morton published a series of twenty- 
two cases with a little less than twenty-three per cent, of 
recoveries. About the same time MacCormac collected 
thirty cases in which laparotomy had been performed 
(Morton's were included), and gave the recoveries at a lit- 
tle over twenty-three per cent. Since then a collection of 
thirty-five cases shows eighteen recoveries, or a little over 
fifty-one per cent. 
Of stab wounds which were operated on, Morton repor- 
ted nineteen cases with sixty-three per cent, recoveries ; 
MacCormac eighteen cases with over fifty-five per cent, 
of recoveries. A collection of nineteen cases made since 
then gives over seventy-nine per cent, of recoveries. 
Joseph D. Bryant. 
544 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, 
(SUPPLEMENT.) 
Intestine Wounds. 
Intra-Uter. Tampon. 
INTRA-UTERINE TAMPON.-The present methods 
of treating morbid conditions of the interior of the uterus 
are revolutionary when compared with the methods of 
a generation ago. Nay, they are revolutionary when 
compared with the methods of some teachers who are 
still high in authority, and deservedly so. That which 
in all past ages of medical science and practice has been 
considered noli me tangere is now approached with per- 
fect unconcern, if with perfect cleanliness, and with clear 
foresight and expectation of beneficent results. The 
cases are rare indeed in which this expectation is disap- 
pointed if the manipulation has been attended by the req- 
uisite cleanliness and without undue rudeness. 
It must ever be remembered, now as well as in pre- 
antisepticdays, that the uterus is a contractile organ, that 
it is enormously vascular, and that it is enormously ab- 
sorptive, and. no one should invade the organ without 
due regard for this headlight. Another point of great 
importance which has received due recognition only in 
very recent times, is that morbid secretions or accumula- 
tions within the uterus should be drained away as thor- 
oughly as they would be drained from any other cavity ; 
that is, the principle of drainage applies to the uterus as 
well as to other cavities containing poisonous material, 
and if such drainage is not free and unobstructed the 
chances of mishap are very great. Many of the ills of 
womankind are due to the fact that uterine drainage has 
been ignored or misunderstood. If nature provided an 
outlet for decomposing material, wTell and good, but if 
not, nature and not man must be held accountable, to 
the great detriment, however, of the patient. Such rea- 
soning has tilled many grave-yards, and is in harmony 
with that other sophistry, " meddlesome midwifery is 
bad "-apologies, both, for the timid and the ignorant. 
The intelligent management of uterine drainage is one of 
the most valuable adaptations of modern uterine pathol- 
ogy, and it is the tampon more than any other means or 
instrument which has made such treatment efficacious. 
That the unimpregnated uterus is susceptible of dilata- 
tion is a fact which has long been known, but only in re- 
cent years has dilatation been practised to any great ex- 
tent. The use of tents composed of various materials 
has been advocated and practised for many years, but 
owing to imperfections in the materials used and want of 
care in the way of using them disaster has not infre- 
quently resulted, and the profession has come to look 
upon them with more or less distrust. The field of their 
utility was believed to be limited, and they were often 
used with fear and trembling, perhaps, when no other 
means seemed available. The inflatable rubber bag in- 
vented by Barnes for the facilitation of the first stage of 
labor was a most ingenious and valuable device, but the 
material was unreliable and might betray one in the 
hour of utmost need. The stems of glass, rubber, and 
metal which have been devised by Sims, Peaslee, Wylie, 
and others, have served, and still serve, a useful purpose 
in demonstrating the dilatability of the unimpregnated 
uterus, and the many useful ends which can be sub- 
served with an open uterine canal and free drainage. 
The powerful uterine dilators which are now in such com- 
mon use, and which are, for the most part, modelled after 
the powerful instrument of Sims, must be' mentioned 
in connection with the means which have been, and still 
are, used for the dilatation of the uterus, and for prepar- 
ing it for the use of the curette or the tampon., It finally 
remained for Vulliet to demonstrate that the uterine 
cavity could be greatly enlarged by the gradual use of a 
tampon of antiseptic cotton, and that by its aid one was 
enabled to treat the various diseases of the endometrium 
and uterine muscle with a convenience and success which 
had previously been unknown, or at any rate unprac- 
tised. 
Materials for the Tampon.-The object of the tam- 
pon is, primarily, dilatation. This may be effected by 
any material with which the uterine cavity can be filled. 
But the presence of a foreign body within the uterus ex- 
cites secretion ; hence two conditions are pre-requisites in 
the tampon material-it must be aseptic and it must be 
absorbent. The imbibition of the secretions of the endo- 
metrium by the tampon increases its volume and its di- 
lating power and at the same time favors the absorp- 
tion of poisonous material; hence the necessity of abso- 
lute certainty that the tampon material be aseptic, and 
that the tampon be not retained too long. Of all the 
substances with which the uterus may be tamponed, 
there are but two, so far as 1 know, which commend 
themselves for general use-absorbent cotton and gauze. 
Absorbent cotton imbibes the secretions of the uterus 
with great avidity and quickly becomes converted into a 
hard, firm mass, which may become painful and irritat- 
ing in a very short time. Nevertheless, it is readily intro- 
duced, can be adjusted with great compactness, and is 
highly approved by many writers, notably by Vulliet, 
whose credit it was. as already remarked, to advocate 
the persistent and extensive dilatation of the unimpreg- 
nated uterus. Preferable to absorbent cotton as a tam- 
pon material, at least in my opinion, is antiseptic gauze, 
which has all the merits of absorbent cotton and none of 
its objections. 
Introduced in narrow strips, from twelve to eighteen 
inches in length, it is readily adjusted, adapts itself to the 
shape of the uterine cavity, absorbs secretions readily, 
does not become hard like absorbent cotton, and is more 
readily removed. Either the plain sterilized gauze may 
be used, or gauze which has been prepared with iodo- 
form, carbolic, boric, or salicylic acid, and it frequently 
happens that it may be retained several days without 
acquiring the odor of decomposition. 
Conditions in which the Tampon is Indicated.- 
The gauze tampon is equally indicated for the impreg- 
nated and the unimpregnated uterus. The conditions 
may be tabulated as follows : 
I. The impregnated and puerperal uterus; 
1. During pregnancy. 
2. During parturition. 
3. Post-partum either at term or prior to it. 
II. The unimpregnated uterus : 
1. For exploratory and operative purposes. 
2. For the relief of hemorrhage. 
3. For endometritis. 
4. For the relief of stenosis. 
5. For the drainage of accumulations within the 
tubes. 
I. The Impregnated and Puerperal Uterus.- 
1. During Pregnancy.-There are many conditions asso- 
ciated with the impregnated uterus which have hereto- 
fore been treated, and with fair success, by tampon of 
the vagina, the pressure of the tampon being the efficient 
agent. This method, however, is often indirect and 
troublesome, and will eventually be superseded by the 
more logical and effective tampon of the uterus. Of 
course there are casesin which a tampon of the vagina will 
be preferable, and yet others in which both uterus and 
vagina may be tamponed with advantage. Tampon of 
the uterus is indicated when an abortion is imminent or 
is necessitated. It is simply a substitution of means. 
Instead of a bougie or tent a tampon of gauze within the 
cervix, or within the corpus, if necessary, will bring on 
the desired uterine contractions and facilitate the empty- 
ing of the organ. On the other hand, a light tampon 
within the cervix, with a moderate tampon of the vagina, 
will in some cases avert an abortion, checking the 
hemorrhage and permitting the pregnancy to continue. 
No fixed rules for action in such cases can be given ; one 
must exercise his discretion according to the" situation. 
The wounding of the uterus, which so often occurs in 
induced abortion by the use of instruments of various 
kinds, may usually be avoided when the tampon is used. 
2. During Parturition.-A slowly dilating uterus in 
the first stage of natural labor is often one of the most 
vexatious conditions, especially with primiparae, for both 
patient and physician. In such cases an uterine tampon 
is of great value. Its use requires judgment and a cer- 
tain degree of skill, for the soft uterine tissue may be 
readily torn, or undue violence may be shown to the organ 
in its insertion. It is best introduced with the patient in 
Sims's position, the uterus being steadied with a volsella, 
and the narrow strips of gauze pushed as high as the lower 
545 Intra=Uter. Tampon. 
Intra-Vasc. Infusions. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
pole of the advancing foetus. As labor progresses the tam- 
pon will be extruded into the vagina, and it should be at 
once removed, as its function has been accomplished. 
3. Post-partum, either at Term or Prior to It.-When 
Diihrssen suggested the tamponade of the uterus for post- 
partum hemorrhage, his proposition was received with 
incredulity, almost with ridicule. To tampon effectively 
a bleeding, viciously inert uterus is indeed an operation 
for which one is seldom prepared. The quantity of 
gauze which can be stuffed into such an organ is almost 
unlimited, and there is no time to send for supplies when 
the emergency is present. But one can always carry 
half-a-dozen rolls of sterilized gauze bandages, three or 
four inches wide, and, if this is insufficient, clean pocket- 
handkerchiefs, or strips from napkins or pillow-cases, 
are usually available for such a crisis. Of course there 
must be no suspicion of dirt about anything which is 
introduced into the uterus, and the mass must be removed 
at the earliest practicable moment. This operation has 
proved a life-saving measure in so many instances that it 
must now be regarded as one of the recognized expedi- 
ents in severe post-partum floodings. 
In hemorrhage after abortion the intra-uterine tampon 
will be found quite as effective as in the similar accident 
at term, and the operation in the former case may usu- 
ally be done with more deliberation and precision than 
in the latter. In cases in which there is septic matter 
or a suspicion of septic matter within the uterus after 
labor or abortion, the intra-uterine tampon will sometimes 
be of service. The statement is made thus cautiously 
because in such cases curettage and irrigation have a 
field which will sometimes be adjunct to the tampon and 
sometimes will take its place. The possibilities which 
the tampon has for usefulness in this class of cases are 
very great, and I can speak with much satisfaction and 
assurance of the valuable aid which it has rendered me. 
in my practice. The usefulness of the tampon may also 
be mentioned in cases in which the uterus contracts im- 
perfectly or irregularly after labor or abortion, a condi- 
tion which is commonly known as subinvolution. The 
tampon stimulates such uteri to contraction, relieves the 
turgid veins, effects good drainage, and may prevent 
protracted or even serious disease. 
II. The Tampon in the Unimpregnated Uterus.- 
Useful and sometimes invaluble as the tampon is during 
pregnancy and the morbid conditions which attend and 
follow it, it is equally valuable for many conditions 
which are unassociated with pregnancy. 
1. For Exploratory and Operative Purposes.-In the 
presence of intra-uterine neoplasms, whether benign or 
malignant, dilatation is always necessary prior to opera- 
tion, and exploration will frequently decide what the 
condition is, and wThether an operation is practicable or 
advisable. Such dilatation may often be effected rapidly 
by means of the powerful steel dilator of the Sims, or a 
similar, pattern. But there are cases in which such vio- 
lent treatment may be inadvisable, and in these the de- 
sired effect may be obtained more gradually by means of 
the tampon. The field which has heretofore been occu- 
pied by the uterine tent is destined to be reserved for the 
tampon. In those cases in which the uterus is to be 
opened from the abdominal cavity or to be extirpated, 
the danger of sepsis from its interior may be entirely an- 
ticipated by a preliminary tampon, and in those cases in 
which tumors have been removed from the wall of the 
uterus, which have so often proved fatal because of de- 
ficient drainage, the value of the tampon will be ines- 
timable. It is a singular fact that so useful an adjunct 
for such operations has so long remained unappreciated. 
2. For the Relief of Hemorrhage.-The indications for 
the tampon to relieve uterine hemorrhage are many, and 
doubtless some which might not be deemed valid by the 
majority of the profession at the present time, will be so 
considered in the near future. Among such indications 
may be mentioned profuse menstruation in the feeble 
and anaemic, hypertrophy and inflammatory conditions 
of the endometrium, malignant disease of the cervix or 
corpus, intra-uterine tumors of all descriptions, uterine 
congestion accompanying disease of the adnexa, retention 
(SUPPLEMENT.) 
of the products of conception, etc. The profuse men- 
struation of the feeble and anaemic, which has so long 
been treated by the profession with nauseating drugs, or 
with expectancy, that is, with a confession of helpless- 
ness, should no longer subject us to reproach. Does 
not nature sometimes shame us by plainly teaching that 
the rational method is to check such loss of vitality 
when she checks the menstrual flow in connection with 
some of the wasting diseases ? The wonder is that such 
losses can be so long tolerated by those wTho suffer them, 
and wrho wait in vain for the relief which is promised 
them-in time. Tamponade of the uterus in the un- 
married, especially in young girls, is an operation which 
a sensitive and conscientious physician naturally shrinks 
from, but it is immeasurably the lesser evil and should 
be boldly and thoroughly carried out. The necessity 
for the tampon in the other conditions mentioned will 
probably be admitted without further argument. If 
mistakes are occasionally made by such a procedure they 
will only be the exceptions proving the rule. In almost 
all cases it will be well to precede the tamponade by 
a careful curettage. With me such a procedure is a 
routine method, for it frequently clears up a diagnosis 
which may have had elements of obscurity. 
3. For Endometritis.-Endometritis is not necessarily 
accompanied by hemorrhage. In the septic varieties, in 
endometritis accompanied with hypertrophy, with excess 
of glandular secretion, with inertia, and atony of the 
uterine muscle, the benefits to be derived from curet- 
tage, tamponade, and drainage are unquestionable and 
extensive. 
4. For the Relief of Stenosis.-Unwilling as many are 
to admit the existence of evil arising from mechanical 
obstruction within the uterine canal, especially with ref- 
erence to the performance of the menstrual function, 
the facts are against them, the facts of induction on the 
one hand and the theories of deduction on the other. 
Those who pin their faith upon clinical experience 
through a series of years, in a series of careful observa- 
tions, may have reasonable confidence in their conclu- 
sions. The day of stems and tents for the relief of 
uterine stenosis is past, or rather a better instrument for 
the treatment of this condition is at hand in the tampon. 
Whether the stenosis is natural or the result of disease 
or traumatism, whether the condition to be relieved be 
sterility or dysmenorrhoea, the indication may usually be 
met by the judicious application of the tampon. 
5. For the Drainage of Accumulations within the Fallo- 
pian Tubes.-The use of the tampon for this purpose, 
which has been so ably advocated by Polk, does not 
seem to me to have so extensive an application as he 
thinks. I have operated upon several cases in which 
the dilatation of the tubes did not extend far beyond the 
uterine cornua, the cornua themselves being distended 
and the tissue friable with infiltrated pus. The tampon 
undoubtedly drains such cases very well, but suppose the 
case is not seen sufficiently early to drain thus efficiently. 
Suppose, moreover, that the ovaries are seriously dis- 
eased, while the abdominal ostium of the tube is still 
pervious, as is not infrequently the case ; or suppose the 
tube is divided into loculi, each filled with pus, and sep- 
arated from each other by impervious septa, or that the 
tubes are dislocated and the purulent accumulations be- 
yond the reach of the tampon ; under such unfavorable 
conditions, which are far more numerous than the favor- 
able ones, temporizing or palliation may be dangerous. 
Therefore, while conceding the value of Polk's proposi 
tions and suggestions, the utility of the tampon seems 
to me here to be very limited. 
Methods of Using the Tampon.-Polk's broad prop- 
osition that the tampon should be introduced withall the 
precautions and all the adjuncts of any surgical proced- 
ure, including the administration of an anaesthetic, is, of 
course, susceptible of limitations. In the tamponade of 
the uterus for hemorrhage post partum the urgency of 
the situation will forbid the deliberation and attention to 
details of a less serious condition, and in many other 
cases in which the uterine canal is patulous, the tissue 
soft, and the patient not unduly sensitive, an anaesthetic 
546 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
, Intra-Uter. Tatnpou. 
Intra-Vase. Infusions. 
will be unnecessary. I have tamponed such cases many 
times in office and clinic practice. For other cases the 
.safeguards which Polk mentions are timely and requi- 
site. As I have already said, the introduction of the 
tampon should invariably be preceded by curettage with 
the dull or sharp curette, as the case may require, by irri- 
gation, and frequently by dilatation. Roughly speak- 
ing, if the canal is half an inch in diameter the gauze 
may readily be introduced. For some conditions (which 
will suggest themselves as occasion arises) the lateral 
position of the patient will be preferable for the opera- 
tion ; for others the dorsal. I have sometimes been 
obliged to change the one for the other. The lower lip 
of the uterus may be steadied with a volsella while an 
assistant steadies the upper lip. The gauze, in strips 
two inches wide and twelve to eighteen long, may then 
be passed up the fundus with long dressing-forceps until 
the entire cavity is sufficiently packed. The firmness 
with which it is to be packed will depend upon the con- 
dition for which it is used. I have not been able to use 
Polk's cannula to advantage, nor do I like to recommend 
the use of the auger-pointed introducer. The latter is 
too dangerous for unskilled hands, and unskilled hands 
must frequently perform this operation. The tampon 
may be retained from one to seven days, according to 
the indication, and it may be renewed as often as neces- 
sary. (I have kept a myomatous uterus dilated for weeks 
in succession.) No special rules are necessary for its 
extraction ; it may readily be removed with long dress- 
ing-forceps. With regard to contra-indications the tam- 
pon may be so modified, as to quantity, firmness, and 
duration of retention, that I am unable to conceive of 
the impropriety of its use in any case in which intra- 
uterine treatment is admissible. Combined with the 
principle of drainage and the use of the curette it forms 
one of the most powerful and efficient means in uterine 
therapeutics. Andrew F. Currier. 
INTRA-VASCULAR AND SUBCUTANEOUS INFU- 
SIONS OF BLOOD AND OF SALINE SOLUTIONS. 
The treatment of extreme conditions of exsanguination, 
whether from the direct and immediate loss of a large 
amount of blood by sudden hemorrhage, or from the 
effects of rapidly exhausting disease, has long been the 
subject of careful study on the part of skilful practi- 
tioners, and of elaborate and protracted experimenta- 
tion by the most able and diligent observers. Such 
an alarming loss of blood is so terrifying, the degree 
of prostration is so profound, the shock to the system 
is so great, that few of the emergencies of professional 
life appeal more strongly to the sympathy of the phy- 
sician, or urge him to greater exertion to ward off the 
fatal termination which must speedily occur if aid to 
the sufferer cannot be promptly rendered and efficiently 
applied. In the greater number of accidents and in- 
juries followed by hemorrhage, it is possible to con- 
trol the loss of blood by the adjustment of a tourni- 
quet, by occlusion of the lacerated vessels by means of a 
ligature, by compression of the bleeding vessel by direct 
force applied over the seat of the injury, or by acupress- 
ure or other appropriate means. These means are not, 
however, applicable to many cases of bleeding, such as 
post partum hemorrhage, secondary hemorrhage after 
amputation, and the accidental hemorrhages attending 
certain of the febrile diseases to which the human organ- 
ism is susceptible-e.g., typhoid-or the purpuric con- 
dition, or in cases of hemorrhagic diathesis, or in certain 
organic affections of the internal organs, such as ulcer 
of the stomach, cancer of the alimentary tract, occasion- 
ally tuberculous ulcerations of the intestinal wall, and 
other analogous conditions, which at times present them- 
selves. 
From the nature of the case, all patients with sudden 
and alarming hemorrhage must be considered as cases of 
the gravest emergency, and any treatment applied for 
the relief of the patient must possess certain special ad- 
vantages, chief among which must be its universal and 
easy procurement and simple preparation ; and in addition 
to these it must be harmless in its relations to the tissues 
(SUPPLEMENT.) 
or organs with which it may come in contact during its 
presence in, or action upon, the system. 
F. P. Henry and Alfred Stengel publish in Sajous's 
Annual (1892, vol. ii., E., p. 16), a paper in which Thomp- 
son reports twelve cases of acute anaemia, such as those 
due to hemorrhage after labor, operation, etc., treated 
with sterilized solution of sodium chloride. Of the 
twelve cases, eight were treated by intra-venous injection, 
two by intra-venous and intra-peritoneal, and two by 
intra-peritoneal. Four recovered and eight died. Thomp- 
son regards the intra-venous the best "method, because, 
when the heart is weak, solutions injected subcutane- 
ously may not be absorbed, and because the action is 
more prompt. His experience would lead him to con- 
demn the intra-peritoneal injections. Injections of saline 
fluids prolong life, but must be followed by injections of 
detibrinated blood. The sugary solution of Landerer lias 
no special merit. Holmes, from studies of injections in 
acute anaemia, draws the following conclusions : 1, Auto- 
transfusion should be done first; 2, then infusion of large 
quantities of saline solution ; 3, immediate intra-vascular 
injection of salt solution should not be practised ; 4, 
secondary intra-peritoneal or subcutaneous injection of 
blood, when there is dangerous anaemia, is a conjectural 
matter, but should not be practised until reaction occurs ; 
5, immediate subcutaneous injection of blood is proble- 
matical ; and, 6, the rotary surgical pump is the best 
apparatus. Several of these conclusions are now an- 
tiquated. 
Marshall experimented with rabbits to study the effect 
of injections of mixtures of defibrinated blood and sodium 
chloride, and found, after a week, restoration of the num- 
ber of corpuscles, and after three weeks, of the haemo- 
globin. Stable obtained good results from Landerer's 
sugar solution, as did Weber and Frank with simple salt 
solution. Weldon thinks that blood-transfusion has 
fallen into undeserved neglect, because dissimilar bloods 
were employed, and therefore untoward results obtained. 
Castellino speaks favorably of injections of 14 to 16 
fluid ounces (420 to 480 grammes) of a three-quarters of 
one per cent, solution of soda. Lapine advocates the in- 
troduction of goat's serum directly into the veins. He 
uses about 50 c.c. (If ounce), and has found no evil con- 
sequences, though such might be feared theoretically. 
He suggests that possibly the introduction of the serum 
of non-tubercular animals may prove useful in the treat- 
ment of tuberculosis. It is noticeable that in this some- 
what extended review, no suggestion is offered as to the 
temperature of the solution or of the blood which is to 
be injected into the vascular system of the patient. In 
the earlier attempts to replace the blood lost by the sys- 
tem, it was supposed that the blood of the human organ- 
ism, or that of only a few animals, could be utilized for 
this purpose. After this operation it was found that ac- 
cidents of peculiar kinds were apt to occur, such as the 
coagulation of the injected blood in the vessels, this often 
inducing embolism, or thrombosis. Defibrination of the 
blood was then substituted for immediate transfusion, in 
which the blood was whipped with straw's, and the fibrin 
thus collected upon them was in this way removed. The 
remaining fluid, supposed to be normal blood, minus only 
the fibrin, was then injected into the vessels. A certain 
number of the patients survived this procedure, but the 
dangers from the introduction of air into the circulation, 
of septic infection of the blood in the processes of prep- 
aration or otherwise, together with the peril attaching 
to instruments and to hands which are not aseptic, have 
led most practitioners to abandon this mode of treatment 
of sudden and alarming hemorrhage. 
Among the procedures which have proved the safest 
and best, and which should-certainly be employed in pref- 
erence to the more complicated and elaborate methods, 
is the infusion of hot saline solutions into the vascular 
channels ; thus adding to the bulk of the circulating 
fluid, and relieving the heart from the danger of sudden 
and fatal collapse. We now know that as good, if not 
better, results are reached by injecting warm saline-alka- 
line water as by transfusing blood. " Aside from the ob- 
vious dangers-clotting, embolism, sepsis, etc.-attend- 
547 I nt ra-Vascular 
Infusions. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
ant upon the use of any kind of blood, we now know 
that blood-cells other than human are broken down and 
disintegrated almost at once within the human body ; and 
in consequence, a great mass of detritus is thrown upon 
the organs having charge of metabolism of tissue, threaten- 
ing to overwhelm them with work. Even human blood- 
cells are probably so destroyed, though more slowly, 
when transferred into another body than that which 
gave them birth. What seems needed is only some un- 
irritating fluid, which can supply the lacking volume 
within the heart and vessels ; that is, to give to the heart 
a sufficient amount of some harmless current running 
through its chambers to excite systolic action. If this 
is done, and done promptly, at the right temperature, 
before the patient suffers too much from the shock caused 
by sudden and extreme anaemia, it is wonderful how 
large a loss of blood may be sustained ; and how rapidly, 
as if by magic, nature supplies multitudes of new red 
blood-cells to supply those which have been lost."1 
The following quotation from William Hunter {British 
Medical Journal, August 10, 1889, p. 309), is of interest 
in this connection : "After the greatest loss of blood in 
animals a sufficient number of red corpuscles always re- 
mains in the circulation to carry on respiration, provided 
that the circulation is maintained. In animals, after the 
loss of half to two-thirds of the total quantity of blood in 
the body, the number of corpuscles per cubic millimetre 
may be found as high as 3,000,000 or 4,000,000. The 
absolute loss is great, but the relative loss is slight, and is 
of little importance. The animal's health is in no way 
injuriously affected by the loss. ... In man, a loss 
of blood can never be so great as in animals ; syncope 
occurs earlier. Transfusion of blood is, therefore, never 
required for the purpose of supplying red corpuscles to 
carry on respiration after sudden loss of blood, in a pa- 
tient previously healthy. The immediate source of the 
danger in such cases is not the want of red corpuscles, 
but the disturbance of the relations between the vascular 
circulation and its contents. . . . It is remarkable 
how slight the disturbance may be in cases, for exam- 
ple, of pernicious anaemia, in which the red corpuscles 
may be reduced to the extent of ten percent., or even 
less, of their original number. I have observed cases 
in which the number of corpuscles was as low as 500,- 
000 or 600,000 per cubic millimetre, instead of 5,000,000 
as in health ; the respirations never rising above 20 per 
minute, and the breathing, during quietude, being per- 
fectly natural." 
In cases in which the loss of blood is not immediate, as 
in conditions of great prostration from exhausting dis- 
ease, or in pernicious anaemia and kindred diseases, the 
introduction of saline solutions into the connective tissue 
of the body, whence it is rapidly and easily absorbed 
into the systemic circulation, has been followed by most 
gratifying results. It would seem that the presence of a 
large amount of circulating fluid within the vascular 
channels, must exercise a stimulating influence upon the 
cardiac muscle, and possibly upon the tissues at large, 
with the result of invigorating the entire body. This ap- 
plication of hot saline solution has not, however, had the 
extensive use which has attended the intra-vascular injec- 
tion of saline liquids, at bodily temperature, and its 
beneficent effects are not so well known. 
Of course, if one had abundant time in which to pre- 
pare it, the best saline-alkaline fluid would be one iden- 
tical in its components and their proportionate quanti- 
ties with blood-serum. Most surgical text-books give 
a formula more or less approaching this. Of late it has 
been recommended by Ludwig, of Leipzig, to add to 
our saline-alkaline water a little sugar; this being a 
natural ingredient of the blood. Simplest of all, and 
so far as we can see, practically about as good as the 
most complicated of these formulae, is simple warm 
water plus a little table-salt. It has the great advantage, 
too, of being always at hand when wanted. The best 
proportion of salt is six parts in one thousand -parts of 
water, or about the density of blood-serum. This would 
be, roughly estimated, a heaped teaspoonful in a quart of 
w'ann water. The water should be first boiled, for asep- 
(SUPPLEMENT.) 
tic reasons. We must never forget the salt. Such an 
omission would be fatal. Pure water, devoid of sodium 
chloride, when injected in any considerable amount, will 
at once dissolve out of the blood-cells their haemoglobin, 
and thus promptly kill the patient. 
Dr. F. C. Shattuck, in " Hare's Therapeutics," Vol. I., 
p. 780, has recently contributed to our latest knowledge 
in relation to transfusion and infusion, an article which 
is so carefully weighed in its estimate of the worth of 
these procedures, and so fair in its judgment, that I take 
the liberty to transcribe a portion of it in this connection. 
He says, " It is estimated that a person can stand a single 
blood-loss of at least one-third of its total volume with- 
out a directly fatal result; perhaps with a surprisingly 
rapid recovery. 
" If the patient does not show signs of rallying from 
the collapse following hemorrhage, the question naturally 
arises of artificially supplying, to a greater or less degree, 
the loss sustained. 
" A simple and ready means of stimulating the circula- 
tion is the application of heat, internally by a rectal in- 
jection of a quart of warm saline solution ; externally, by 
hot bottles; some form of alcohol being given by the 
mouth if the patient can swallow'. Or a sterilized solu- 
tion of common salt, of 0.06 per cent., or 0.07 per cent., 
can be thrown into a vein, into the subcutaneous tissue, 
or into the peritoneum. It has been, and is still main- 
tained by some, that such a saline solution is just as potent 
to save life as is the transfusion of pure or defibrinated 
blood, while it is free from some of the dangers incident 
to the last procedure. There are numerous cases re- 
corded in which the saline solution seemed certainly to 
save life, though it is possible to assert in these that re- 
covery would have ensued without its use. The last 
word has probably not been said as yet on this question. 
For intra-venous injection of defibrinated blood, or of a 
0.05 per cent, or 0.06 per cent, solution of salt, all the 
apparatus required consists of a glass funnel, some rubber 
tubing, and a cannula ; the rapidity of the flow being re- 
gulated by raising or lowering the funnel. According to 
Mayette, if the median basilic vein be selected for in- 
fusion, the amount should be about a fluid ounce per 
minute, though not much harm is likely to arise if ten 
ounces be injected in six minutes. This should generally 
be the maximum, except in cases of extreme urgency, in 
which the relative emptiness of the vessels is the chief 
source of danger. The same simple apparatus is also 
sufficient for the subcutaneous infusion of salt solution, 
from 500 c.c. to 1,000 c.c. (from 17 to 83 ounces fl.) may 
be injected under the skin of the back or in the axil- 
lary region, absorption being aided by gentle massage. 
Should the skin become too greatly distended, a second 
injection may be made in some other locality. Thia 
method of rapidly making up a deficiency in the quantity 
of the circulating liquid is free from danger, can easily 
be done without trained assistance, and in many cases in 
practice has been successful." 
Ziemssen has largely practised another method which 
seems to be at least safe-namely, the substitution of de- 
fibrinated human blood. Its first results were not satis- 
factory, but after an interval of about ten years he has 
lately resumed his work in this line, and has now so per- 
fected his technique as to aVoid all undesirable effects 
and obtain marked benefit. Strict antiseptic precautions 
are observed throughout the operations of drawing and 
injecting the blood, which is done under the skin of the 
thighs. He uses a syringe containing 25 c.c., the con- 
tents of which are thrown slowly into the tissues, while 
an assistant, with hands w'ell anointed with vaseline, 
puts his " full strength" into the massage of the part, so 
that the blood is diffused widely and thus put into a 
favorable form for rapid absorption. From six to six- 
teen syringefuls are injected at a sitting, the patient 
being under anaesthesia, as the injection and the massage 
are alike painful. 
In attempting the operation of infusion, certain pre- 
cautions against septic infection should be preserved. 
These relate to the apparatus which is used as well as to 
the vessel holding the liquid itself. If the instrument be 
548 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Intra-Vascular 
Infusions. 
a hypodermic needle, after the wire is withdrawn from 
the canal of the needle, this should be cleansed by forcibly 
passing several syringefuls of boiled water through it, 
and then holding it above the flame of a lamp or gas-jet, 
until the water contained within the hollow needle is 
transformed into steam and issues as such from the end 
of the needle. The needle may then be considered asep- 
tic. The rubber tube, if this is used, should be subjected 
to thorough disinfection by some efficient germicide, and 
may remain in the solution until wanted for use. If a 
common Davidson syringe is used it should be most care- 
fully disinfected, as this instrument is exposed to unusual 
dangers from septic infection. 
A very simple and perfectly efficient plan of disinfec- 
tion is to fill the syringe, and hypodermic needle, or the 
cannula, with boiling water, and then to immerse and 
boil them in water for a fewT minutes. 
Previous to operation, the place selected for the intro- 
duction of the needle should be thoroughly washed, and 
subsequently scrubbed with some form of antiseptic solu- 
tion. The hands of the operator, as well as those of his 
assistants, should also receive the necessary cleansing ap- 
propriate to a surgical operation. The solution to be 
injected should consist of freshly boiled water, prefera- 
bly distilled water, in which has been dissolved common 
salt (sodium chloride), in the proportion of 0.06 per cent, 
or 0.07 per cent., and which has then been allowed to 
cool to the required temperature. Most authorities as- 
sert this to be anywhere about 100° F. There is reason 
to think that a much higher temperature, as first pointed 
out and insisted upon by Professor Dawbarn, of New 
York,1 is to be preferred on account of the added stim- 
ulation from the elevation of the temperature of the 
liquid as it comes in contact with the visceral organs in 
which the vitality is reduced from the loss of blood, and 
in which there is also greater radiation from the surface 
and no corresponding rapid production of heat in the 
body. It is a noticeable fact that in cases of extensive 
hemorrhage there is always a feeling of chill on the part 
of the patient, and that the surface of the body is cov- 
ered with a clammy and decidedly cold sweat. The in- 
fusion of heat, as well as the increase of volume of fluid 
in the circulating organs, may therefore be considered as 
a distinct advantage, and is undoubtedly of positive ben- 
efit in cases of extreme danger.* 
Transfusion of blood has been urged as a remedy in 
the coma of diabetes mellitus by Dieulafoi,2 but the meas- 
ure has been found to be practically of no advantage, 
while the dangers and difficulties are almost of themselves 
sufficient reason for its abandonment, except possibly in 
institutions where the apparatus and necessary assistance 
can be readily procured. It need hardly be added here, 
that blood-transfusion, either mediate or immediate, has 
now been dropped by almost all surgeons (Dawbarn). 
The results so far obtained do not warrant us in believing 
it to be a measure that can in many instances enable us to 
save from death patients who have become comatose. 
The use of such injections has, however, in some cases, 
apparently been the means of cure, while in others it has 
been of decided benefit, although not completely success- 
ful. Dickinson reports a very interesting case in which 
he employed the method with apparent benefit. The ac- 
count is chiefly of interest from the fact that after the in- 
jection the patient regained consciousness for a time, and 
that during thirty-two hours, four hundred and fifty-six 
ounces of fluid were injected. In his opinion the best 
site for the operation is the prominent vein upon the 
instep, the tissues there being easily dissected and the 
vein hooked up, while its distance from the heart insures 
a more perfect admixture of the solution and the blood- 
(SUPPLEMENT.) 
column before they reach the heart and the medulla. 
The solution should be freshly prepared from boiled and 
filtered or distilled water, to which has been added a 
drachm and a half of sodium chloride and fifteen grains 
of sodium carbonate to each quart of fluid used. The 
fluid should be warmed to 100° F. and then injected 
slowly by means of gravity pressure, the reservoir being 
held at a height of three feet above the cannula. The 
latter should be of about one-sixteenth inch bore. Pro- 
fessor Dawbarn urges, upon physiological grounds, that 
the salt-water should be very hot, not less than 120° F., 
which is as hot as the hand can possibly bear. It was 
shown in his kymographic experiments that no harm 
could result from less than forty degrees hotter than 
this; on the contrary, the stimulant effect of the hot 
water on the heart, and also upon the unstriped muscu- 
lar tunics of the vessels in restoring their lost "tone," 
was almost magical. In Dickinson's cases above men- 
tioned, there were added to the water potassium chloride, 
and the sulphate and phosphate of sodium. Alkalies 
may also be administered by the mouth, but they are not 
in this way so rapidly utilized as by intra-venous injec- 
tion. Struempell recommends the subcutaneous injec- 
tion of ether or camphor, with lukewarm baths and 
douches. 
The new and simple technique which Dr. Dawbarn has 
applied to the operation of infusion of salt solution, " in- 
volves no cutting whatever, no searching for a collapsed 
vein, no freshened knowledge of anatomy, no tying in of 
a cannula, no cannula at all, in fact. All the appliances 
needed are such as are likely to be right at hand (it can 
be reasonably assumed) in nearly every instance. The 
instruments are, an ordinary Davidson syringe, and an 
ordinary hypodermic needle-large size preferred, though 
this is not essential. Even if the patient be pulseless at 
the wrist, we can almost to a certainty feel the femoral 
beating just below Poupart's ligament. Now, take the 
needle and push it directly into this artery, going slowly, 
until bright-red blood is seen to well up from within the 
needle. (As the artery here is large enough to carry a 
lead-pencil, the needle will not miss it, if a little care be 
exercised.) As soon as the arterial blood is seen in the 
needle, slip over its base the syringe-end, or other tube, 
both being filled with the hot solution, and tie a thread 
tightly about the syringe, securing it to the base of the 
needle. Now, holding the needle firmly and steadily, 
pump the fluid directly into the arterial current. To 
avoid possible pumping of air by an old or leaky syringe, 
make an abundance of the salt water, and keep the entire 
syringe, with the hand working it, beneath the surface. 
From the moment the determination to use the saline so- 
lution is reached, until the moment when the infusion is 
actually entering the blood-current, need not exceed five 
minutes. Should it be objected that this plan injures a 
very important artery, I would reply, that this is decid- 
edly a lesser evil among those which confront the patient 
dying from loss of the circulating fluid. Furthermore, I 
have several times used this plan upon the human sub- 
ject, saving the patient's life, and with no subsequent an- 
noyance regarding the femoral artery. A further advan- 
tage of this technique is the fact, that thereby it is difficult 
to make the otherwise common error of throwing in the 
injection-fluid too fast, suddenly overwhelming the tired 
heart. Until one has tried it, one hardly realizes how 
much the intra-vascular pressure will obstruct the inward 
flow through the needle, even in a patient with a badly 
flagging heart. There will be so much resistance that 
it will seem as if the needle must be plugged with a clot 
or some other foreign body, so slowly, in spite of vig- 
orous pumping, does the stream pass in ; and yet in the 
course of half an hour's steady work, a pint or more 
can be made to enter. 
" Whoever has noted the vigor with which unstriped 
muscular fibre everywhere, reacts to the use of heat (for 
example, the much stronger and decidedly more per- 
manent contraction which results from hot post-partal 
injections as opposed to cold ones), must believe it prob- 
able that such unstriped muscle, forming as it does a 
most important tunic of the blood-vessels, would be aided 
* In two cases of acute anaemia recently reported by Dr. E. Sternberg, 
in the New York Medical Record, the hot infusion of salt water (120° F.) 
as advocated by Professor Dawbarn, was followed by complete recovery ; 
whereas several patients treated in the same way, except that the fluid 
was injected at the temperature of the normal blood, died in succession. 
There appears to be no good reason why the injection of saline fluid 
should not be repeated at intervals, both for the support of the circula- 
tion and also for the purpose of aiding the elimination of excrementitious 
matter from the systemic emunctories. 
549 Intra-Vasc. Infusions. 
Intubation. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
by hot saline infusions in regaining its lost tone. Per- 
haps, too, the central sympathetic centres would feel and 
respond to this stimulus." 
So far as the writer has been able to discover, the ex- 
tremely simple and ready method of saline infusion herein 
described by Dr. Dawbarn-i.e., using an ordinary hypo- 
dermatic needle in an artery, etc., has not heretofore been 
published, nor his suggestion of the value of a very high 
temperature in the injected fluid, instead of that normal 
to the body. Albert N. Blodgett. 
1 Arterial Saline Infusion. Dr. Dawbarn. A report of three additional 
cases by the New Technique, etc.; reprint from Medical Record, Novem- 
ber 12, 1892. 
2 See Dr. F. A. Packard's article in Hare's Therapeutics, Vol. ii., p. 
1035. 
INTUBATION. Since the publication of Vol. IV. of 
the Handbook, six years ago, intubation, then in its in- 
fancy, has made rapid progress in public as well as in 
professional favor. In fact, its progress in some respects 
has been altogether too rapid for the good of all con- 
cerned, especially for that of the little sufferers from 
croup who are too often the innocent victims of bad in- 
struments and incompetent operators, the two evils that 
beset this procedure and for which there seems to be no 
remedy. 
Intubation is unfortunately a difficult and dangerous 
operation to attempt without a previous training on the 
cadaver, and but few of those who practise it have had 
such training. It is difficult solely because respiration 
is suspended during its performance, which requires 
that it must be done quickly, and to acquire the dex- 
terity and educated touch necessary to do it thus quickly, 
and at the same time gently, requires a large amount of 
practice. Were it possible, without endangering life, to 
consume half a minute in any single attempt to locate 
the larynx, fix the epiglottis, and pass the tube, there 
would be little difficulty or danger attending the opera- 
tion, but cutting off the small supply of air the patient 
is getting-when the operation is necessary-for even 
one-third of this time, is not always safe in bad cases. 
No amount of skill in the performance of other opera- 
tions affords the least aid to that of intubation. The 
most accomplished surgeon or laryngologist is therefore 
no more competent to do this operation without the prac- 
tice referred to above than the merest tyro in these arts. 
The laryngologist educates his sense of sight while the 
intubationist requires an educated touch combined with 
manipulative skill, a sufficient degree of which can be 
acquired on the cadaver to insure, in the performance of 
intubation, safety to the living. 
The following case, reported by Dr. G. Hunter Mac- 
kenzie (Edinburgh Medical Journal, February, 1892), is 
a good example of many that might be published but 
are not: " Case X., girl aged two years, under the care 
of Dr. Henry Hay, February 3, 1891. Diphtheria of 
pharynx and larynx. At 11.30 a.m. the pulse could not 
be counted and great inspiratory dyspnoea was present. 
Intubation was at once performed, with immediate and 
marked improvement to the breathing and strengthen- 
ing and slowing of the pulse. February 4th, the child has 
breathed freely all day and is apparently going on well. 
She had slept well during the night. Brandy is being 
freely administered, a moderate degree of difficulty in 
swallowing is present. February 5th, the child continues 
to do well. At 4 p.m. I considered it advisable to remove 
the tube, which had been forty hours in the larynx, and 
this I tried to do with the assistance of the child's father. 
The process of gagging and the insertion of the extrac- 
tor, along with some struggling on the part of the little 
patient and some difficulty in locating the blades of the 
extractor inside the very small tube, appeared to com- 
pletely exhaust the patient, and induced a condition of 
death-like collapse. Artificial respiration was immedi- 
ately resorted to and produced a partial revival only, for 
the child never returned to her former condition. She 
died a few hours afterward without a recurrence of the 
symptoms of obstructed respiration." 
(SUPPLEMENT.) 
apnoea from prolonged attempts to remove a tube from 
the larynx of a child free from dyspnoea at the time the 
operation was begun. How much more liable is this 
accident to occur either in the introduction or removal 
of a tube when the dyspnoea is extreme ! In unskilful 
hands a fatal result from this cause is not by any means 
rare. Yet there are many who claim that every practi- 
tioner should be prepared to intubate in case of emer- 
gency. 
Any immediate danger to life attending the introduc- 
tion or removal of a tube from the larynx, excepting 
cases moribund at the time, is chargeable to the oper- 
ator and not to the operation. Cases very difficult to in- 
tubate are met with not unfrequently, owing principally 
to the engagement of the distal extremity of the tube in 
one of the ventricles of the larynx or in a subglottic 
stenosis, but the skilful operator, knowing the cause of 
the obstruction, knows also how to overcome it. 
The most convincing proof of the popularity of in- 
tubation as compared with tracheotomy, is found in the 
large individual experiences that have been accumulated 
in the short space of time that has elapsed since the in- 
troduction of this operation. Dr. F. E. Waxham has 
recently reported four hundred and twenty-one cases in- 
tubated by himself. Dr. Dillon Brown has also passed the 
four hundred mark, and the author is approaching it. 
Over twelve hundred cases by three operators in a few 
years ; and many others have passed well into the second 
hundred. 
Individual experience with tracheotomy, on the con- 
trary, with very few exceptions, is comparatively small, 
Dr. Jacobi being probably the only tracheotomist in this 
country who can number his cases by hundreds. 
In a recent discussion of intubation versus trache- 
otomy at the New York Academy of Medicine, Dr. L. 8. 
Pilcher, a well-known tracheotomist of Brooklyn, re- 
ported sixty-six tracheotomies as the outcome of sev- 
enteen years of active professional life, while Dr. 
McNaughton, from the same city, has intubated over one 
hundred and forty cases in five years. This difference 
is not due to any greater prevalence of croup in recent 
years than in the past, but to the fact that the people, 
especially of the poorer class, among whom this dis- 
ease principally prevails, would not tolerate the cutting 
operation except in a small percentage of the cases. 
As far as private practice is concerned, the comparative 
merits of the two operations in saving life constitute 
therefore a subject of scientific rather than of practical 
interest. 
Diphtheritic, fibrinous, or membranous croup, with rare 
exceptions, is the only form of acute stenosis of the larynx 
in children that demands surgical interference, and this 
disease is so complex in its nature and is attended with so 
many elements of danger, independently of the laryn- 
geal stenosis, that no brilliant results can ever be ex- 
pected from any mechanical method of treatment. The 
principal cause of the great mortality after both intuba- 
tion and tracheotomy, is the extension of the disease to 
the bronchial tubes where surgery cannot reach it. Then 
come catarrhal pneumonia, systemic poisoning, nephritis, 
and paralysis, all of which may be combined in the same 
case, but any one of which alone is sufficient to produce 
a fatal result. 
For a description of the intubation instruments, with 
illustrationsand method of operating, see Vol. IV., page 
419, of this Handbook. The only material difference in 
the construction of the tubes since the article referred to 
was wwitten, consists in making the distal extremities 
somewhat bulbous, in order to prevent them from engag- 
ing in one of the ventricles of the larynx, the usual start- 
ing-point of a false passage. In the article referred to, the 
production of a false passage by forcing a tube through 
one of the ventricles and into the cellular tissue of the 
neck underneath the skin was barely mentioned as an 
accident unlikely to happen, but I have since learned 
from various sources that it is not at all uncommon in 
the hands of beginners; hence this modification in the 
form of the instrument, which renders the penetration of 
the tissues almost impossible. 
The fatal result in this case was undoubtedly due to 
550 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Intra-Vasc. Infusions, 
Intubation. 
Almost all the other accidents attributed to the opera- 
tion of placing a tube in the larynx are due to the same 
cause, viz., want of skill on the part of the operator. 
Pushing membrane down before the tube is far more 
curative than dangerous, because this membrane, if de- 
tached above, and if also free below the partial or com- 
plete cast of the trachea, is easily expelled. If the 
pseudo-membrane is anchored below by extension into 
the bronchial tubes, it is difficult to get rid of it through 
the natural passages, even with the aid of the short, large- 
calibre tubes devised for this purpose. In all the cases 
in which casts of the trachea with numerous bronchial 
branches attached have thus been gotten rid of, death 
has resulted from reproduction or still further extension 
of the disease, and the same result would follow its re- 
moval by means of secondary tracheotomy. 
A gradual obstruction of the tube may occur from the 
scanty tenacious secretions that usually accompany a 
high temperature, especially if associated with occlusion 
of the nostrils and mouth-breathing, which can be pre- 
vented by keeping the inspired air moist by means of 
sprays, steam, or the frequent administration of mild alka- 
line solutions, such as Vichy, lime-water, etc., some of 
which (the patient being in the upright position) will then 
enter the tube. 
The only danger worthy of serious consideration while 
a tube remains in the larynx, and one which cannot al- 
ways be guarded against, arises from loose membrane in 
the lower portion of the trachea which closes like a valve 
around the distal extremity of the tube and obstructs 
expiration almost exclusively. The only absolute safe- 
guard against this accident is to remove the tube and at- 
tach a thread to it whenever loose membrane is detected at 
the point indicated, which can always be done if the child 
be induced to cough. It is, in fact, the best plan, for those 
who have had but little experience wdth the operation, to 
have the string attached in all cases in which it is pos- 
sible, as the removal of the tube is more difficult than its 
introduction. 
The method of feeding adopted by Casselberry, of 
Chicago, has practically done away with the two greatest 
objections urged against intubation, viz., the difficulty of 
nourishing patients with a tube in the larynx and the 
possible danger of pulmonary complications from the 
aspiration of portions of solid or liquid food swallowed. 
It consists in placing the patient's head considerably be- 
low the horizontal while being fed, so that anything that 
enters the tube during deglutition will escape by force of 
gravity alone. In the upright position this can only be 
accomplished by the act of coughing. In young children 
the best position is lying on the back across the lap with 
the head hanging so well down that it is necessary, when 
the child is fed from a spoon, to reach the mouth over the 
nose instead of over the chin. The bottle can be given 
in the same manner, and when wet-nursed the child can 
be given the necessary inclination of body by passing its 
legs over the opposite shoulder of the nurse. Older 
children may be permitted to assume any position they 
wish, provided the head and neck be considerably below 
the level of the body. 
Patience and perseverance are necessary to induce some 
children to adopt this unnatural position in the beginning, 
but they soon learn that they can swallow so much better 
than when they are sitting up or even lying flat, that they 
readily assume it. 
Intubation in the Treatment of Chronic Steno- 
sis of the Larynx.-The value of intubation in the 
treatment of chronic stenosis of the larynx, as well as in 
the acute forms, is now generally recognized, and is prac- 
tised in many parts of Europe as well as in this country. 
Dr. C. H. Knight, of New York (Boston Medical and 
Surgical Journal, July 7, 1892), reports the case of a boy, 
aged ten years, in whom intubation was resorted to for 
the relief of urgent dyspnoea due to what was supposed 
to be a subglottic neoplasm or a tubercular thickening of 
the mucous membrane, although no disease of the lungs 
could be discovered. The tube was worn intermittingly 
for about three months, and with comfort, when it was 
decided to do thyrotomy for the removal of the growth. 
(SUPPLEMENT.) 
Death from general tuberculosis rapidly followed the 
operation. Dr. Knight comments on the slight amount 
of disturbance excited by the tube in the larynx and the 
absence of objection to its long retention. 
Drs. Pitts and Brook, of the Great Ormond Street Hos- 
pital, London(" Trans. London Medical Society," Decem- 
ber 1, 1890), report four cases of chronic stenosis of the 
larynx in children in whom intubation was resorted to for 
the purpose of getting rid of retained tracheal cannulas, 
one of which had been retained three and another five 
years. They were all originally cases of croup for which 
tracheotomy was performed, and were all practically 
cured, the cannulas having been dispensed with, but at 
the time the report was made two cases required occasional 
dilatation by means of an intubation tube. 
In one of my own cases of cicatricial stenosis in an 
adult, of syphilitic origin, after thorough dilatation of the 
stricture occasional intubation had to be practised for 
three years before the tendency to recontraction was 
finally overcome. 
If we take into consideration the limited amount of ex- 
perience with intubation which these gentlemen must 
have had at the time when the treatment of the above 
cases was begun, it must be admitted that it was admir- 
ably managed, very few mistakes having been made. 
The necessary precaution of keeping the external wound 
open until sufficient breathing-room in the larynx was 
obtained to sustain life in case the tube should be expelled, 
was adopted in each case. This was accomplished by 
means of a hard-rubber plug attached to a collar similar 
to that on the tracheal cannula. 
In one case, aged three years, the largest intubation- 
tube for children, or that suitable for a child of twelve 
or thirteen years, was used without injury, which was 
due to the fact that the cricoid cartilage had been di- 
vided not long before the intubation was practised, thus 
permitting this naturally narrow and unyielding portion 
of the larynx to expand and accommodate itself to the 
very large tube. While it is true that larger tubes can 
be used with safety in chronic stenosis of a non-cica- 
tricial nature than in croup, the increase should not ex- 
tend beyond two sizes. When a very small tube has to 
be used, as is often necessary to begin with, the upper 
end of the instrument should be increased in size to suit 
the age, and when the size proper for the age is expelled 
the dilated lower end alone should be made larger rather 
than the whole of the tube. There is no necessity for 
haste in the treatment of this class of cases,-because the 
difficulty of swallowing met with in the beginning, the 
same as in croup, is soon overcome, and all kinds of food 
can be taken with ease. The gentle, long-continued 
pressure of a tube suitable to the age is much safer than 
forcing in a large one which may endanger the integrity 
of the cricoid cartilage. 
In a boy of eight years, in whom I used a tube several 
sizes too large, in order to hasten the process of dilatation, 
there developed a cricoid perichondritis with abscess 
which opened externally. This promptly disappeared 
when a smaller tube was substituted. Sloughing of the 
subglottic mucous membrane and necrosis of the cricoid 
cartilage would undoubtedly have followed had the large 
tube been allowed to remain long in position. 
It is important to remember that it is that portion of the 
larynx which is bounded by the cricoid cartilage and not 
the chink of the glottis that determines the size of the 
intubation-tubes, and that it is the high operation in- 
volving this portion of the larynx that is the cause of 
retained tracheal cannulas in the great majority of cases. 
The difficulty of getting rid of a retained tracheal can- 
nula usually bears a direct proportion to the length of 
time during which it has been retained. 
Anchylosis of the crico-arytenoid articulations and 
atrophy of the muscles that move them, together with 
general shrinkage of the larynx, are the inevitable result 
of long-continued disuse. In the normal condition these 
little joints never rest, and were never designed to do so, 
but continue their motion with every inspiratory expan- 
sion and expiratory relaxation of the glottis, day and 
night, during sleeping and waking. Enforced rest in 
551 Intubation. 
Iodine. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
consequence of allowing the air to enter through an arti- 
ficial opening is, therefore, more disastrous to these ar- 
ticulations than it would be for the same length of time 
to any other joint in the body. 
Dr. E. Schniecgelow, of Copenhagen, practised intu- 
bation in eight cases of chronic stenosis of the larynx, 
six of which were for retained tracheal cannulas. One 
of the remaining two cases was that of a man, aged 
twenty-four years, who as a child had contracted cica- 
tricial stenosis of the trachea following tracheotomy ; 
the other was one of aphonia spastica. One of the cases 
was lost because the external wound was allowed to close 
before there was sufficient breathing-room in the larynx 
to sustain life without the tube, and another on account 
of plugging of the tube by tenacious, muco-purulent 
secretions, the case being complicated with a purulent 
tracheo-bronchitis. 
With ordinary precautions there should never be any 
danger, at least in adults, of an intubation-tube becoming 
obstructed from secretions, because a few vigorous coughs 
will expel any accumulation as long as air enough can be 
obtained to make this act effective, and patients should be 
so instructed. The use of steam or sprays aids materi- 
ally in keeping the tube clear by rendering the secretions 
less viscid. 
In adults the external wound can be kept open in many 
cases by wearing a small tracheal cannula with the intu- 
bation-tube, as was done in one of my own cases, both 
tubes having been kept in position at the same time for 
several weeks, the outer one being corked. When the 
wound involves the subglottic portion of the larynx 
there is not room for both. 
Dr. V. Nicolai (Bolletino della Paliambulanza di Mi- 
lano) reports five intubations in adults, in four of which 
it was employed for the purpose of relieving dyspnoea 
due to laryngeal tuberculosis, which result was accom- 
plished. In the other case the dyspnoea was the result 
of an intense inflammation following the removal of a 
foreign body which had been long impacted in the 
larynx. This case proved fatal from perichondritis with 
suppuration and burrowing of pus as far down as the 
bifurcation, followed by hemorrhage, the exact source 
of which could not be determined. The perichondritis 
may have been the result of injury done to the larynx 
in the removal of the foreign body or of pressure from 
the use of too large an intubation-tube. 
In chronic stenosis the same tube, if metallic, should 
not be allowed to remain in the larynx longer than about 
two weeks, on account of the irritation produced by the 
calcareous deposits that always take place to a greater or 
lesser extent on its surface. Such deposits do not occur 
on vulcanite tubes, which can therefore be allowed to re- 
main for a much longer time. In croup the tube be- 
comes coated more rapidly, and for this, as well as for 
other reasons, it should not be allowed to remain in posi- 
tion longer than a week at a time. Joseph O'Dioyer. 
INTUSSUSCEPTION.-During the last few years some 
advances have been made in the treatment of intussus- 
ception by operation, and the mortality of laparotomy 
performed for that variety of intestinal obstruction has 
diminished considerably. The mortality in the article 
in the main work was calculated from seventy cases col- 
lected from the literature of 1873 to 1887 inclusive, and 
reached seventy-six per cent. 
In a paper published in 1891, the writer was able to 
analyze a total of one hundred and five cases, and found 
a mortality of only seventy per cent.-a very encourag- 
ing improvement. (Medical Record, 1891, xl., p. 534.) 
The corrected table would then read as follows : (see at 
top of next column)- 
Out of sixty-five cases in which the intussusception 
could be reduced, only thirty-eight died, a mortality of 
fifty-eight per cent. Among the children of this group, 
the mortality was sixty-six; among the adults, only 
forty-seven per cent. Of seventeen cases in which the 
affected bowel was resected and sutured, only two recov- 
ered, both adults. Of sixteen cases in which an artificial 
anus was made (with or without reduction or resection 
(SUPPLEMENT.) 
Chil- 
dren. 
Adults. 
Age un- 
known. 
Total. 
| Mortality. (Per 
cent.) 
Recovered. 
Died. 
Recovered. 
Died. 
Recovered. 
Died. 
| " | _ m,: 53 | Recovered. 
Died. 
T. Intussusception reduced 
15 
29 
5 
7 
6 
1 
48 
10 
2 
1 
1 
14 
9 
2 
8 
1 
6 
26 
2 
2 
- 
88 
15 
7 
- 
74 
58 
100 
88 
88 
88 
70 
II. Intussusception not reduced : 
A. Nothing done 
B. Resection and suture 
C. Artificial anus made: 
1. After resection or reduc- 
tion 
2. Without resection or re- 
duction 
Total 
15 
Results of Laparotomy for Acute Intussusception. 
of the intussusception) two cases recovered, also both 
adults. These figures show again that prolonged opera- 
tions are almost invariably fatal, and furnish another 
argument etgainst delay, which is the usual cause of the 
conditions that render operations difficult, besides being 
directly responsible for the fact that the majority of the 
patients are in very bad condition when operation is 
finally resorted to. 
In the technique of treating the bowel when laparotomy 
has been performed, no new suggestions have been made 
for those cases in which the intussusception is reducible, 
unless it be Senn's suggestion (Canadian Practitioner, 
August, 1891) to prevent recurrence of the invagination 
by making a fold or plait in the mesentery, parallel with 
the long axis of the bowel, and securing it with a few 
sutures. The efficiency of this manoeuvre can, in the 
nature of things, only be verified by its successful use in 
many cases, but that the danger is real and serious is 
shown by the very considerable number of cases in which 
relapses have occurred, even directly after reduction, 
whether by injections or by operation. Thus Gould 
(Medical Press and Circular, 1891, ii., p. 385) reports a 
case in which he operated successfully upon a patient 
upon whom Hulke had also operated three months pre- 
viously ; and Pick (Lancet, 1891, i., p. 1312) had a recur- 
rence necessitating reopening the wound thirty-six hours 
after the first operation, the patient dying of shock 
finally. 
The method of dealing with doubtful and even half- 
sloughing gut demands a few words. Recent experience 
has shown that the isolation method suggested by Hahn 
for intestinal resection and suture, consisting in wrapping 
the sutured portion in iodoform gauze and allowing it to 
lie just within the abdominal wound, or even entirely 
outside of the wound on the wall of the abdomen, can be 
applied to such cases. If perforation should occur, the 
escaping contents would be taken up by the gauze and 
conducted outward, and the peritoneal cavity would not 
be infected. In a case reported by the writer (toe. cit.) 
in which reduction was accomplished with difficulty and 
the condition of the bowel was doubtful, the suspected 
loop was wrapped in iodoform gauze, the ends of which 
were brought out of the abdominal wound, and the latter 
packed with the same, its lips being prevented from gap- 
ing by being drawn against the packing with temporary 
sutures of silver wire or coarse silk. The patient was al- 
most moribund when the operation was performed, and 
died of shock, but the bowels moved before death, show- 
ing that this method can be employed in such cases with- 
out producing obstruction at the point where the gauze 
is packed around the bowel. If it is feared that the loop 
might be displaced by peristalsis, a strip of gauze can be 
passed around it, penetrating the mesentery at a point 
free from blood-vessels. 
If the intussusception be irreducible, Senn (loc. cit.) 
strongly recommends anastomosis, when there is no gan- 
grene of the sheath, if the invagination be small. If the 
intussusception, on the other hand, be large, he advises 
a preliminary resection of the intussusceptum through a 
552 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Intubation* 
Iodine. 
longitudinal incision in the sheath, after having secured 
the neck with a rubber ligature, the anastomosis being 
made subsequently. In either case the obstruction in the 
bowel is left unrelieved, but a passage is made around it 
for the circulation of the contents. Barker (Lancet, 1892, 
i., p. 79) appears to deserve the credit for the suggestion 
to remove the intussusceptum through a longitudinal in- 
cision in the sheath, but he advised it as a part of a form 
of circular suture, Lembert sutures being introduced 
around the neck before opening the sheath, and the two 
coats of the intussusceptum being sewed together by a 
few stitches through all the coats after the resection. 
Maunsell has lately ("Transactions of the Intercolonial 
Medical Congress of Australasia," 1889, p. 236) advocated 
a similar proceeding for all cases of intestinal resection, 
first making an artificial invagination of the portion to 
be removed. The danger of these methods lies in the 
liability to continued invagination, fresh portions of the 
gut becoming involved, and also in the possible occur- 
rence of stricture at the point of resection. Barker lost 
both of the cases upon which he operated, but through 
no fault in the method, and states that two others oper- 
ated upon according to a similar method gave no sign of 
stricture several months, and five years later. 
Kammerer {Medical Record, 1890, xxxvii., p. 113) re- 
ports a successful laparotomy for intussusception in an 
infant only six months old, which together with Sands's 
case {N. i. Medical Journal, 1877, xxv., p. 561) shows 
that extreme youth is no barrier to successful operation 
for this condition. Korte {Berlin, klin. Wochenschrift, 
1892, p. 652) found an ascending intussusception in a pa- 
tient upon whom he operated successfully-a variety 
which some suppose never to occur in the clinical form, 
although some cases of chronic intussusception have been 
reported in which this variety was found after death. 
Prolapsed intussusceptions have been frequently extir- 
pated by drawing them out of the anus until the upper 
limit could be reached, and sewing the layers together 
circularly before the intussusceptum was cut away. 
Until recently the sutures were passed through all the 
coats of the bowel at once, the surgeon inserting one fin- 
ger into the lumen of the intussusceptum until normal 
bowel was reached above, and assuring himself by press- 
ure between that finger and another outside, that there 
was no loop of bowel or other abdominal organ between 
the peritoneal surfaces of the intussusception, and then 
introducing a curved needle from without into the lumen 
of the intussusceptum under the guidance of the finger, 
and then out again, so as to make a stitch which took up 
a small portion of both layers of the intussusceptum. 
This was tied on the outside, and when the entire bowel 
had thus been surrounded with sutures above the neck 
of the intussusceptum, the latter was cut away just be- 
low the line of stitches. But a loop of bowel has occa- 
sionally been wounded in operating by this rather blind 
method, and, moreover, sutures thus introduced through 
all the coats of the bowel may be the cause of infection, 
leading it from the mucous membrane through the wTall 
of the gut into the peritoneal cavity. The latter danger 
has compelled the rejection of all methods of intestinal 
suture which depend upon such stitches, and although it 
is true that if the sphincter were paralyzed by stretching, 
or were divided, there would not be quite the same dan- 
ger in the rectum as elsewhere in the intestinal tract, be- 
cause the intra-intestinal pressure could be reduced to a 
minimum, yet there would certainly be some danger, 
and most modern surgeons would prefer the method 
suggested by Mikulicz (Wiener medizin. Presse, 1883, Nos. 
50 and 51). In this procedure the intussuceptum is 
drawn down until its upper limit is reached, and then a 
superficial incision is made on its anterior surface, and 
gradually deepened until the peritoneal cavity is opened, 
the vessels being tied as they are divided. A row of fine 
silk sutures is then inserted through the peritoneal coats 
only, like Lembert sutures, securing the peritoneal sur- 
faces of the two layers of the intussusceptum together. 
The posterior half is next treated in the same way, and 
then the intussusceptum is removed by dividing the inter- 
nal layer step by step, securing its cut edge to that of the 
(SUPPLEMENT.) 
outer (" middle") layer by sutures, taking up all but the 
peritoneal coat, as the incision is carried around the tumor. 
In this manner the peritoneal cavity is shut off before 
the bowel above the point of obstruction is opened, and 
this is a great advantage, for even if there is no fecal 
accumulation, it is impossible to cleanse this part before- 
hand. The danger of penetrating sutures, moreover, is 
avoided, and it is impossible to overlook any loops of 
bowel which may lie prolapsed between the coats of the 
intussusceptum. 
In case of emergency it might be well to remember 
the excellent expedient employed in three successful 
cases by Weinlechner and by Hofmokl, quoted by Mi- 
kulicz. They passed a stiff tube into the intussusceptum 
and ligated it at its neck upon the tube with a rubber 
ligature, allowing the ligated mass to slough off, by which 
time the adhesions were complete. This would answer 
very well where it was impossible to command the assist- 
ance and skill necessary for the operation of excision and 
suture, although the danger of sepsis from the sloughing 
process should limit the use of the method to such cases. 
B. Farquhar Curtis. 
IODANTIFEBRIN. This is prepared from acetanilide 
by substituting iodine for one hydrogen atom. Its for- 
mula is CelLINHCaHaO. It was prepared by Dr. Os- 
termayer, who also introduced iodantipyrin. It is a 
white crystalline powder insoluble in cold, but soluble in 
hot water and alcohol. The experiments of Dr. Oster- 
mayer showed that it was devoid of any therapeutic 
action. No effects were observed that could be attrib- 
uted either to the acetanilide or to the iodine, nor could 
either be detected in the urine after its administration. 
It appears that the iodine destroys the activity of the 
compound and that no absorption takes place. 
Beaumont Small. 
IODANTIPYRIN ; IODOPYRIN. This compound, in- 
troduced in 1891 by Dr. Ostermayer, is antipyrin in 
which one hydrogen atom has been replaced by iodine. 
Its formula is CnHnlNO. It forms in colorless, shin- 
ing, prismatic needles, not very soluble in cold water 
or alcohol, but readily soluble in either when hot. 
lodopyrin was supposed to be a soluble combination of 
the therapeutic properties of antipyrin and iodine, but 
experience has shown that in the stomach it is decom- 
posed by the hydrochloric acid, and forms antipyrin 
and iodide of sodium. The same object may be ob- 
tained by administering iodide of potassium and anti- 
pyrin. Its antipyretic effects are those of antipyrin. 
In typhoid fever, pulmonary phthisis, rheumatic fever, 
and other febrile conditions, it lowers the temperature 
rapidly, and lowers the pulse and respiration ; at times it 
produces a free perspiration. The dose is from seven 
and a half to twenty-two grains. The value of the iodine 
is uncertain, as no decided benefit has been traced to it. 
One case of a persistent headache, thought to be syphi- 
litic in character, is reported, in which a cure was effected 
in twenty-four hours. The iodine may be detected in 
the urine after fifteen to twenty-two grains have been 
given. Beaumont Small. 
IODINE TRICHLORIDE. A compound introduced 
by Langenbuch, of iodine and chlorine, made by pass- 
ing chlorine gas over iodine. It forms a reddish crys- 
talline powder, hygroscopic, very soluble in water, al- 
cohol, and glycerine, and has a pungent and disagree- 
able odor. It is a stable compound, and will keep for a 
long time in powder or in solution ; it must be dissolved 
in distilled water, as any organic matter decomposes it at 
once. When brought in contact with the pus and secre- 
tions of the tissues, it is at once decomposed and its con- 
stituents eliminated. It is a powerful antiseptic and 
bacteriacide ; a one per cent, solution sterilizes cultures 
of the ordinary pus-producers-staphylococcus and strep- 
tococcus. 
Belfield (Medical Record, vol. xiii., No. 3) has used it 
extensively in surgical practice. He considers that it 
combines the valuable properties of iodoform and hydro- 
553 Iodine, 
lodoplienin. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
gen peroxide. It is a more active antiseptic than iodo- 
form, and is more stable than the peroxide, remains longer 
in contact with the parts, and sterilizes all moist animal 
tissues as well as pus. Its disadvantages are its caustic 
properties when used in strong solutions, and its inju- 
rious action on instruments and clothing. It must be kept 
from the light and air. It has been used in various tu- 
bercular diseases and all forms of suppuration, and in all 
it proved of decided value. Internally the dose is one-fifth 
grain ; it is also used by hypodermic injections of one- 
tenth to one-half per cent, solution, and the same solu- 
tion is used for washing out the bladder, the urethra, 
and other sensitive mucous membranes. For irrigating 
wounds, a one to five percent, solution, either alone or 
with glycerine, may be employed ; for putrid surfaces, a 
five to twenty per cent, solution in equal parts of water, 
glycerine, and alcohol. Gauze may also be prepared by 
medicating with the solution. In eye affections, a one 
to five thousand solution is used as an ordinary anti- 
septic wash. Beaumont Small. 
IODOFORM. This drug has recently acquired a rep- 
utation as an antitubercular agent, and has been exten- 
sively employed in the treatment of the various forms 
of tuberculosis. In chronic abscesses, disease of bones, 
of joints, and of the tissues about the joint, and in all 
forms of tubercular disease subject to the surgeon's 
knife, iodoform may be applied to the affected part with 
as much confidence in its specific and curative action as 
has always been placed in it in the treatment of wounds 
of a simple character. It is well known to be antagonis- 
tic to the growth and extension of tubercle. It checks 
the growth of the bacilli and counteracts the ptomaines 
and other products of their growth, and evidence is now 
showing that it exerts a decided destructive action on the 
bacilli themselves. It was shown some years ago by 
Sanger and Braus 1 that the bacilli of tuberculosis and 
anthrax were both influenced by the presence of iodo- 
form, becoming lessened in number and weakened in 
virulence and infective power. Others have confirmed 
these facts, and among the more recent reports are the ex- 
periments of Drs. G. Troje and F. Tangl.1 They report 
the result of their investigations upon the effects of iodo- 
form, in the form of vapor, powder, and emulsion, upon 
cultures of the tubercle bacilli. It was found that the 
vapor killed the organisms after fifty days. After it had 
acted six days the growth was decidedly diminished, and, 
at the end of six weeks, had ceased. The powder, when 
strewn on the bacilli, rapidly checked their growth, and 
the culture when mixed with the powder, in the propor- 
tion of one part to fifteen, was rendered innocuous in 
eight days. A ten per cent, mixture of iodoform with 
oil or glycerine, was found to have greater destrucive 
properties than either the vapor or the powder. The oil 
proved somewhat stronger than the glycerine mixture. 
During their experiments they found that the influence 
of the emulsion was less when a mixture of the oil and cult- 
ure was injected in the tissues than when they remained 
outside the body. The tissues proved a suitable soil for 
the growth of the bacilli, and they acquired a new energy. 
It was also found that the bacilli, when acted upon by 
the iodoform, could be so weakened that only chronic 
forms of abscess followed their inoculation. In the cold 
abscess arising from bone disease and other chronic forms 
of suppuration, the bacilli are few in number and less 
active, and more readily acted upon by iodoform than 
the cultures outside the body, or when freshly inocu- 
lated. The conclusions they reached, as a result of their 
experiments, were : that iodoform is a true disinfecting 
agent, and that it has a direct poisonous action on the 
bacilli, if left sufficiently long in contact. 
In addition to the action on the bacillus, iodoform also 
exerts a stimulating action on the diseased tissue, and 
promotes an active granulating surface inclined to re- 
pair. It has been shown2 that the walls of a tubercular 
abscess consist of four layers: (1) a layer of thick po- 
rous tissue ; (2) a layer of spindle cells in active prolifera- 
tion ; (3) actual tuberculous granulations ; (4) necrotic and 
degenerated tissue. The two inner layers contain the 
(SUPPLEMENT.) 
bacilli, and these, under the action of the iodoform, dis- 
appear, and healthy granulations spring from the spindle- 
cell layer. 
Whatever may be the influence of iodoform, clinical 
evidence is very clear regarding its decided curative 
action. In a report of two hundred and fifty-five cases 
over forty per cent, were decidedly improved. Other 
authorities claim that eighty per cent, of all abscesses 
may be made to disappear by this treatment, and in our 
own journals the numerous reports of cases in which a 
cure has been effected indicate the value of the drug. 
To obtain the benefits of this method of treatment the 
remedy must be brought in direct contact with the dis- 
ease. As generally followed, the abscess is evacuated and 
washed with an antiseptic solution of carbolic acid or 
boracic acid, and a ten per cent, solution of iodoform is 
then to be injected. The amount to be used varies great- 
ly, from one or two drachms up to one and even two 
ounces having been recommended by various authorities. 
Bryant2 advises the use of two or three ounces ; Curtis 3 
and Darling4 find the most satisfaction by using from 
one to two drachms. The injections are repeated in ac- 
cordance with the recurrence of the pus and subsidence 
of the effects of the former injection, the time varying 
from a few days to two or three weeks. In contrast 
with this mild treatment are the heroic methods of the 
European surgeons. Professor Billroth5 has adopted this- 
method of treatment since 1881, and the results have 
exceeded his expectations. His method is to open the 
abscess with a free incision, and when its contents have 
been evacuated the walls are rubbed with iodoform 
gauze, the cavity washed with sublimate solution, and 
then stuffed with iodoform gauze until all bleeding 
ceases. Before opening the abscess he uses an Esmarch 
bandage, which is removed after the cavity is emptied. 
When the bleeding has been checked the gauze is re- 
moved, the emulsion poured in, and the wound stitched. 
If diseased bone is present it is scraped and cleansed also. 
In most of the cases the operation was followed by fever, 
varying in degree. In the most favorable cases there is 
very slight fever or pain, no tension, and healing by first 
intention ; the dressings are allowed to remain for two* 
weeks, the stitches are then removed and dressed again 
for another two weeks, when a cure is complete. Gen- 
erally there is sharp fever and pain, and serum escapes 
through the incision. In these cases the dressings are- 
removed every few days and drainage-tubes used until 
serum ceases to be discharged. If recovery does not 
take place in five or six weeks, the operation of opening 
the wound and cleansing the cavity is repeated. Profes- 
sor Jassinski6 reports the result of eighty-six cases treated 
by aspirating and injecting with the emulsion. The re- 
sults were much the same. A number healed without 
further interference, and others had to be opened and 
treated by washing and pouring in the emulsion. Fever 
and pain generally followed, but in no case was there- 
any toxic action produced, although as much as one- 
hundred and eighty grammes were injected. 
In tuberculous disease in which suppuration has not 
taken place, the emulsion (from ten to twenty minims) is- 
injected into the diseased tissue and made to diffuse itself 
by gentle massage. In enlarged glands the same treat- 
ment is adopted, and also in tubercular disease of the 
testes, bladder, and rectum, and in tubercular empyema. 
The iodoform is prepared for use by dissolving in alco- 
hol, or ether, or by forming an emulsion with oil or glyc- 
erine. The formula of the emulsion used by Mosetig- 
Moorhof, who first used iodoform for this purpose, was : 
iodoform, 10 parts ; ol. ricini, ol. amygdalae, aa 15 parts. 
This has passed through various modifications, until at 
present a ten per cent, mixture is very generally adopted, 
and oil or glycerine is the menstruum selected. The 
alcoholic or ethereal solutions are not so frequently em- 
ployed, on account of the pain and irritation that follow 
their use. They are, however, more diffusible, and cor- 
respondingly more active. The more concentrated solu- 
tions, particularly the ethereal, are very unstable, iodine 
being set free and coloring the solution. The prepara- 
tions should be recent, and the oil employed should be 
554 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Iodine, 
lodoplienin. 
sterilized. This may readily be done by boiling for half 
an hour. Camphor increases the solubility of iodoform, 
and a six per cent, solution may be obtained by using a 
saturated solution of camphorated oil. The use of oil 
heated to 100° F. will allow of more iodoform being dis- 
solved. and this is now recommended as a more efficient 
way of securing a suitable solution. 
There is very little danger of toxic symptoms, espe- 
cially if the emulsions are used. Whenever any constitu- 
tional disturbance has occurred it has generally been in 
cases where the ethereal or alcoholic solution was used. 
No definite quantity that may be injected with safety has 
been determined. In some instances a few grains have 
caused much trouble, and in others very large amounts 
have been used with perfect safety. When the system is 
affected there is a sense of lassitude and sickness, a bad 
taste in the mouth, accompanied by headache, restless- 
ness and delirium, and fever in some cases, and in 
others by drowsiness and collapse. Bromide of potas- 
sium is said to act as an antidote, not only as a neutral 
potash salt, but also by its specific bromide action. This 
is thought to arise from its solvent properties for iodo- 
form. The presence of iodine in the saliva may be de- 
tected by placing in the mouth a piece of silver, when a 
garlic taste is immediately developed. The saliva may 
also be tested by mixing it with calomel. If iodine be 
present a canary-yellow color is produced, due to the for- 
mation of iodide of mercury. 
Iodoform has been employed in the treatment of 
tuberculosis of the respiratory organs, but not with so 
much success as in the forms of tuberculosis in which it 
may be applied directly to the part. Its administration 
by the mouth was found to be very uncertain in its 
action, and to cause gastric irritation. This method has 
been replaced by subcutaneous injections which convey 
the drug more directly to the lung tissue and enable it 
to act more energetically. It is said to lessen the muco- 
purulent secretion and render it more fluid. It softens 
the hardened tissues and allows the air to permeate 
deeper into the lungs. Although it is not thought to act 
on the cause of the disease, it aids the elimination of the 
broken-down tissue and favors the cicatrization of the 
ulcerated surfaces in the alveoli. The ethereal solution, 
or an emulsion of sterilized oil, may be used. The dose 
for internal administration is one-third to one-sixth grain 
several times a day, or, if used hypodermically, two doses 
in the day will be sufficient. In tubercular phthisis it is 
more frequently combined with guaiacol for hypodermic 
injections, and in this form has given much satisfaction. 
Beaumont Small. 
1 Berlin, klin. Woch.. November 20, 1891. 
2 New York Medical Journal, February 20, 1892. 
3 Ibid., August 27, 1892. 
4 Ibid.. October 29, 1892. 
6 British Medical Journal, April 19, 1890. 
6 Ibid., July 5, 1890. 
IODOL (Tetra-iodo-pyrrol). This compound of io- 
dine may be prepared by dissolving pyrrol in alkaline 
water and mixing it with a solution of iodine in iodide 
of potassium. The precipitate is collected, dissolved 
in alcohol, and reprecipitated. It is also obtained 
by the reaction that takes place when alcoholic solu- 
tions of pyrrol and iodine are mixed for twenty-four 
hours. Iodol separates when the mixture is added to 
water. 
It is a pale yellow, finely crystalline powder. It is 
without taste and does not possess any disagreeable odor. 
It is insoluble in water, and very slightly soluble in 
dilute alcohol. Strong alcohol dissolves one part in six ; 
glycerine, one part in thirty-four. Iodol is very soluble 
in ether and chloroform. It contains about ninety per 
cent, of iodine. Heated to 140° or 150° C. it is decom- 
posed with the evolution of violet iodine vapors. 
Iodol was introduced in 1885 by Ciamician and Silber, 
as a substitute for iodoform, its freedom from any dis- 
agreeable odor being a decided advantage. Like iodo- 
form it does not rank high as a germicide, but it has the 
(SUPPLEMENT.) 
same power of inhibiting the growth of bacteria and 
maintaining a surface clean and aseptic. To wounds, 
ulcers, and all suppurating surfaces it is applied in the 
same manner as iodoform, by dusting the powder on the 
part, or making it into an ointment with lanoline or vase- 
line. It may also be used in solution of alcohol, ether, 
or coilodium. Ether, 5 parts ; coilodium, 50 parts ; 
iodol, 1 part, is a favorite combination for local appli- 
cation. For gynaecological purposes a solution of io- 
dol, spirits, and glycerine, 1 : 16 : 34, may be used for 
saturating tampons, etc. Its local use has been highly 
recommended for ulcerations of the nose, pharynx, and 
larynx, particularly when due to a tuberculous or syph- 
ilitic cause. 
Iodol has been employed internally with success in 
conditions of the stomach and intestines accompanied by 
putrefactive and fermentative changes. It has been used 
with success in gastro-intestinal catarrh and ulceration 
of the mucous membrane. When its action is directed 
to the stomach it should be given in the intervals between 
meals ; when it is desired to act on the intestinal canal 
the most favorable time for its administration is immedi- 
ately at the close of the digestive process. As its con- 
stituent iodine is excreted in part by the pulmonary or- 
gans, it has been used in bronchitis, phthisis, and various 
diseases of this locality. In these conditions, in addition 
to its internal administration, inhalations and insuffla- 
tions were used. In syphilis it is also recommended : in 
tertiary forms of the disease it has given the greatest 
success. It is well borne by the system, having no effect 
on the temperature, circulation, or respiration ; iodism 
is of very rare occurrence. It is also thought to be of 
benefit in diabetes. The dose is from five to fifteen 
grains, two or three times a day : it should be given in 
wafers or pill form. Although the proportion of iodine 
is very large, toxic effects are very rarely noticed. The 
iodine is evolved very slowly, and its action is slow and 
gradual. Beaumont Small. 
IODONAPHTHOL - BETA (Naphthol-beta di-iodide). 
This derivative of iodine was introduced by Dr. Braille 
(Hepert. de Phar., November 10, 1891) as a substitute 
for iodoform, aristol, and other iodine compounds. It 
is prepared by mixing a solution containing 24 grammes 
of iodine and 27 grammes of potassium iodide with an- 
other solution containing 110 grammes of naphthol-beta 
and 40 grammes of caustic soda. There is then added 
a little solution of the hypochlorite of sodium corre- 
sponding to ten times its volume of chlorine. Iodo- 
naphthol is then precipitated. It is a greenish yellow 
powder, inodorous, tasteless, insoluble in water, very 
slightly soluble in alcohol, but soluble in ether and 
chloroform. 
It is recommended for the treatment of wounds, ulcers, 
and all conditions in which iodoform and other anti- 
septics are employed. It is applied as a powder dusted 
on the part affected. Beaumont Small. 
IODOPHENIN (lodophenacetin). This compound of 
iodine and phenacetin was described by Dr. Schol- 
vein, in 1891, at a meeting of the Berlin Pharmaceuti- 
cal Society. It contains fifty per cent, of iodine and 
forms in steel-blue crystals, with an odor of iodine, and 
a burning taste ; it colors the skin yellow. It is insolu- 
ble in water, soluble in alcohol and glacial acetic acid. 
Heated, or even when mixed with water, it is decomposed 
and iodine is set free. 
Owing to the looseness with which the iodine is re- 
tained in combination, it is recommended as a useful an- 
tiseptic. Experiments show that it possesses this prop- 
erty in a marked degree, but also has the irritating effects 
of free iodine, and it is doubtful if it has any advantage 
over pure iodine. 
When employed as an internal remedy it forms com- 
binations with the alkalies of the intestinal canal, and, 
from the readiness with which iodine is given up, poison- 
ous symptoms often follow the use of even small quan- 
tities. Beaumont Small. 
555 lodo-Salicylic Acid. 
Jamaica. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
IODO-SALICYLIC ACID. A compound of iodine and 
salicylic acid in which one atom of hydrogen is replaced 
by one of iodine. It contains fifty per cent, of iodine. 
A di-iodo-salicylic acid is also prepared in which two 
atoms of hydrogen are replaced by iodine. It contains 
two parts of iodine in three of the compound. They are 
white, fine crystalline powders, slightly soluble in water, 
soluble in alcohol, ether, fixed oils, and collodion. 
They possess the combined action of iodine and sali- 
cylic acid, and are said to be very serviceable antiseptics. 
Internally, in doses from twenty to sixty grains daily, 
they have proved servicable in rheumatism and have suc- 
ceeded in relieving the fever and pain when the other 
salicylates have failed. 
Sodium di-iodo-salicylate. This salt occurs in white 
needles, and is recommended as an antithermic and anti- 
rheumatic. It is also said to be of great value as a local 
application in parasitic affections of the skin. The dose 
for internal administration has not been determined. 
Beaumont Small. 
IODOSULPHATE OF CINCHONINE (Antiseptol). 
This compound is obtained by the action of iodated 
iodide of potassium upon a solution of sulphate of cin- 
chonine, twenty-five parts to two thousand of water. It 
contains fifty per cent, of iodine. It is a very light, 
brownish powder, odorless, insoluble in alcohol and chlo- 
roform. 
It is an antiseptic and is said to pro^e serviceable in all 
conditions in which iodoform and similar compounds are 
employed. It may be combined with powdered talcum, 
one part to two ; or mixed with vaseline or lanoline, one 
part to ten. Beaumont Small. 
JAMAICA. Brief mention was made of this island in 
the article on the climatology of the West Indies in Vol. 
VIL, but owing to its increasing importance as a health 
resort and as a winter residence for invalids and others 
from the United States and Canada, it has been thought 
advisable to give a rather more detailed account of its 
climatic and other advantages in the present volume. 
Jamaica, a British colony, is an island in theCaribbean 
Sea, lying between 17° 43' and 18° 32' North latitude, and 
76" 11' and 78° 20' 50" West longitude. It is about 90 
miles south of Cuba, nearly 5,000 miles from Southamp- 
ton, and a little more than 1,400 miles from New York. 
It is 144 miles in length and from 21i to 49 miles in 
(SUPPLEMENT.) 
width. The surface of the island is crumpled up into a 
central mountain range with numerous outlying spurs. 
The highest points of this range, contrary to the usual 
rule, are in the eastern portion, whence the surface slopes 
irregularly toward the west, where the only level parts 
of any extent are found. There is one principal range, 
called the Blue Mountains, running east and west through 
the centre of the island, and from this secondary ridges 
run north and south, themselves giving off other and 
shorter spurs in a direction parallel to the central range. 
The highest point is Blue Mountain Peak which rises to 
an elevation of 7,360 feet ; Catherine's Peak has an alti- 
tude of over 5,000 feet, and there are several others, vary- 
ing in height from 4,000 to 5,000 feet. The island is in 
general well watered, the abundance of rivers and springs 
in most parts giving plausibility to the generally accepted 
interpretation of the name, Jamaica, which is believed to 
have signified in the aboriginal tongue the "Isle of 
Springs," or the " Land of Wood and Water." 
It is difficult, in a brief article of this nature, to describe 
satisfactorily the climate of Jamaica, as owing to the 
diversity of elevation and other causes, it varies greatly 
in different parts of the island ; in some parts it is hot, 
in others temperate and even cool ; in some it is dry 
in others the rainfall is very great ; and indeed the only 
characteristic common to all the varying climates of 
Jamaica is equability. Thus at the sea-coast the average 
temperature is 78° F. (the extreme range for the entire 
year being only 35° F.), while on the mountains at an 
elevation of between 4,000 and 5,000 feet the mercury 
ranges from 50° to 70° F., occasionally falling, on the 
summit of the highest peak and in midwinter, even to 
the freezing-point. In the accompanying charts, com- 
piled from the official figures in the " Handbook of Ja- 
maica," the mean temperature is given for the city of 
Kingston, and this may be regarded as the mean maxi- 
mum for the entire island. Unfortunately, systematic 
observations of the variations of temperature in the more 
elevated portions of the interior are wanting, but numer- 
ous unofficial readings of ordinary thermometers, taken 
with more or less regularity for a number of years by 
private individuals, show that the indoor temperature in 
places in the interior is on an average from 5° to 15° be- 
low the figures here given. From June, 1880, to the end 
of the year 1886 the readings of the thermometer were 
taken at eight-hour intervals, to wit, at 7 a.m. and 3 and 
11 p.m., but since that time at 7 a.m. and 3 p.m. only. 
Januarj' 
February 
March 
April 
May 
June 
July 
August 
September.... 
October 
November.... 
December.... 
Means ortotals 
Month. 
Barometrical press- 
ure (Inches). 
For 
i 
0.054 
0.049 
0.034 
0.008 
9.97! 
0.001 
0.024 
9.983 
9.951 
9.937 
9.962 
0.005 
the Ten Y< 
78.1 
74.6 
74.7 
75.8 
77.9 
79.4 
80.8 
81.1 
80.4 
80.1 
78.9 
77.8 
75.7 
Mean. 
Temp 
(Deg 
3 
00 
86.4 
85.8 
85.7 
86.5 
87.2 
88.5 
89.7 
89.4 
89.7 
38.9 
88.9 
87.0 
Maximum. 
104 
66.8 
•16.8 
67.8 
69.8 
72.4 
73.8 
73.5 
73.2 
73.3 
72.1 
70.7 
68.4 
Minimum. 
?ratu 
rees). 
?ars f 
g 
Range. 
cd 
o 
1 
s 
68 
77 
68 
74 
115 
103 
80 
70 
56 
53 
57 
Wind, m 
diem 
les per 
p 
CD 
g 
29 
27 
29 
39 
56 
57 
52 
55 
62 
58 
44 
38 
Cloud, per 
of whole 
centage 
sky. 
1880 
co 
78 
78 
77 
75 
78 
[ 78 
76 
79 
80 
81 
78 
78 
Humidity. 
o 
op 
£ 
0.96 
0.32 
1.59 
1.02 
6.00 
5.51 
2.15 
4.09 
3.59 
4.69 
1.22 
1.50 
Kingston. 
Rail 
(Incl 
i 
3.87 
2.62 
2.88 
4.18 
8.40 
7.83 
4.32 
6.83 
6.86 
7.84 
5.07 
5.60 
The island. 
ifall 
les). 
8 
g 
68.4 
69.6 
70.4 
74.9 
77.1 
79.0 
78.6 
76.8 
76.9 
75.6 
72.7 
69.8 
7 A.M. 
84.7 
o ix io ex ix ex c© io ix c© co 
3 p.m. 
lean 1 
(D 
87.5 
86.8 
86.7 
S5.8 
86.3 
87.0 
87.7 
90.4 
91.2 
89.4 
87.1 
84.1 
87.1 
Maximum. 
empe 
egrees 
CT 
66.5 
66.9 
67.4 
71.9 
73.1 
74.9 
75.0 
74.5 
74.4 
74.0 
69.3 
69.4 
Minimum. 
rature 
0- 
16.0 
20.3 
19.8 
18.4 
14.4 
13.9 
12.8 
15.4 
16.7 
15.0 
13.1 
14.8 
17.7 
Range. 
91.5 
90.4 
. 90.2 
1 91.4 
89.1 
91.0 
90.9 
96.1 
96.7 
91.7 
91.7 
89.9 
89.3 
Maximum. 
Extr 
P 
(I 
for the 
67.7 
61.5 
63.6 
63.2 
68.4 
69.9 
72.2 
72.0 
70.0 
70.5 
70.3 
66.9 
63.9 
Minimum. 
?me of 
eratur 
Jegrees 
: Year 
8 
bo 
28.9 
26.6 
28.2 
20.7 
21.1 
18.7 
24.1 
26.7 
21.2 
21.4 
23.0 
25.4 
Range. 
tem- 
D. 
1891. 
•s 
£ 
53.9 
127.1 
73.5 
70.0 
63.5 
112.7 
116.7 
69.8 
41.6 
77.8 
63.1 
77.1 
Wind, miles per 
diem. 
co 
50 
13 48 
30 40 
25 42 
31 53 
48 63 
50 74 
38 62 
44 , 74 
56 84 
74 90 
36 68 
23 61 
7 a.m. 
3 P.M. 
Cloud, per- 
centage of 
whole sky. 
8 
84 
79 
80 
78 
78 
76 
72 
79 
SO 
84 
88 
83 
7 a.m. 
Humid- 
ity. 
8 
69 
99 
li 
1 69 
99 
; 99 
99 
K9 
( 19 
69 
99 
09 
3 P.M. 
28.86 
0.41 
0.27 
0.04 
1.25 
2.03 
6.47 
. 0.49 
3 08 
1.54 
9.10 
3.95 
0.23 
Rainfall, Kingston 
only (Inches). 
Meteorological Charts for the City of Kingston, Jamaica. (Compiled by Maxwell Hall, M.A., F.R.A.S., F.R.M. et S.) 
During the entire period the highest temperature observed 
was 96.1° F., recorded on September 12,1880, and the low- 
est was 56.7° F. recorded on December 4, 1887. The abso- 
lute maxima and minima are not given in the first table ; 
but their averages are about four degrees above and below 
the maxima and minima deduced from the daily readings. 
The most striking peculiarity of the climate of Jamai- 
ca is its variety combined with equability. A ride of a 
few miles into the hills will bring one from the torrid 
zone to the temperate-from an average temperature of 
nearly 80° F. to one of 65° or 70° F. But whatever dis- 
trict one may select, whether a warm or a cool one, he 
556 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
lodo-Sallcylic Acid. 
Jamaica. 
will find the temperature very nearly constant, the ex- 
treme range for any one month being seldom over 25° F., 
while that for the entire year at Kingston is but 35° F., 
and in some parts of the island the excursions of the 
mercury are even more restricted than this. As regards 
humidity, also, there is the same choice of climate open 
to the invalid or the pleasure-seeker, who may select a 
place of residence with a humid or a dry atmosphere as 
suits best his inclinations or the necessities of the affec- 
tion from which he suffers. Jamaica, indeed, enjoys all 
the advantages in respect to uniformity of temperature 
of island climates in general, while the differences in ele- 
vation and in exposure to, or protection from, the prevail- 
ing trade winds, give to it the pleasing diversity, as re- 
gards temperature, humidity, and rainfall, of the most 
temperate of continental climates. 
In the first of the meteorological charts the rainfall is 
given in two columns, one for Kingston and the other 
the average for the whole island. There is, as a rule, less 
rain in Kingston than in most of the other parts of the 
island, the trade winds being drained of their moisture by 
the mountains to the north and east of the city. The heav- 
iest precipitation occurs in the Parish of Portland, which 
forms the northeastern extremity of the island. There 
are two principal rainy seasons, namely in May and Oc- 
tober, but there is usually more or less rain all through 
the summer months ; in the winter season in the neigh- 
borhood of Kingston the precipitation is very light. The 
rain usually comes in heavy showers of only a few hours' 
duration, and the days during which the sun does not 
shine at all are very rare. It is always possible to tell 
when rain is coming, as it can be seen, quite a while before 
its arrival, advancing from the mountains, thus giving 
one ample time to get under cover before the downpour 
begins. This is fortunate for the visitor, as a wTetting is 
one of the three things that an unacclimated person in 
the tropics must avoid, the other two being exposure to 
the direct rays of the noonday sun and to the cool night 
air. 
The population of Jamaica, according to the census of 
1891, is 639,491, an increase of about 60,000 since the cen- 
sus of 1881, and of 133,000 since that of 1871. The cap- 
ital and chief city is Kingston, the largest and most 
important as well as the healthiest seaport town of the 
British West Indies. It is a city of 48,500 inhabitants, 
situated on gently sloping ground on the shores of a large 
land-locked harbor. The land on which the city lies is a 
gravel bed, and as it has a slope to the sea of about ninety 
feet to the mile the natural drainage is excellent. The 
water supply is drawn from two rivers at a distance of 
several miles from the city, and, as regards freedom from 
contamination, is above reproach. 
The Myrtle Bank Hotel, pleasantly situated on the 
shore of the bay near the outskirts of the city, affords ex- 
cellent accommodation for visitors, and there are also 
several other hotels and a number of boarding-houses 
where one may live modestly and at moderate expense. 
Another well-built hotel, having accommodation for one 
hundred and fifty to two hundred guests, is at Constant 
Spring, six miles from Kingston, near the foot of the 
mountains which enclose in the form of an amphitheatre 
the Liguanea plain. The hotel lies at an elevation of 
five hundred feet above Kingston, and from it is had a 
fine view of the harbor and Caribbean Sea beyond. The 
temperature here is uniformly ten to twelve degrees 
lower than that of the city. Other comfortable hotels 
are found in Santiago de la Vega, usually called Spanish 
Town, which was formerly the capital of the island, and 
at Moneague, a charming spot in the Parish of St. Ann, 
on the northern slope of the central mountain range. 
Mandeville, a beautiful little place in the hills, celebrated 
for its delicious oranges, is a favorite resort for Jamai- 
cans from Kingston and other coast towns who may feel 
the want of a change of air and scene. There are a hotel 
and several boarding-houses here, but intending visitors 
must take the precaution to apply in advance if they 
would be sure of being well suited. Among the coast 
towns on the north side of the island, Lucea, St. Ann's 
Bay, and Montego Bay are the most important from the 
point of view of the tourist and the invalid. In these and 
the other towns of the island visitors may find accom- 
modation at various boarding- and lodging-houses ; about 
which, however, it would be wise to inquire before mak- 
ing a selection, as they are of varying degrees of excel- 
lence and the reverse. 
At Port Henderson, on the southern shore of the island, 
at the entrance to Kingston harbor, there is a saline cal- 
cic spring which is said to possess tonic properties of no 
mean order and is much resorted to as a bath by conva- 
lescents and others from the neighboring districts. There 
is also a good beach for sea-bathing. There are several 
buildings here in good order, but the accommodations 
are not extensive. The place can readily be reached, 
however, by a steam launch from Kingston in forty-five 
minutes. No analysis of the water of the spring has 
ever been published. 
The diseases for the climatic treatment of which Ja- 
maica is well suited are bronchitis, fibroid phthisis, in- 
cipient pulmonary tuberculosis, catarrhal affections of 
the respiratory passages, Bright's disease, rheumatism, 
various forms of dyspepsia, and nervous prostration. All 
parts of the island are naturally not suitable for the treat- 
ment of all these varied affections, but for each one a 
locality exists where the patient can find the climate es- 
pecially adapted to the necessities of his particular dis- 
ease. Respiratory affections especially do well in this 
mild and equable climate, as may be judged from the 
records of one of the life insurance companies doing busi- 
ness on the island, which show that the company lost but 
one life from diseases of the respiratory organs (bronchi- 
tis) during a period of thirty-five years. Patients suffer- 
ing from these troubles are relieved in almost any part 
of the island, although there is even here a choice, as 
cases with scanty expectoration are most benefited in 
those districts where the atmosphere is most laden with 
moisture, while those in which there is free or even pro- 
fuse secretion are more quickly relieved in the neigh- 
borhood of Kingston and other parts where the humid- 
ity of the air is at a minimum. Patients with nervous 
prostration receive more benefit from a stay near the sea- 
shore than they do in the uplands, and the same is in a 
measure true of dyspeptics, especially of those in whom 
the gastric trouble is partly nervous in its origin. Suf- 
ferers from Bright's disease do well, as a rule, in all parts 
of the island, except possibly in the most elevated regions, 
where in the winter months the thermometer is apt to fall 
a little too low after the sun goes dowm, and where, es- 
pecially on the northern slope, there is at times rather 
too much rain to be agreeable. The same remarks apply 
also in the case of rheumatic patients, but the latter 
would do well to take a course of the waters at one of the 
numerous mineral springs, of which a few words may be 
said in closing this article. 
There are several medicinal springs in Jamaica, some 
thermal and others cold, which possess therapeutic prop- 
erties of no little value, and which are deserving of more 
careful study by balneologists than they have hitherto 
received. The most important of These, or at least the 
best known and the only ones at which passable accom- 
modations for visitors are as yet provided, are the Bath 
of St. Thomas the Apostle, about a mile from the town 
of Bath, in the Parish of St. Thomas, the Jamaica Spa, at 
Silver Hill, in St. Andrew's Parish, and the Milk River 
Bath at Vere, in the Parish of Clarendon. The first of 
these is a thermal sulphur, the second a chalybeate, and 
the third a thermal saline water. The table on the next 
page, extracted from a brochure on the " Mineral Springs 
of Jamaica," by the Hon. J. C. Phillippo, M.D., shows 
the results of analyses of these three and two other springs 
on the island. All of these springs are quite easily acces- 
sible from Kingston. 
The limits of this article will not permit of a detailed 
description of each of these springs, but the subjoined 
analyses will suffice to indicate their character and to 
suggest their therapeutic application. The waters of one 
or the other of the springs are of value, taken internally 
and applied in the form of baths, in the treatment of gout, 
rheumatism, chronic bronchitis, catarrhal conditions of 
557 Jamaica. 
Joints, Diseases of. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Mineral Springs of Jamaica 
(SUPPLEMENT.) 
Handbook of Jamaica," published annually in London 
and Kingston. Thomas Lathrop Stedman. 
JAMBUL. This is the local name applied to the bark 
and seeds of Sizygium Jambolanum De Candolle \Eugenia 
Jambolana Lamarck), a tree belonging to the natural 
order Myrtacese. It is indigenous to tropical Asia and 
the neighboring islands, where it grows to a large size 
and bears a crop of edible fruit in July and August. It 
is also known as rose apple and Java plum. The Eugenia 
pimenta, the common allspice tree, and Eugenia cargo- 
phyllata, from which cloves are obtained, are both 
closely allied species. The fruit varies in size from a 
cherry to a pigeon's egg, and when ripe is olive-shaped, 
smooth, juicy, and purplish-black in color. It contains 
a single seed, which is enclosed in a thin, papery shell. 
All parts of the tree are astringent, and the bark fur- 
nishes a beautiful brown dye. The bark is smooth and 
whitish, and the cell-structure contains a number of char- 
acteristic pitted cells which are visible to the naked eye. 
The chemical constitution of the plant has not received 
much attention. It probably contains an alkaloid or 
glucoside, but none has been separated so far. A white 
crystalline substance has been obtained, termed jambo- 
rine, which is tasteless, insoluble in cold water, soluble 
in alcohol, ether, and chloroform. It is said to possess 
the active properties of the seeds, but its composition and 
properties are uncertain. The following analysis of the 
seeds has been furnished by Elborne ; Essential oil, a 
trace ; chlorophyll and fat, 0.27 ; resin soluble in alcohol 
and ether, 0.30 ; gallic acid, 1.65 ; albumin, 1.25 ; color- 
ing matter, 2.70 ; moisture, 10.0 ; insoluble residue, 83.73. 
The plant is highly esteemed in India for its medicinal 
properties, and is used by the native physicians in the 
treatment of many diseases. The sap or juice expressed 
from the leaves and bark contains the astringent proper- 
ties of the plant, and when mixed with goat's milk is 
thought to be particularly beneficent in the intestinal 
disorders of children. The juice, and an infusion of the 
bark, are also employed in dysentery, diarrhoea, and in 
leucorrhoea. A liquor, jambava, is prepared from the 
fruit by fermentation ; it possesses a stimulating and 
tonic action, and is a favorite beverage of the Hindoos. 
The most important use of jambul is as a remedy for 
diabetes, and it is in the treatment of this disease that it 
has acquired notoriety and attracted the attention of the 
profession during the past few years. It has long been 
employed for this purpose in the East, where it has the 
reputation of producing a rapid and, in many instances, 
a permanent cure. The quantity of sugar and urine is 
reduced, the many distressing symptoms relieved, and a 
return of health and strength is said to follow its admin- 
istration. This treatment was brought to the notice of 
the English physicians in 1883, by Banatvala, a medical 
officer in the service of the Madras government, and has 
been the subject of numerous clinical and experimental 
researches. 
Von Mehring and Graser1 performed an important 
series of experiments to demonstrate its power to check 
the production and lessen excretion of sugar. They pro- 
duced artificial diabetes in animals by the administration 
of phloridzin, and carefully estimated the amount of 
sugar excreted when phloridzin was given alone, and 
when it was given in combination with jambul. The 
diminution was found to be invariable and very decided. 
The following figures indicate the results in three exper- 
iments : 
Sugar excreted without jambul 12.2 10 10 
Sugar excreted with jambul 2.1 1 1.5 
They also proved that it was devoid of any toxic ac- 
tion, as very large quantities were given without pro- 
ducing any ill effects. 
Experiments have also been made to show its inhibitory 
action on saccharine fermentation by adding it to a solu- 
tion of starch and malt, and it has been clearly shown that 
the quantity of sugar is reduced in accordance with the 
amount of jambul present. In one instance it was found 
One Pint contains: 
Milk River Bath. 
(Analysis by Sa- 
rony and Moore.) 
1 St. Thomas the 
Apostle. (Anal- 
ysis by Bowrey.) 
Jamaica Spa. 
I (Analysis by E. 
Turner.) 
Silver Hill 
Spring. (Anal- 
ysis by Bowrey.) 
M a n a t e e Bay 
Spring. 
Carbonate of sodium 
Carbonate of iron 
Carbonate of calcium 
Chloride of potassium 
Chloride of magnesium.... 
Chloride of sodium 
Grains. 
Grains. 
0.21 
Grains. 
Grains. 
Grains. 
1.44 
0.04' 
0.866 
2.71 
37.08 
4.34 
186.93 
1.48 
0.125 
52.52 
Chloride of calcium 
13.50 
1.31 
Chloride of lithium 
traces. 
Sulphate of sodium 
27.93 
0.79 
0.341 
Sulphate of magnesium . .. 
Sulphate of calcium 
Sulphate of iron 
Sulphate of aluminium.... 
Phosphate of aluminium .. 
Iodide of sodium 
2.831 
1.745 
0.62 
1.234 
2.210 
0.833 
4.168 
1.360 
traces. 
traces. 
Bromide of sodium 
traces. 
Bromide of potassium .... 
Bromide of magnesium.... 
Silicate of sodium 
traces. 
traces. 
0.45 
Silica .... 
traces. 
0.883 
Totals 
266.88 
3.59 
10.075 
6.521 
60.88 
Temperature (Fahrenheit). 
Sulphuretted hydrogen.... 
92° 
130° 
63° 
mined. 
the stomach and intestines, constipation from abdominal 
plethora, hepatic and other congestions of the abdominal 
viscera, amenorrhoea, anaemia and chlorosis, various forms 
•of skin diseases, tertiary syphilitic lesions, and chronic 
malarial affections. The Government has made grants 
from time to time for the improvement and care of the 
buildings at these baths, but there is yet much to be de- 
sired in the matter of cuisine, bathing facilities, attend- 
ance, and other things that contribute to the comfort and 
entertainment of the invalid. In the absence of these 
•desiderata they still possess the great advantage that they 
may be visited in the winter season, when the more pre- 
tentious and better equipped spas in Europe and the 
United States are closed. 
There are several lines of steamers running between 
■Jamaica and New York, Boston, and Halifax, the voyage 
from New York being made in from four to six days. 
During one season steamers plied between Tampa, Fla.; 
and the north shore of Jamaica, and it is probable that 
this service will be resumed again as soon as the railroad 
.across the island, now nearly completed, is open for travel. 
There is usually no lack of amusements in Kingston in 
the way of horse races, yachting, tennis and cricket 
matches, etc., and there is also a theatre where perform- 
ances and concerts are given occasionally during the 
winter. The roads throughout the island are up to the 
best English standard and the facilities for riding and 
driving are unsurpassed. A railroad runs from Kingston 
in a northwesterly direction to Montego Bay, with a 
branch line to Anatto Bay and Port Antonio, towns on 
the north shore. Communication with the coast towns 
is had also by steamers which sail around the island once 
a week, leaving Kingston every Tuesday. There is fre- 
quent mail communication with the United States and 
Canada, and the island is also connected with this coun- 
try by cable. Churches of all the leading denominations 
are found nearly everywhere, and in most of the larger 
towns are well-appointed clubs, libraries, and social or- 
ganizations of various sorts. 
The best months in which to visit Jamaica are Novem- 
ber to April inclusive, as these are the coolest and dryest 
of the year, but one accustomed to the fierce summer 
heats of our northern cities would find a grateful change 
in the hills of Jamaica even in midsummer. 
Much valuable information concerning Jamaica as a 
health resort may be obtained from a work on "The 
■Climate of Jamaica," by the Hon. J. C. Phillippo, M.D., 
published by T. & A. Churchill, London, and from " The 
558 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Jamaica. 
Joints, Diseases of. 
that a solution of rice starch with a definite proportion 
of malt produced 27.4 parts of sugar ; when fifteen grains 
of jambul were added the amount was reduced to 9.4 
parts, and when twenty-five grains were used there was 
only 1.3 part of sugar formed. 
Accompanying this evidence in favor of the drug have 
been a number of reports of cases treated, and in nearly 
all it was found that the desired effect was produced in a 
greater or less degree. Among these are reports by such 
observers as Kingsbury,2 Saundly,3 E. H. Fenwick,4 
Mahomed,6 Egasse,6 Villy,1 Lewaschewq8 Lawrence,9 
and Britto.10 In some of the cases in which it was used it 
failed altogether, in others the sugar reappeared immedi- 
ately the remedy was discontinued, and frequently it 
would only lessen the symptoms in a slight degree ; but 
the general tenor of the reports is in favor of the remedy. 
Villy, who views this treatment more sceptically than 
any of the others, acknowledges that it is of service " in 
cases of moderate severity, provided the diet be abso- 
lutely restricted." 
In reviewing these reports, there is apparent a great 
deal of uncertainty in the employment of the drug. 
Some of the cases were treated with small doses and the 
most satisfactory results were obtained ; in other instances 
the reporters state that in larger quantities only can any 
benefit be expected. The same variation is observed in the 
dieting of the patients : some were allowed to eat freely 
of any food they desired, while others were restricted to 
a proper diabetic regimen, and in both classes were suc- 
cesses and failures recorded. A more scientific turn has 
been given to the study of the remedy by the British 
Medical Association, in empowering its therapeutic com- 
mittee to inquire into the mode of action. A supply of 
the fresh seeds was obtained and furnished, with certain 
directions, to such of its members as desired to make use 
of them. 
How the drug acts, or what are the forms of the disease 
in which it is indicated, have not been determined. It has 
been thought to act by simply checking the transforma- 
tion of starch into sugar, producing the same effect as a 
carefully prepared diet; but the experiments of Graser 
would indicate its action to be of a more radical charac- 
ter, and in many of the cases in which its use has been 
followed by marked benefit, a restricted diet and numer- 
ous other remedies had previously been employed. 
Villy, who studied the drug under the direction of Du- 
jardin-Beaumetz, considers that any beneficial action 
only accompanies the use of the remedy when starchy 
food is excluded, and he seems to think that it has very 
little power in preventing the transformation of starch 
into sugar. He repeated the experiments with solutions 
of starch and malt, and found that instead of the diasta- 
tic ferment being checked, the conversion of the starch 
proceeded more rapidly with the jambul added than 
without its presence. 
The seeds and the bark both possess the anti-diabetic 
action, but the seeds are the more active of the two. A 
paper presented by Dr. T. Stevenson, of Bombay, to the 
Pharmaceutical Conference, held at Edinburgh, 1892, 
states that the fresh seeds, or an extract prepared from 
the fresh seeds, is the most serviceable and the only cer- 
tain method of securing the medicinal properties. Un- 
der any circumstances, it is recommended that the seeds 
should be carefully preserved and only reduced to pow- 
der as required. Some such variation in the active 
properties of the drug may account for the uncertainty 
of its action and the difference in the quantity adminis- 
tered. The usually recommended dose is five to ten 
grains of the powder, or five to ten minims of the ex- 
tract, three or four times a day. This, however, appears 
to be inadequate, and much larger doses are now advised. 
Dr. Britto, who reports from India his successful treat- 
ment of a number of cases, gave it in doses of one 
drachm of the powder, or one fluid drachm of the ex- 
tract, three times a day ; and Professor Lewaschew, who 
reports his experience of two years, in which he em- 
ployed the drug with marked success, advocates it in 
doses of as much as from twenty to forty grammes (5 
to 10 drachms) in the twenty-four hours. The British 
(SUPPLEMENT.) 
Association, in their recommendations for its experi- 
mental use, state that the dose of the powdered seeds 
should be from one drachm to one ounce daily. No 
toxic action follows its use, but instances of nausea and 
depression have been reported from its continued use. 
Beaumont Small. 
1 The Lancet, p. 902. 1889. 
2 British Medical Journal, March, 1887. 
3 The Lancet, October, 1887. 
4 Ibid., October, 1888. 
6 London Practitioner, December. 1888. 
• Bulletin General de Thdrapeutie, July, 1890. 
7 Ibid.. January, 1891. 
8 British Medical Journal, March, 1891. 
9 The Medical News, January, 189.3. 
10 The Therapeutic Gazette, February, 1893. 
JOINTS, DISEASES OF THE. Treatment in 
General.-Local applications of all kinds, poulticing, 
blistering, the cautery, and ice-bags, so much used a few 
years ago, are no longer employed with the expectation 
that any effect will be gained upon the disease itself, or 
that anything more than temporary relief to the super- 
ficial symptoms will be attained. The same may be said 
of compression in tubercular synovitis. Massage and 
passive motion are not only of no use, but are productive 
of much harm when used during the course of the dis- 
ease. After the disease has terminated, they have a cer- 
tain cosmetic value ; they hasten the time when the full- 
est possible motion and the greatest attainable plump- 
ness are regained, but they accomplish nothing which 
will not be sooner or later gained by use alone. 
Subcutaneous Injections.-Various medicaments have 
been injected into masses of tubercular tissue and tuber- 
cular abscesses, but none have held the confidence of the 
profession except iodoform in glycerine or olive oil. This 
is used in ten per cent, strength and carefully sterilized. 
When injected into tubercular tissue a few drops are de- 
posited here and a few drops there throughout the mass. 
When used in abscesses, the abscess contents are as com- 
pletely evacuated as possible, and then from one to four 
drachms are injected, and moderate compression applied. 
The cavity usually refills, and the process may have to be 
repeated many times ; or after any one of the injections it 
may not refill, but gradually close, and the tubercular lin- 
ing membrane shrink away. If the injection be kept 
strictly aseptic a cure is effected in much less time than 
could be had in any other way ; but if septic infection 
does result, the injection proves an injury instead of a 
benefit. In young children who fear the pain of the in- 
jection, the advisability of the procedure may be ques- 
tioned, it being borne in mind that treatment by brace 
must in any case be continued for many months. 
Fixation and Traction.-The treatment of chronic 
joint disease by "motion without friction," attained by 
elastic traction in an ambulatory apparatus, is no longer 
attempted. All surgeons now agree upon the necessity 
of fixation during the active stage of the disease. At a 
somewhat later time many allow motion within the 
limits of muscular restriction, while others insist upon 
immobilization until a complete cure appears to have 
been accomplished. 
Traction, or " distraction," is employed either for the 
fixation which it gives (Judson); or because of the in- 
creased area of motion possible during its use (Sayre) ; or 
as a means for allaying muscular spasm (Shaffer). 
It is obvious that whatever will most quickly allay 
muscular spasm is of prime importance. The advocates 
of traction believe that traction is of the first importance, 
and the best, if not the only, means for satisfactorily do- 
ing this. On the other hand, the advocates of pure fix- 
ation claim that fixation alone without traction will more 
quickly allay the spasm than will traction, or fixation 
combined with traction. The two methods have not 
been given a fair, unprejudiced trial and comparison. 
Meantime, the majority of the profession use a more or 
less perfect, and more or less defective, combination of 
both principles. 
In treating joint diseases in the lower limbs, traction 
during recumbency and during walking are quite differ- 
559 Joints, Diseases of. 
Joints, Diseases of. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
ent problems, and we feel quite convinced that continu- 
ous, uninterrupted traction cannot be had by any splint 
upon which the patient walks. 
Hip Disease.-The etiology of the various deformi- 
ties of hip disease has recently been studied by Dr. A. 
M. Phelps, of New York, who arrived at the following 
conclusions : 
Abduction always precedes flexion, or is attended by 
it, in the first stage. 
Abduction and outward rotation are always present in 
the second stage. Flexion is nearly always present, but 
is absent in a few cases. 
When the limb is flexed beyond forty degrees, and fre- 
quently at a much lesser degree (twenty degrees), it 
quite rapidly passes to the deformity of adduction, in- 
ward rotation, and flexion, 'whether the capsule contains 
fluid or not. 
Assuming the work of the glutaeus maximus operating 
in a given triangle with two pounds and a half weight to 
be fifty pounds, other muscles operating in different tri- 
angles of different weights can be accurately estimated 
as to their comparative strength. Following this rule, it 
was found that the glutaei muscles were capable of one 
hundred and thirty-one pounds, whereas the adductors 
were only capable of one hundred and sixteen pounds, 
proving that the abductor group was much stronger than 
the adductor in the subject examined. From clinical 
observation it was concluded that the reason why the 
limb went over to the deformity of the third stage of 
hip-joint disease, was because the actions of these muscles 
were all changed by the flexion of the limb, or from 
pathological destruction of the joint changing or annul- 
ling the action of the muscles by destroying the leverage. 
In the first stage the limb is slightly flexed and ab- 
ducted to relieve the tension of the capsule. This de- 
formity is increased as the case passes to the second 
stage by the spasm of the muscles about the hip-joint. 
The great glutaei, outward rotators, tensor vaginae femo- 
ris, and flexors have the advantage of leverage. As a 
rule, the deformity of the third stage appears only after 
flexion to twenty-five degrees has 
taken place. This is because after 
the limb has passed to twenty-five 
degrees of flexion, the adductors to 
a very great extent become internal 
rotators ; the external rotators al- 
most totally lose their power as 
external rotators, and become ab- 
ductors (with the exception of the 
quadratus femoris and obturator 
extern us), and the tensor vaginae 
femoris becomes a powerful inward 
rotator. 
Erratic deformities occur from 
partial or complete dislocations, and 
from shortening of the neck of the 
femur, which destroys the action of 
the flexors, and often of the ad- 
ductors, by changing the leverage. 
Extreme flexion may be accom- 
panied with abduction and outward 
rotation ; or adduction may be ac- 
companied with outward rotation. 
The treatment may be by fixation 
with a plaster-of-Paris splint, or by 
a brace. If the plaster splint be 
made use of, it should extend from 
the ankle to the axilla. It is diffi- 
cult to apply without favoring in- 
creased flexion deformity. Bartow, 
of Buffalo, partially suspends pa- 
tients in the conventional suspen- 
sion apparatus and applies the splint, while the patient 
bears a part of his weight by the well limb upon a block, 
the affected limb dangling, or gently pulled downward 
into the best possible position. 
The Thomas hip-splint (Fig. 368) is the only purely 
fixative splint in general use. The objections which 
have been raised to it are : (1) That it does not furnish 
(SUPPLEMENT.) 
complete fixation ; (2) that it does not prevent subluxa- 
tion ; (3) that it does not counteract muscular contrac- 
tion ; (4) that it increases pain because of its leverage 
action. It is proper to say that these objections are 
•raised by surgeons who have not used a properly con- 
structed splint upon the principles laid down by Mr. 
Thomas, and the objections are therefore purely theoret- 
ical, and based upon an imperfect 
knowledge. 
The persistent deformity of hip 
disease is flexion. So long as flex- 
ion is present, and so long as mus- 
cular spasm tending to flexion is 
present, the splint, by its direct an- 
tero-posterior leverage action, if 
properly applied, absolutely con- 
trols antero-posterior motion. Lat- 
eral motion, to which there is less 
tendency, is controlled in the same 
way, but less efficiently. When 
there is no longer any deformity, 
and when the joint has so far re- 
covered that muscular spasm no 
longer tends to deformity, the fixa- 
tive power of the splint is greatly 
lessened ; but at that time a certain 
amount of motion does no harm, 
as is admitted by those who object 
to the use of this splint. As to sub- 
luxation of the femur during the 
use of the splint: One such case 
has been reported, but there is no 
evidence to show that the reporter 
of the case knew how properly to 
use the splint. On the other hand, 
subluxation now and then happens 
when the traction-splint is being 
used, both in walking and recum- 
bent cases. As to muscular spasm : 
Whatever is able to keep the parts in most perfect quiet, 
that most quickly relieves the spasm. In my experience 
the Thomas splint does this ; and after using the long 
traction hip-splint in many hundreds of cases, I have en- 
tirely abandoned its use. I am very certain that pulling 
upon the muscle is not logically, nor is it clinically, the 
most successful way to abolish the involuntary muscular 
spasm of joint disease. That which acts to allay the in- 
flammation from which the spasm arises ought to most 
quickly allay the spasm, and in practice we find that 
immobilization of the joint does this. As to the increase 
of pain : It does in many cases increase the pain for the 
few days during which the deformity is being overcome, 
but the sum total of pain had better be condensed into 
two or three days than spread over the days and nights 
of two or three months. That injury is inflicted by the 
leverage action which causes the increase of pain has not 
been proven by any increase in the number of patients 
having abscesses, stiff joints, or short legs. 
The Thomas hip-splint (Fig. 369) consists of a main 
stem and several bands. The stem is of fiat bar iron, 
from x f to J x inch ; in length, reaching from the 
lower angle of the scapula to the lower third of the leg. 
The size of the bar must be large enough to prevent any 
bending or tremor. The chest band is of the same width 
as the main stem, but thin enough to be bent by the hands 
of the surgeon in fitting it to the chest. In each end is 
forged a hole three-fourths of an inch in diameter, and 
at its middle it is riveted to the top of the main stem. It 
is long enough to surround the chest below the axillae. 
The thigh and calf bands are of somewhat lighter iron ; 
the thigh band is riveted to the stem at such a point that 
it shall be a little below the perineum ; and the calf band 
is at the lower end of the splint. Both are large enough 
to nearly surround the limb at the points indicated. At 
times an abduction or an adduction wing is attached to 
the main stem at a point where it will pass around the 
flank of the patient above the iliac crest and below the 
ribs. It is of iron of the same thickness as the chest band. 
In the main stem are two bends dividing it into a 
Fig. 369.-The Thomas 
Hip-splint, as used by 
the Author. 
Fig. 368.-The Thomas 
Hip-splint Applied. 
560 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Joints, Diseases of. 
Joints, Diseases of. 
straight body portion and a straight leg portion, the 
lower portion being parallel to and slightly in advance of 
the upper portion. The lower bend is opposite the glutaeo- 
femoral crease, and the upper one opposite the hip-joint. 
The splint is applied by opening out the wings of the 
bands on one side and slipping it 
under the patient until the stem 
rests in proper place, when the 
wings are again bent in to the side 
of chest and leg. The splint is sup- 
ported by a strip of broad band- 
age looped around the main stem 
beneath the chest band, and car- 
ried over each shoulder and down 
to the holes in the ends of the chest 
band in front, after the manner 
of suspenders. The limb is band- 
aged to the splint by an ordinary 
roller from the bottom to the thigh 
band, or by a short piece at the 
bottom and another above the knee, 
or by a figure-of-eight around the 
knee. 
If the limb 
cannot be 
brought fair- 
ly down, the 
brace may be 
bent at a 
point oppo- 
site the hip- 
joint and 
straightened 
during the 
s u c c e e ding 
three or four 
days; but 
this should not be done if it can 
be avoided. If the splint tends to 
shift to right or left, the wings on 
the side toward which it moves 
should be somewhat opened and 
those on the op- 
posite side 
drawn closer in 
to the patient. 
Abduction and 
adduction are 
corrected a n d 
prevented by an 
extra wing at- 
tached to the 
m a i n stem a t 
such a point that 
it will pass 
around the flank on the side toward 
which it is desired to draw the limb. 
When rapidly straightening a deform- 
ity, and in cases where the muscular 
spasm is intense, the skin underneath 
the brace should be changed once or 
twice a day and kept dry and well 
powdered. In moving a patient with a 
very sensitive joint, the patient places 
his well limb across the affected mem- 
ber, while the assistant lifts him by 
placing one hand under the brace and 
limb at the back of the knee, and with 
the other grasps the chest band. 
Judson's splint (Fig. 372) is the most 
rigid of the long traction hip-splints. 
The hip band is of heavy steel coated 
with hard rubber. This is firmly 
bolted to the head piece of the side- 
bar, so that there may be no motion 
between them. The side-bar and 
sheath are of steel, about one-quarter 
of an inch thick, and in width from one-half inch at 
the bottom to one and a quarter inch at the upper part, 
(SUPPLEMENT.) 
where most of the strain must be borne. Adhesive 
plasters attached to the thigh and leg give means for 
traction, and a perineal strap gives counter-traction as in 
the conventional traction hip- 
splint. 
Ridlon's hip-splint (Fig. 
373) (no longer used by the 
author) consists of one of the 
earlier forms of the Taylor 
hip-splint to which has been 
added a side-bar extending up 
the side of the body to the 
axilla, and a chest band sur- 
rounding the chest at this 
point. A strong bolt fastens 
the chest-piece, the hip-band, 
and the extension-bar im- 
movably together. Traction 
a n d counter - traction a r e 
made in the usual way. The 
advantage of the splint over 
the usual forms of traction 
splint is, that the patient can- 
not voluntarily bend to any 
extent from foot to axillae. 
Phelps's splint (Figs. 374 
and 375) is a combination of 
the ring of the Thomas knee- 
splint, the usual extension- 
bar placed, however, at the 
inner side of the leg and 
thereby subjected to less lat- 
eral strain, and Ridlon's 
chest-piece. To these is ad- 
ded a lever to exert lateral 
traction by pulling outward 
upon a band passed around 
the thigh. The splint more 
rigidly immobilizes than does 
Ridlon's splint, but has this disadvantage, that it cannot 
be applied while any considerable deformity is pres- 
ent. The deformity must first be reduced by other means. 
Correction of Deformities.- 
Flexion, abduction, and ad- 
duction, when disease is still 
present, should be corrected 
as rapidly as possible by 
leverage action, supplemented 
or not by traction, as the case 
may demand. True shorten- 
ing cannot be remedied, but 
may be obscured by placing 
the limb in abduction and 
slanting the pelvis. Deform- 
ities present in cured cases 
may, if there be any motion 
present, be corrected by lever- 
age, supplemented or not by 
section of the shortened soft 
parts. If there is no motion 
and no muscular spasm, sec- 
tion of the bone by saw, or 
preferably by chisel, is indi- 
cated, supplemented or not 
with section of the shortened 
soft parts. Whatever method 
is employed to correct the 
deformity, the limb must be 
thoroughly immobilized until 
all pain, tenderness, and mus- 
cular spasm have subsided. 
Knee-joint Disease.- 
The same principles govern 
the treatment of disease at 
this articulation as at the hip, 
and need not be rehearsed. 
The most effective apparatus is the Thomas knee- 
splint (Figs. 376 and 377). It is made in two forms : the 
bed splint and the caliper splint. They differ only in 
Fig. 370. - The Double 
Thomas Hip-splint. 
Fig. 373. Ridlon's Traction 
Hip-splint. 
Fig. 371. - The Thomas 
H i p-splint, shortened 
for walking during con- 
valescence. 
Fig. 372. Judson's 
Hip-splint. 
Fig. 374.-Phelps' Hip-splint. 
561 Joints, Diseases of. 
Joints. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
the manner of termination at the bottom, as will be seen 
in the description. The splint consists of a thigh-ring 
and two side-bars ; it is made of one-fourth to seven-six- 
teenths inch iron wire, the 
ring being welded to the 
side-bars and sloped from 
without inward and from 
before backward. The 
angle formed by the lateral 
plane of the ring and the 
inner bar is about 135 de- 
grees ; the posterior angle 
formed by the plane of the 
ring and the inner bar is 
from 55 to 70 degrees, de- 
pending upon the thick- 
ness of the padding of the 
ring. The slope of the ring 
must be sufficient to leave 
that part of the ring which 
comes beneath the tuber- 
osity of the ischium a little 
lower than any other part. 
The shape of the ring is 
irregularly ovoid, consid- 
erably flattened in the front 
and drawn out at the in- 
ner portion of the back. 
The shape varies somewhat, 
depending upon the thick- 
ness of padding to be put 
on. 
The ring is padded firm- 
ly with felt and covered 
with tan sheep-skin put on 
wet, stretched snugly, and 
sewed on the outer surface 
of the ring. When the 
brace is to be used in bed it is made to extend six or eight 
inches beyond the foot, and usually is dimpled at the ex- 
tremity so that the straps from the adhesive plasters will 
not slip, if they are used 
to give fixative traction. 
When it is desired to trans- 
form the bed-splint into 
the caliper, the portion ex- 
tending beyond the foot 
is cut off an inch below 
the sole and an inch of 
each end bent to a right 
angle toward the opposite 
bar. These bent ends are 
sprung into a hole or tube 
set transversely through 
the heel of the shoe. In 
either splint a sling of 
leather, from four to six 
inches wide, is stretched 
across from one bar to the 
other at the back of the 
knee, and another nar- 
rower piece at the back 
of the ankle. A pad is 
placed over the front of 
the thigh, close down to 
the patella, and another 
over the shin just below 
the knee-joint, and back- 
ward pressure is made by 
strap or a piece of band- 
age passed across the pad, 
beneath each side-bar and 
back across the pad and 
fastened. When any back- 
ward displacement of the 
tibia is present, the sling at the back is slipped lower and 
only the thigh-pad used for backward pressure. In 
using the caliper splint care must be taken that it shall 
be long enough to keep the heel clear from the sole of 
(SUPPLEMENT.) 
the shoe in walking. The form of Thomas knee-splint 
extending fonr inches below the foot and terminating in 
a patten bottom is no longer used, as it does not give 
efficient immobilization. 
Elbow-joint Disease.-This joint can be most effec- 
tively immobilized in a very simple manner. A strip of 
broad bandage is tied about the wrist, the forearm is 
flexed to such a point as will be most useful in case an- 
chylosis results, the bandage is then carried to the neck 
and tied, and then around the neck and again tied, so 
that neither hand nor head can be drawn from their re- 
spective loops. 
At first sight it would seem that this sort of immobil- 
ization would be far from complete, but the contrary is 
the case. The position which the forearm assumes in 
relation to the arm in elbow-joint disease is one of ex- 
tension to about one hundred and sixty degrees, so that 
if the forearm be held flexed to about seventy-five de- 
grees, the tendency to extension acting in opposition to 
the restraining influence of the sling gives effective im- 
mobilization. The patient does not voluntarily flex the 
forearm beyond the position of restraint so long as the 
disease is sufficient to be aggravated by such motion. 
In diseases of the other joints nothing worthy of record 
has been recently advanced. John liidlon. 
JOINTS, MOVABLE BODIES IN. There is little, in- 
deed, of unusual moment that can be added now to that 
which has already been stated in the original article writ- 
ten for the Handbook in 1886. Now, as then, joint de- 
rangements are due, not only to the effects of injury and 
disease on the component parts of the articulation, but 
also to the presence in them of the products of various 
histological processes that happen elsewhere in the body, 
in similar tissues. The semi-lunar cartilages are common 
seats of injury and disease in the knee, as not only them- 
selves, but also the ligaments connected with them, suffer 
conjointly and separately, or with interchangeable rela- 
tionship with each other. The injuries and diseases char- 
acteristic of these joint-structures constitute the most im- 
portant items of affliction incident to the life-history of 
joints thus provided. The cartilages themselves may be 
displaced, bruised, crushed, or torn, and the ligaments 
maintaining them in proper relationship with the artic- 
ular surfaces and properly attuning their functional 
movements, may be stretched, bruised, or ruptured. The 
internal semi-lunar cartilage of the knee-joint and its 
attachments suffer more frequently than do the external 
similar structures. The exact reasons for this are some- 
what problematical. It may be accounted for by the fact 
of the greater degree of functional activity that is present 
during motion at this portion of the joint ; for the internal 
semi-lunar cartilage moves over a greater area of artic- 
ular surface than the other, in order to meet its functional 
requirement in connection with the inner condyle of 
the femur, which condyle passes through the segment of 
a larger circle than its fellow. Also greater weight is 
received on the inner condyle than on the outer, and, 
too, it is more exposed to external violence than is the 
former. Functional derangement of these cartilages, 
resulting in their becoming pinched between the moving 
articular surfaces, is predisposed by any roughening proc- 
ess that hinders the harmony of action necessary for the 
proper performance of the advancing and retiring move- 
ments imposed on them during activity of the articular 
surfaces between which they are placed. And should 
this condition be present together with relaxed ligament- 
ous attachments of the cartilages, then, indeed, will the 
danger of pinching be increased, and even actual displace- 
ment be threatened. Especially is this true of the inner 
cartilage in the presence of an actual extension with 
supination of the leg. In their normal state these carti- 
lages cannot be broken, although they may be bruised, 
torn, and twisted. If, however, they have become 
hardened by morbid processes, then it is not impossible 
that they may be displaced or broken by severe circum- 
scribed violence directed from without. They may be 
broken, or their coronary attachments may be ruptured 
under these circumstances by violence, while the weight 
Fig. 375. Phelps's Hip-splint Ap- 
plied. 
Fig. 376. - The 
Thomas "Cali- 
per" Knee- 
splint, for walk- 
ing. 
Fig. 377.-The 
Thomas Knee- 
splint for use 
when patient 
is in bed. 
562 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Joints, Diseases of. 
Joints. 
of the body is borne on the extended limb, but they can- 
not then be displaced. Violence directed against the 
outer border during the act of flexion of the leg and 
thigh, may cause them to be torn from their attachments 
and even ruptured, and then if extension follow quickly 
and forcibly, they may be overridden by the opposing 
articular surfaces, and thus held or be forced to the pos- 
terior part of the joint cavity. If the joint be already 
impaired by ligamentous relaxation and other structural 
changes, then, surely, derangement and displacement of 
these so-called cartilaginous structures much more read- 
ily takes place. 
The special indications of semi-lunar involvement re- 
late more especially to modifications of the normal con- 
tour of the joint surface at the site of the cartilages, as 
determined by palpation. With the leg extended, the 
external rounded borders of these cartilages can be easily 
felt in the normal state, and it will be noticed that 
they will recede gradually from the touch as the limb 
is being flexed, causing instead a marked depression 
corresponding to their former site. If the cartilage 
be displaced outward, then undue prominence is noted at 
that point, which may or may not disappear with flexion 
of the limb. The semi-lunar cartilages may become dis- 
placed outward at other aspects of the joint, but in these 
instances their mobility is less influenced by the normal 
movements of the joint than in the first instance. If the 
displacement be inward toward the centre of the joint, 
then the degree of extension which may be attainable 
need not return the cartilage to its normal site, and, there- 
fore, a depression is noted in lieu of the normal contour 
of the cartilage. If the coronary ligaments be ruptured, 
these cartilages will recede and advance perceptibly dur- 
ing flexion and extension of the leg, provided the articular 
surfaces, and those of the adjacent cartilage, are smooth, 
and properly lubricated, If otherwise, they may be 
easily pinched and perhaps overridden during extension 
of the limb. One should judge of the nature and extent 
of the injury of a joint by carefully comparing its physi- 
cal and functional characteristics with those of its un- 
injured fellow. 
Treatment.-If the cartilage be displaced, its prompt 
reduction should be attempted. Various methods of 
procedure are advised to accomplish this purpose. The 
chief element of a successful reduction is based on the fact 
that flexion of the leg relaxes the connecting structures 
of the joint in direct proportion to the degree of that act. 
Now, since relaxation loosens, joint tension, it follows 
naturally that loosening of the tension favors the restora- 
tion of the displaced cartilage, either by its own inherent 
elasticity or by direct manipulation, in the best possible 
manner. For this reason various degrees of extent and 
rapidity of flexion, combined with supination and pro- 
nation of the leg, are advised, for the purpose of reduction. 
The following, advised by Allingham, is sufficiently com- 
prehensive to suggest, and probably even meets the de- 
mands incident to, displacement. " Flex the leg as much 
as possible on the thigh, drawing upon the tibia as if to 
separate the articular surfaces from the femur. Then 
rotate the tibia inward, if the internal cartilage be dis- 
placed, and outward, if the external cartilage be displaced. 
Both movements should be resorted to if the usual one 
does not succeed. Then extend the leg on the thigh 
quickly, but not with great violence, at the same time 
pressing with the thumb upon the projecting cartilage." 
After reduction, rest and immobility, until the danger of 
inflammation has subsided, will commonly suffice. If re- 
duction fail of accomplishment, then one of two plans 
can be pursued :- 
1. The employment of massage and passive motion, 
after the symptoms incident to the injury have subsided. 
This course will in time restore the function of the joint, 
although at intervals derangements will ensue, the same 
as may happen even when the reduction is accomplished 
at first. 
2. The exploration of the joint through a liberal per- 
pendicular or oblique incision made into it at the aspect 
of the displaced structure, about three-fourths of an inch 
from the ligamenturn patellae. If the integrity of the car- 
tilage will permit, it should be returned to its proper 
position, and be stitched there with fine aseptic silk. If 
this be not allowable, on account of the great extent to 
which its structure has been damaged, it should be re- 
moved entirely. In cither instance, finally, the joint 
should be irrigated with an antiseptic solution and closed 
by two rows of sutures-the first including only the sy- 
novial membrane and its closely adjacent connective tis- 
sues ; the second, the remaining tissues of the wound. 
Either silk or catgut can be used, as best suits the wish 
of the operator. The employment of drainage will de- 
pend greatly on the extent of handling to which the 
structures of the joint-cavity have been subjected. Ordi- 
narily it need not be employed ; still, the introduction 
into the joint of carbolized horse-hair, or a small rubber 
tube, for drainage purposes, cannot in itself do harm, and 
should, therefore, be employed when, in the judgment 
of the operator, such a step is indicated. 
The alar structures of a joint may become so elongated 
or enlarged, as the result of disease, as to be pinched by 
the articular surfaces.' Extravasations of blood within 
their folds may so change their relations with the joint 
surfaces as to cause pinching at once, or bring it on at 
some later date, on account of the formation of fibrin- 
ous bodies within them, which remain attached to the 
borders of these structures, or are eventually discon- 
nected and wander freely in the cavity. Histological 
changes taking place singly or otherwise in the various 
tissues constituting a joint, often lead to the pres- 
ence within it of movable and attached bodies that can 
be characterized according to the nature of the process 
causing them, or the structure of the tissues that give 
them birth. Consequently, they may be described as of 
fibrinous, fibrous, cartilaginous, fibro-cartilaginous, osteo- 
cartilaginous, tuberculous, and biform origin, etc. The 
symptoms of the presence of these morbid bodies are 
illustrative of joint derangement in the full sense of the 
term, as compared with those of cartilaginous displace- 
ment proper, and little of practical importance can be 
added now to what has already been stated elsewhere 
in the Handbook on this subject. 
Dr. Robert F. Weir recently called attention {Medical 
Record, July 16, 1892) to an interesting condition causing 
joint derangement of the knee, which simulated in all 
essential respects the presence in this joint of a movable 
body. Exploration of the joint revealed the fact that a 
duplication of fibrous membrane extended from the under 
surface of the patella and the adjoining surface of the 
femur to such a length as to be caught between the arti- 
cular surfaces during flexion, thus "locking" the joint, 
and also impeding extension. A grating sound beneath the 
patella attended the establishment of motion in the two 
cases of this disease which he had observed. Both were 
readily cured by removal of this obstructing agent. The 
treatment for movable bodies relates to the manipulations 
employed to overcome the joint-locking incident to them, 
which differs in no essential respect from that used to re- 
store displaced semi-lunar cartilages. Vigorous extension 
of the leg, during its complete flexion, with or without 
rotation, will commonly dislodge the troublesome agent 
and relegate it, for a time at least, to some remote recess 
of the joint cavity. 
The operative treatment is the most important, since it 
offers the only means of prompt and permanent relief, and 
also because it is attended with an element of risk to the 
patient which begets at the same time a respectful con- 
sideration of the joint cavity on the part of all those re- 
sponsible for the result of operative measures. The fol- 
lowing statement presented by Tuttle will emphasize the 
operative measure and its dangers much more pointedly 
than mere words alone can do. It is very important, in- 
Cases. 
Cured. 
Failures. 
Mortality. 
Per cent. 
Per cent. 
Per cent. 
Beamdorf 
216 
66.2 
IS. 99 
14.81 
Lorry. 1860 
167 
68.86 
19.76 
11.38 
Browne, 1884 
88 
82.95 
' 5.68 
14.36 
Tuttle 
107 
97.19 
2.81 
563 Joints. 
Knock-Knee. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
deed, to note the difference in the results as modified 
by the recent antiseptic measures, since the results in no 
uncertain manner impress upon one the fact that the wise 
use of modern methods relieves nearly all of the afflicted, 
without causing any of them the loss of life or limb. 
Joseph D. Bryant. 
KAVA-KAVA. This is the native name of Piper Methys- 
ticum, a shrub belonging to the natural order Piperaceae. 
It is indigenous to the Polynesian Islands. It has ac- 
quired a local reputation as a remedy for dropsy and pain- 
ful affections of the bladder and the urinary tract, but 
it is chiefly prized as the source of a native national 
beverage. The plant is reduced to a pulpy mass by mas- 
tication and allowed to ferment, until an intoxicating 
liquor is produced. The primary effect is as a stimu- 
lant, but ultimately it causes a peculiar form of intoxica- 
tion in which the limbs and body are uncontrollable and 
helpless, while the mental faculties are clear or slightly 
dazed. The root is the part employed for medicinal 
purposes, and has been closely investigated by Dr. L. 
Lewin, of Berlin, who directed attention to its impor- 
tance as a remedial agent. He analyzed it and obtained 
an essential oil; two resins, alpha- and beta-resin kava ; 
and a neutral crystalline principle called kavahin, or 
methysticin, which is closely allied to piperine. The 
crystalline body exists to the extent of one per cent., 
but has been found inactive. The alpha-resin, which is 
obtained by means of alcohol, and is insoluble in water, 
contains the medicinal properties of the plant, and is 
thought by Lewin to be the active ingredient. It has, 
however, been shown that the watery infusion also is 
useful, and this would in- 
dicate that the virtues of the 
plant are not limited to the 
resin itself. At present the 
resin and the fluid extract, 
not miscible with water, are 
the preparations employed 
for medicinal p u r p o s e s. 
Kava-Kava has formed the 
subject of an exhaustive 
study by Dr. Cerna {Thera- 
peutic Gazette, January, 
1891) who arrives at the fol- 
lowing conclusions regard- 
ing its physiological action: 
Moderate doses produce a 
stimulating effect, particu- 
larly on the central nervous 
ganglia ; in larger quantities 
it produces general autesthe- 
sia, and diminishes and ulti- 
mately abolishes reflex ac- 
tion by influencing the spi- 
nal cord, and probably also 
the spinal centres. The 
great muscular weakness 
observed is not due to any 
action on the higher cere- 
bral centres, as they main- 
tain their normal functional 
activity. Very large quan- 
tities depress the circulatory 
a n d respiratory systems, 
and, in poisonous doses, 
death is produced by failure of the respiration, or by car- 
diac paralysis. Placed on the tongue, it at first causes a 
burning sensation, which is followed by numbness and 
anaesthesia, which continue for some time and are accom- 
panied by a free flow of saliva. On the cornea and con- 
junctiva the same effect is produced. The local anaesthetic 
action is said to be equal to that of cocaine, but its use is 
restricted by the insolubility of the preparations in water. 
Kava-Kava is advocated as a remedy in cystitis, gon- 
orrhoea, and chronic inflammatory conditions of the 
mucous membrane of the urinary organs. It also pos- 
sesses a diuretic action, and has been used with success in 
dropsy. Its tonic and stimulating properties add to the 
(SUPPLEMENT.) 
general well-being of the patient, and increase its bene- 
ficial action. Its administration should be accompanied 
by copious draughts of water, which soon promotes a 
plentiful flow of urine which rapidly moderates the in- 
flammatory action and exerts a remarkably soothing in- 
fluence. This is followed by a lessening of the puru- 
lent and catarrhal discharges. The fluid extract is the 
most convenient preparation to use, and has been em- 
ployed with decided success. It may be given in doses 
of twenty to sixty minims three times a day, and has been 
combined with sweet spirits of nitre and glycerine when 
these are indicated. The alpha-resin is given in doses of 
one to one and a half grain, three times a day. A solid 
extract is prepared, the dose of which is two to six grains. 
The principle, kavahin, is not employed, as its therapeu- 
tic action and dose are uncertain. Beaumont Small. 
K1LRUSH AND KILKEE. Popular sea-side resorts in 
County Clare, Ireland. There are a number of ferru- 
ginous springs near these places. Kilrush is on the north 
shore of the estuary of the Shannon, and Kilkee faces 
the Atlantic Ocean. At the latter place there is a fine 
sandy beach. The climate of these resorts is on the 
whole good. It is decidedly bracing, and at times the 
westerly gales are trying. The amount of rainfall is not 
greater than the average for Great Britain. The accom- 
modations are rather primitive. There are many oppor- 
tunities for excursions on land and sea. Scattery Island 
is only one mile from Kilrush. Edmund C. Wendt. 
KISSINGEN. The principal features of this important 
German spa have already been described in Vol. IV. of 
Fig. 378.-General View of Kissingen. 
this Handbook. The writer has had occasion, on his sev- 
eral visits to the place, to gather abundant evidence as to 
the good results obtained there in suitable cases. It is, 
however, one of those resorts where it is by no means 
superfluous to remain under strict medical supervision 
while taking a course of the waters. Patients acting 
without professional advice are at times injured by the 
waters. 
Recently some needed sanitary reforms have been 
completed at Kissingen. The little town is now well 
drained and is supplied with good drinking water. It is 
so pleasant a place to spend a summer in, that many visi- 
tors now go there who *re not invalids. 
564 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Joints. 
Knock-Knee. 
(SUPPLEMENT.) 
Kissingen has excellent facilities for all kinds of baths, 
inhalations, mechanico-therapeutics, massage, etc. There 
are also various private medical establishments, under 
supervision of competent physicians. Dr. v. Sohlern has 
a special sanitarium for the treatment of gastric disorders, 
and the results of treatment there are known to be often 
highly satisfactory. 
In regard to the brine baths, Dr. Thomas More Mad- 
den, after a recent inspection (7%<? Provincial Medical 
Journal, December 1, 1892), speaks as follows : 
" About a mile from the other springs, to the north of 
the town, rises the Soolensprudel. This well is contained 
within a handsome square building facing the river. 
The hall occupies the entire central part of the structure, 
and is lighted from the dome, while at each side differ- 
ent galleries run round. In the middle of this apartment 
is a raised structure, somewhat like an immense bee- 
hive, with glazed cover, about two feet high, beneath 
which is the Soolensprudel. The shaft of the well, seen 
through this cover, is about twenty feet deep by about 
eight feet in diameter, and seems to be lined with wood- 
work. Through the bottom of that shaft an artesian well 
was bored in 1822 to the depth of nearly three hundred 
feet in the sandstone, and this it is which now supplies 
the Soolensprudel. 
" This source presents a very remarkable phenomenon, 
namely, it intermits, or ebbs and flows, with great regu- 
larity, eight or nine times daily. If we arrive a little 
before the ' flow,' on looking down the shaft through 
the thick glass cap we see the well apparently empty of 
water ; we then hear a distant rumbling noise, which 
gradually becomes louder, and draws nearer, till in 
about half an hour from the time it was first heard, 
the water is seen foaming below ; it gradually as- 
cends, and in another quarter of an hour reaches 
within a few inches of the top of the well, covered 
with white foam, and hissing and seething with 
great turbulence. Above the water hangs a heavy 
layer of carbonic acid gas, rising and falling with it. 
This gas is collected and ingeniously utilized in various 
forms of gas baths. Indeed, the entire system of vapor, 
gas, and water baths in the establishment is extremely 
perfect. 
" Internally used this water is strongly purgative, and 
diluted, as from its strength it could not otherwise be 
drank, it is employed in the same class of cases as the 
other springs. It is, however, principally used for bath- 
ing, in rheumatic, neuralgic, and cutaneous affections. 
It acts as a powerful stimulant to the skin, producing red- 
ness and considerable irritation of the surface. From its 
close resemblance to sea water, having, however, in ad- 
dition, a small proportion of iron and a considerable 
amount of carbonic acid gas, it might, and perhaps even 
more advantageously than sea-water, be employed in 
scrofulous cases. The mother lye, or concentrated saline 
water of the Soolensprudel, is applied with wonderful 
results as a local application to scrofulous glandular 
swellings and similar affections." 
Physicians and their families are very courteously 
treated at this spa, and annually visit Kissingen in large 
numbers. The hotels are large, and many of them are 
quite modern in the provision of comforts. 
Edmund C. Wendt. 
KNOCK-KNEE. In the treatment of knock-knee by 
mechanical means two essential points must be insisted 
upon during the period of attempted correction of the 
deformity, namely, the patient must be kept off his feet, 
and the mechanical device must be applied with the knee 
in full extension, and be capable of constantly maintain- 
ing that position without motion at the joint. The dis- 
credit which has generally fallen upon the mechanical 
treatment of this deformity, and led to the employment 
of operative procedures, is due to the use of braces so 
constructed with a joint at the knee as to allow the 
patient to walk with a reasonable degree of comfort. 
Only when the knee is fully extended is the leverage 
action of any brace effective ; as soon as the leg begins 
to flex, the deformity becomes less, and, before flexion 
reaches a right angle, entirely disappears, and the feet 
can be brought together. This is due to the fact that 
the divergence from the normal relations of the condyles 
is more a longitudinal than an antero-posterior one. The 
divergence of the condyles from the normal may be either 
a shortening of the external, or an elongation of the in- 
ternal ; upon this relation depends the choice between 
the operations of Ogston and MacEwen in operative 
cases. If the internal condyle is considerably elongated 
and the external condyle of normal length, obviously 
Ogston's operation, which allows the split-off inner con- 
dyle to slip upward, is to be preferred to MacEwen's, 
which practically elongates the outer condyle without 
shortening the inner, by the gap at the outer side of the 
lower end of the divided femoral shaft. This deviation 
of the condyles from the normal should also be taken into 
consideration in choosing between the operative and the 
mechanical treatment; otherwise it may be found, when 
the deformity has been corrected, that one lower extrem- 
Fig. 379.-Elongation of Left Limb due to Correction of Knock-knee by 
a Brace. 
ity is considerably longer than the other, as in Fig. 379, 
and that the deformity resulting from the treatment is 
quite as serious as that for which the treatment has been 
employed. Unlike bow-legs, when the choice between 
mechanical and operative treatment depends upon the 
age of the patient and the rigidity of the bones, the 
choice in knock-knee depends upon the nature and loca- 
tion of the abnormality. In all cases the knock-knee 
can be corrected by a brace ; nevertheless, Ogston's op- 
eration is to be preferred if the deformity consists solely 
of great elongation at the internal condyle, and MacEwen's 
in those older cases where the shortening at the outer 
565 Knock-Knee. 
Leprosy. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
condyle equals or exceeds the lengthening at the inner. 
A description of these operations will be found under 
their separate headings. The mechanical treatment con- 
sists of the application of some rigid splint, a simple form 
of which is represented in Fig. 380. It consists of a piece 
of flat bar-iron placed along the outer side of the limb, 
reaching from the greater trochanter to the sole, forged 
round at the bottom, bent at a right angle, and passed 
into a tube or hole in the heel of the shoe ; attached to 
this, at a point just above the malleolus, is a padded band 
of thin iron reaching two-thirds around the ankle; at the 
stimulating properties of this nut. It has been held in 
the greatest esteem from time immemorial, and is now 
looked upon almost as a vital necessity. It has been nat- 
uralized in other countries, and is Valued by the inhabi- 
tants of the West Indies, Brazil, Mexico, and other trop- 
ical countries. In addition to its ordinary use, it has 
acquired a reputation as a specific in counteracting the 
depressing and debilitating effects of alcoholic intoxica- 
tion. Experiments have been made with it in the French 
army which prove that it has decided stimulating proper- 
ties, but is in no sense a food, and any benefit derived 
from its use may be traced to the caffeine which it con- 
tains. 
The tree grows wild upon the western coast of Africa, 
from the Sierra Leone to the Congo, and reaches several 
hundred miles into the interior, where it follows the 
limits of the palm. It grows to the height of thirty or 
forty feet, and is said to resemble the chestnut in appear- 
ance. The leaves are six or eight inches long, pointed at 
both ends ; the flowers are pale yellow spotted with 
purple ; they are destitute of a corolla, but have a five-cut 
calyx, the segments spreading like the spokes of a wheel. 
The flowers are numerous, polygamous, in terminal and 
axillary cymose pannicles. In the male flower the sta- 
mens are united into a very short column, which bears 
the anthers in a single row, the cells of the anthers 
spreading apart. In the hermaphrodite flowers the an- 
thers are subsessile in a ring surrounding the base of an 
oblong five-celled ovary. The ovaries are five in number 
and cohere together, each having a slender stigma but no 
style. Ovules are numerous, anatropal, attached in a 
double row to the ventral suture of each carpel. The 
fruit consists of two, sometimes more, separate pods or 
follicles, which split open on the inner side and contain 
several seeds about the size of horse-chestnuts, weighing 
from seventy-five grains to an ounce. The covering of 
the seeds is brownish-yellow in color, the substance is a 
white mass of cells filled with starch and containing the 
alkaloids which give to the plant its medicinal properties. 
The tree commences to yield fruit about the fourth year, 
and is at its best about the tenth year. The flowering is 
nearly continuous ; and fruit and flowers may be present 
at the same time. There are two collections during a 
year, a tree averaging about one hundred and twenty 
pounds of fruit annually. 
Several analyses have been made of the seeds, with 
slightly varying results, but all point to the caffeine 
as the principle to which its virtues are to be ascribed. 
The following table compares its constitution with tea, 
coffee, and cocoa : 
Fig. 380.-The Thomas knock-knee brace. 
upper part of the thigh is a like band, and these bands are 
joined by a light bar of iron placed directly back of the 
middle line of the limb. At the top of the lateral bar is 
another padded band reaching about two inches to the 
front and an equal distance to the back of the lateral 
bar. The limb is bandaged to the splint by a figure- 
of-eight bandage, fixing the joint first to the poste- 
rior bar, and then laterally by passing the bandage 
around the limb and both bars. This corrected position 
is constantly maintained until the deformity is not only 
corrected, but remains so ; then jointed retention braces 
may be applied and joint motion permitted. 
John Ridlon. 
KOESEN. A popular spa in the Prussian district of 
Merseburg, Germany. 
Location.-Koesen is very prettily situated about six 
hundred feet above the level of the sea. The surround- 
ing country is hilly, and the little town is on the river 
Saale. The climate is mild, the air pure, and the scenery 
tempting. Season-May to September. 
Access.-Koesen is now reached by railroad by way 
of Naumburg. 
Analysis.-The Johanneequelle is a strong saline wa- 
ter. There is also a chalybeate spring, the Muhlbrunnen. 
Koesen is, however, chiefly known for the excellence and 
strength of its brine. Indeed, the principal spring, the 
Soolquelle, supplies so concentrated a brine, that it is 
necessary to considerably dilute it for bathing purposes. 
Indications.-Rickets and scrofula in all their varied 
manifestations are principally treated at Koesen. But 
many women with chlorosis and diseases of the organs of 
generation, and sufferers from gout and rheumatism, are 
benefited by the Koesen baths. 
Accommodation.-The hotels are small and only 
moderately good, but the thermal establishments are 
equipped with all modern appliances. 
Edmund G. Wendt. 
KOLA NUT. The seeds of the kola or cola tree, Cola 
acuminata R. Br., order Sterculaceae, a native of western 
tropical Africa. Kola is to the native of Africa what 
cocoa and mate are to the South American, and marvel- 
lous tales are told of the amount of work and fatigue that 
the African is enabled to endure when supported by the 
Cocoa 
(Mitscherlich' 
Coffee 
1. (Payen). 
Tea 
Green. Black 
(Peligot). 
Kola 
(Heckel). 
Fat 
53.00 
13.00 
0.28 .... 
0.585 
Proteid matters .. 
13.00 
13.00 
3.00 2.80 
6.761 
Theobromine 
1.50 
0.023 
Caffeine ' . 
2.25 
0.43 0.46 
2.348 
Essential oil . . 
0.04 
0.003 
0.79 0.60 
undet. 
Resin 
2.22 3.64 
Sugar 
Starch 
0.56 1 
f 
15.50 
( 
1 
2.875 
33.754 
Gum 
8.5S 7.28 
3.040 
Cellulose 
34.00 
17.08 26.18 
29.831 
Coloring matters.. 
17.24 19.20 
2.561 
Coloring matters.. 
5.00 
2.22 1.84 
1.290 
Extractive 
22.80 19.88 
Tannin 
17.80 12.88 
1.618 
Ash 
3.60 
6.697 
5.56 5.24 
3.395 
Water 
6.00 
12.00 
11.909 
100.00 
ioo.oo 
100.00 100.00 
100.00 
The kola nut and its physiological action was treated 
in a thorough manner by Dr. Monnet in 1884, under the 
direction of Dr. Dujardin-Beaumetz, and an abstract of 
his thesis was published in the Therapeutic Gazette in 
the following year. The physiological and therapeutic 
action he sums up in the following conclusions : 
1. Kola, by the caffeine and theobromine which it con- 
tains, is a tonic of the heart, whose pulsations it accel- 
erates, while it increases its power and regulates its 
contractions. 
2. A second phase of its action, similar to that of dig- 
566 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Knock-Knee. 
Leprosy. 
italine, proves it to be a regulator of the pulse, which 
revives under its influence, the pulsations becoming fuller 
and less numerous. 
3. In consequence of its action upon arterial tension, 
diuresis is increased, and, consequently, kola can be em- 
ployed to good advantage in cases of dropsy with cardiac 
lesion. 
4. It might be deduced from observation that kola, 
which acts energetically upon cardiac contractions, and 
upon the contractility of muscles of organic life, would, 
on the other hand, have a paralyzing ihfluence upon the 
striated muscles, when it is used in toxic doses. 
5. It retards tissue metamorphosis and diminishes the 
excretion of urea resulting from decomposition of azotic 
substances, very likely by exerting a special action upon 
the nervous system. 
6. It is a powerful tonic, through the principles which 
it contains, and its employment is indicated in cases of 
anaemia, in chronic affections associated with debility, and 
in convalescence from acute disorders. 
7. It favors digestion, either by augmenting the secre- 
tion of the gastric juice (eupeptic), or by acting on the 
smooth fibres of the stomach, which it would render less 
atonic in cases of dyspepsia. Under its influence rebel- 
lious anorexia disappears and the digestive functions be- 
come more regular. 
8. Finally, it is an excellent anti-diarrhoea remedy, and 
has rendered great service in chronic diarrhoea or sporadic 
cholera, although its action could not be explained physi- 
ologically. 
Further use of the drug indicates that it does not pos- 
sess any virtue that may not be ascribed to the alkaloids 
which it contains, and it has not secured a very firm foot- 
hold as a remedial agent. Its power to sustain fatigue 
has received more attention than its therapeutic properties. 
Among pedestrians and athletes its use has become very 
popular, and it is thought to prove very satisfactory to 
those who have used it. It has been suggested that the 
red substance that remains after the caffeine has been 
extracted by chloroform is a complex body, and exerts a 
peculiar stimulant action on the muscular and nervous 
tissues. A series of experiments have been made by E. 
Heckel (Repent, de Pharm., October, 1892), to compare 
the action of caffeine and kola rouge or kolanine, from 
which he concludes that the action of the latter on the 
heart is more prolonged and due to the presence of caffe- 
ine in a " nascent " state. Surgeon R. H. Firth publishes 
(Practitioner, July, 1889) some very practical observations 
made upon British troops and natives under his control, 
and concludes that it is in no sense a food, and that its 
physiological action is explained by the contained alka- 
loids ; when pure and not too old it has a peculiar stimu- 
lant action on the nervous system, temporarily strength- 
ens the heart-beat, and increases the arterial tension ; taken 
continuously during times of exertion and fasting, it pos- 
sesses some power of warding off the sense of mental and 
physical exhaustion. This power, however, is not so 
marked as some observers have reported; in the con- 
valescence from long sickness its value is not apparent, 
and its alleged antagonistic action to alcoholic sequelae is 
not capable of proof. 
As a therapeutic remedy it is of benefit in strengthen- 
ing the weak heart, augmenting the general flow of blood 
and vascular tension, and promoting diuresis. Its tonic 
effect has also proved of benefit in disturbances of the 
nervous system and debility of the cerebro-spinal centres, 
and in the prostration accompanying and following se- 
vere fevers and protracted illness. As a remedy for diar- 
rhoea, particularly of an atonic character, it has proved of 
decided value. The combination of the tannic acid and 
its tonic principles makes it of great service in this dis- 
order. The preparations advised are the alcoholic tinct- 
ure, the elixir, and the wine. The tincture is made by 
exhausting fresh kola with five parts of alcohol, and the 
wine by macerating the same proportions of kola in wine 
for a fortnight. The dose is from one to two or three tea- 
spoonfuls tliree times a day. The elixir is prepared by 
diluting the alcoholic preparation with equal proportions 
of syrup. Beaumont Small. 
(SUPPLEMENT.) 
KRONTHAL. A small spa in the Taunus district in 
Nassau, Germany. Kronthal is prettily situated near the 
wooded hills of the Taunus, not far from FranMort-on- 
the-Main. The springs are mild saline, chalybeate ones, 
and are very agreeable to the taste on account of the large 
proportion of free carbonic acid. The Kronthal waters 
are much exported and are quite popular as tonic bever- 
ages. The spa is well suited to the milder forms of 
anaemia, dyspepsia, and neurasthenia. Many invalids 
go there for a so-called "after-cure." The climate is 
mild and pleasant. There are good facilities for excur- 
sions, promenades, and out-door amusements generally. 
A fine thermal establishment has been recently erected, 
in which the usual hydro-therapeutic appliances are 
found, also baths, massage, sprays, etc. The nearest rail- 
road station is Kronberg, from which town Kronthal is 
reached in twenty minutes. Edmund C. Wendt. 
LEPROSY. Etioi ,ogy.-During the past five years 
the etiology of leprosy has received a great deal of at- 
tention, and the discussion has assumed somewhat of a 
public character. Among the most important contri- 
butions is that by1 Zambaco, of Constantinople, who 
has had during ten years two hundred cases under con- 
stant observation. Although he made a careful study 
into the personal as well as the family history of these 
cases, he has not been able to establish a single fact which 
would prove the contagiousness of the disease. He cites 
a number of cases of individuals who have lived in the 
closest contact with lepers and have not become affected. 
He believes that it is contagious in certain localities and 
in extremely rare cases. He adheres to the theory of 
hereditary origin. 
Dr. Heindiston2 has cited several instances illustrating 
the hereditary character of the disease. He mentions the 
case of a child of a leprous mother, deserted soon after 
birth, and brought up by perfectly healthy people in a 
district where leprosy was not known. At ten years of 
age early symptoms became manifest, and at fourteen she 
was admitted into the leper hospital. 
This case is quoted by Zambaco, and would therefore 
appear to be one of the best established instances of hered- 
itary origin. 
Dr. Danielsen has again affirmed that in his long ex- 
perience he has never met with a single case of contagion. 
Dr. Bevan Rake is doubtful as to the proof which has 
so far been produced in favor of direct contagion of 
leprosy. The question in his opinion is narrowed down 
to this : Can a healthy person more readily derive the 
bacillus from an infected human being, or from water, or 
from some host which contains the bacilli or its spores ? 
On the other hand, Hansen, of Bergen, thinks the theory 
of the hereditary transmission untenable. He made careful 
personal investigations into the history and condition of 
the descendants of one hundred and sixty Norwegian 
lepers who settled in the States of Minnesota. Wisconsin, 
and Dakota. He traced out the history of the children, 
grandchildren, and even the great-grandchildren, and 
was not able to find a single case of leprosy among them. 
Dr. Phillips, of Jamaica, is of opinion that the disease 
is communicable by contagion, and Dr. Saunders, of 
Jamaica, is of the same opinion. 
In the " Traitede Medecine," now being published under 
the direction of Charcot, Bouchard, andBroussais, the fol- 
lowing conclusions are given regarding the etiology of 
leprosy : " The sole cause of leprosy is contagion, that is 
to say, the transmission of its bacilli by direct contact 
with a subject affected with ulcerative leprous lesions, or 
by the medium of different bodies upon which leprous 
secretions have been deposited." 
Mr. Jonathan Hutchinson,3 in an article on the "Lep- 
rosy Problem," arrives at conclusions of which the fol- 
lowing are among the more important : 
1. Leprosy is a well-specialized disease of which the 
bacillus of Hansen is the cause. 
2. It is not modified by race, and it appears to have no 
allies. 
3. It is not, for practical purposes, contagious. 
4. It is endemic and affects both sexes. 
567 Leprosy, 
Leprosy. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
5. It may occui' at any age. 
6. It is possibly hereditary. 
7. It may be produced in immigrants or even visitors 
to leprous districts. 
8. The poison which produces the disease gains access 
to the body in the form of food. 
9. The evidence as regards the disease points to fish as 
being probably the article by which leprosy gains access 
to the human body. 
He gives as a reason for the latter theory that in a very 
large number of leprous districts fish is one of the prin- 
cipal articles of diet. 
To what conclusions may we arrive in view of the 
foregoing apparently contradictory opinions ? Now that 
there is a general agreement that the disease is produced 
by the bacilli of Hansen, one might think that we could 
more easily arrive at a satisfactory conclusion. 
The disease being of bacillary origin, must be com- 
municated either by heredity or contagion. If by the 
latter, the virus must be introduced either by inocula- 
tion, in food, or through the atmosphere. 
One cannot deny the possibility of hereditary trans- 
mission, although no instances have yet been reported 
which positively prove its hereditary character. The 
bacilli have never been found in the foetus or in newly- 
born children, as has been the case in tuberculosis. 
The cases cited by Zambaco and Heindiston are not 
conclusive, as in them the disease may possibly have 
originated in some other way. If Hansen in his investi- 
gations had discovered a single case in the descendants 
of the leprous immigrants in the Western States, where 
the possibilities of contagion were at a minimum, it would 
have gone a long way to prove that the disease may, at 
any rate occasionally, be transmitted from parent to 
child. 
There can be no doubt that a tendency to this disease is 
thus transmitted. It is not at all impossible that the dis- 
ease may be communicated in articles of food. That this 
is frequently the case is very doubtful. 
The inhabitants of the Hawaiian Islands used the same 
form of diet after as before the introduction of the disease. 
If the food or drink then contained the virus, the germs 
must have accidentally become incorporated with them. 
Dr. Arning, on a most careful examination of all the sur- 
roundings of patients, water, food, soil, etc., was unable to 
discover the bacilli in any of them. They have never been 
found in fish or any other article of diet, as the bacilli of 
tuberculosis have been found in milk and the flesh of 
animals. In the parishes adjoining Tracadie, in New 
Brunswick, the inhabitants are of the same race, live 
under similar conditions as to food and climate, and yet 
do not suffer from the disease. 
It is possible that further investigation into the subject 
may be rewarded by the discovery of the bacilli in other 
animals than the human being. The theory of conta- 
gion by inoculation, or by prolonged and intimate con- 
tact, seems to best satisfy all the facts. By this theory 
alone can the outbreak in Tracadie or in the Sandwich 
Islands be understood. 
The fact constantly brought forward of individuals liv- 
ing in the closest contact for a lengthened period with 
lepers, and remaining free from the disease, can be ac- 
counted for on the ground of natural immunity. We 
have instances of individual immunity in as contagious a 
disease as small-pox. 
It is true that leprosy appears to be but slightly con- 
tagious, and requires a soil which is only produced by 
certain modes of living, the use of certain food, and in 
certain races. It is also true that there are occasional 
cases of individual susceptibility in the most highly civil- 
ized races and in the highest classes of society. 
On September 30,1884, Dr. Arning inoculated a crimi- 
nal with fresh matter from a leprous tubercle. Local 
inflammatory action ensued which lasted six months and 
disappeared. In September, 1887, tubercular leprosy 
made its appearance, and the patient has since succumbed 
to the disease. 
Dr. Morrow, who visited the Sandwich Islands in 1889, 
excised some of the tubercles of this patient and found 
bacilli in them. Dr. Arning does not consider the case a 
positive proof that the disease originated by inoculation, 
as there existed other possible channels of infection. So 
far all attempts to inoculate animals have failed. 
Pathology.-Subsequent investigations have con- 
firmed the truth of the discovery of Hansen and Neisser. 
The bacilli are the active cause of the various lesions 
peculiar to the disease. 
Leloir4 gives in the following summary the differences 
between the bacilli of leprosy and those of tuberculosis : 
" The bacilli of leprosy are especially distinguishable 
from those of tuberculosis because in the colored sec- 
tions lepromes always maintain an immense quantity of 
bacilli, while tuberculomes always contain much fewer, 
and most usually they are very few in number." 
The size of the lepra bacillus is more uniform and 
more rectilinear than the tubercle bacillus (Cornil). 
They are shorter, thinner, and less pointed than those of 
tuberculosis (Hansen). The bacilli of leprosy are also 
more easily colored than those of tuberculosis. A much 
longer period is required to decolorize them by nitric 
acid. The tubercular bacillus colors only in alkaline 
coloring liquids ; that of leprosy takes color in neutral or 
acid coloring liquids (Neisser). For the purpose of dis- 
tinguishing, for example, the bacilli of leprosy from those 
of tuberculosis, if they occur together in an organ, the 
sections are colored with simple fuchsin for half an hour 
and decolorized with an acid. By this proceeding the 
lepra bacilli alone remain colored (Cornil and Babes). 
Dr. Thin4 has made a careful study of the question as to 
whether the bacilli are intra- or extra-cellular, and con- 
cludes that there is no evidence that the bacilli can live 
and multiply outside the cells. He thinks this accounts 
for the chronicity of the disease and the comparative 
rarity of contagion. 
Boinet6 arrives at the following conclusions with re- 
gard to the existence of giant-cells in leprous tissue : 
" There exist in the lepromes giant-cells like those of in- 
flammation and tuberculosis. They appear to be the 
result of an inflammatory process and in this particular 
case the giant-cells do not seem to exercise any distinctive 
action on the bacilli of leprosy. Of the various parts of 
the body the bacilli are most frequently found in the 
skin. The mucous membranes, except those of the large 
intestines, are generally exempt. The lymphatic glands 
are almost invariably affected. They are not found in 
the brain or spinal cord, but they exist in large numbers 
in the smaller branches of the nerves. 
Dr. Bevan Rake,6 who has made many valuable con- 
tributions to the study of this disease, has published the 
result of his inquiries into the connection between kidney 
lesions and the skin changes in leprosy. Out of forty-one 
cases of nephritis he found bacilli in but two. He also 
found that cases of kidney lesion ran a more chronic 
course than those of the other results or complications of 
leprosy. 
Dr. Schultze 8 has published the results of electrical and 
other examinations into the neuritis of leprous subjects. 
He found the same alteration of motor power and the 
same electrical reactions as exist in the neuritis arising 
from other causes. 
Diagnosis.-The diagnosis between leprosy and 
syringo-myelia was made the subject of a paper read by 
Dr. Morrow at the meeting of the American Dermato- 
logical Association, 1888, and has recently been studied 
by Marestang.8 
The latter author has arrived at the following conclu- 
sions : 
1. Leprosy and syringo-myelia are two distinct diseases. 
2. Syringo-myelia is the result of medullary change 
(chiefly gliomatous), while anaesthetic leprosy is the result 
of neuritic changes 
3. The points of distinction clinically are as follows : 
(a) In syringo-myelia there is loss of thermo-anaesthesia 
and analgesia, with integrity of the tactile sensibility. 
This disassociation of sensory conditions is not found in 
leprosy. 
(6) In syringo-myelia the surface muscles of the face are 
unaffected, there is absence of discolorations on the skin. 
568 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Leprosy. 
Leprosy. 
and the hair remains normal, but there is deviation of the 
vertebral column. 
In leprosy tactile sensibility is abolished, and there are 
atrophy and paralysis of the muscles of the face, thicken- 
ing of the nerve-trunks from infiltration, the presence of 
light-colored patches on the skin, resorption of the fingers, 
excessive alteration of the nails, complete or partial loss of 
hair, and the presence of the bacillus of Hansen in the 
discharge from the ulcerative lesions. 
Zambaco,17 at the Academic de Medecine, Paris, 1892, 
expressed the opinion that Morvan's disease is a form of 
leprosy, as also is one variety of syringo-myelia. The 
writer could not gather from the discussion that the ba- 
cilli of Hansen had been found in either of these diseased 
conditions. 
Prognosis.-Several cases of cure, or rather cessation 
of the symptoms, have been recently reported : one by 
Dr. G. II. Fox, which will again be referred to ; Sandrec- 
zky 9 also mentions a case in which the lesions disap- 
peared ; finally, Dr. Kaurin gives the history of two cures, 
and Dr. Muro, of St. Kitt's, relates the history of one. 
The number of apparent cures, however, is small com- 
pared with the whole number of cases. The disease has 
therefore lost little of its dreadful fatality, notwithstand- 
ing the many new methods of treatment adopted. 
Treatment.-Dr. Unna, of Hamburg, in 1885, pub- 
lished a method of treatment and related one apparently 
successful case. He made external applications of pyro- 
gallol, chrysarobin, resorcin, and ichthyol, and gave 
ichthyol internally. From Dr. Thin's work I would 
infer that Dr. Unna's patient died in South America, 
whether from leprosy or not is not known. 
Dr. Duckman12 relates an advanced case of disease 
treated after Unna's method with apparent success. Ac- 
cording to Dr. Thin, however, the patient died in 1889, 
probably from leprosy. 
Dr. Duckman used ten per cent, pyrogallol ointment 
for the forearms and hands, and ten per cent, chrysarobin 
upon the other parts of the body except the face. On 
the latter he used a plaster of salicylic acid and creasote. 
Ichthyol was given internally. 
Dr. Blue, of New Orleans,13 has reported a number of 
cases treated according to Unna's method. He states 
that pyrogallol, resorcin, and salicylic acid were not at 
all satisfactory when applied to the face, but that they 
were useful on other parts of the body. He gave ich- 
thyol up to six grains a day with negative results. 
Dr. G. II. Fox 14 has reported a case of apparent cure 
in which the principal remedy used was chaulmoogra 
oil. The patient, a young man of New England parent- 
age, was born in the Sandwich Islands, and symptoms of 
leprosy having developed, he came to America, and after 
a time (1883) placed himself under Dr. Fox's care. Af- 
ter other methods of treatment failed he was put on 
chaulmoogra oil in gradually increasing doses, until he 
took sixty drops each day. In time the lesions gradually 
disappeared, and in 1885 he wrote to Dr. Fox from Cali- 
fornia : " There have been no more symptoms of the dis- 
ease in any shape. I have enjoyed almost perfect health 
in every way, and were it not that I still have numbness 
of the hands I would not believe that there could be any- 
thing the matter with me. I take about a hundred drops 
of the oil daily and it does not disagree with me." In 
1887 and 1889 he reported himself as being quite well, and 
Dr. Fox has recently informed the writer (February, 
1893) that the patient is still in good health. 
The favorable result, as Dr. Fox states, is largely due 
in this case to the change of climate as well as to the 
remedy used. 
Dr. Zariago (de Valence) gives chaulmoogra oil in 
large doses with decidedly beneficial results. He speaks 
highly of Unna's method of treatment in the early stages 
of the disease. 
Dr. Falcoo16 gives gynocardic acid in one decigramme 
pills with bitter extract. He begins with two pills 
daily and increases the number to twenty. At the same 
time he uses a pomade of gynocardic acid and vaseline. 
Gurjun oil has been used with apparent benefit by 
some physicians. 
The following quotation from the " Journal of the Lep- 
rosy Investigation Committee," January, 1890, will give 
in brief our present knowledge with regard to the action 
of tuberculin : " The authors consider that these dif- 
ferences (of reaction) prove for us, (a) whether an affec- 
tion is leprosy or tuberculosis, (b) whether at the time 
being leprosy is associated with tuberculosis, and (c) 
whether a suspicious tropho-neurotic disease be leprous 
or not. They observe that it remains to be seen whether 
the remedy can cure leprosy, produce a durable improve- 
ment, or prevent its further development." Tuberculin 
does not seem to have any positive effect in the cure of 
the disease. Dr. Hake has reported the case of a negress, 
in whom vaccination produced an amelioration of symp- 
toms. Several cases have been recorded where the 
presence of an intercurrent affection, such as erysipelas, 
pneumonia, etc., has exerted a favorable influence on 
the course of the disease. 
Prophylaxis.-From a brief survey of the literature 
one is impressed with the idea that leprosy has made 
considerable progress during the last five years. 
Dr. P. S. Abrahams 18 publishes the following state- 
ments with regard to some of the British Dominions: 
The disease is certainly on the increase at the Cape of 
Good Hope. 
The number of cases has increased in the Trinidad 
Asylum, as shown by Dr. Bevan Rake. 
The total number of cases in the Barbadoes has in- 
creased from 96 in 1871 to 120 in 1881. 
In New Brunswick there has been a slight diminution. 
The disease has appeared in British Columbia, but is 
limited, as Dr. Milne, of Victoria, informs me, to the 
Chinese population. 
The present number of lepers in the United States is 
placed at about two hundred, a decided increase. 
Zambaco makes the following suggestions as to pro- 
phylaxis : 
1. All cases of the disease to be placed in a special hos- 
pital, where they can receive proper attention and medi- 
cal treatment. 
2. To prevent marriage in all cases where the disease 
is present or even suspected. 
3. To improve the character of the food and surround- 
ings of the people. 
4. To carefully inspect and supervise the children of 
leprous parents. 
Dr. Bevan Rake, who, with Zambaco, is still sceptical 
on the subject of contagion, also recommends isolation. 
It will thus be seen that in the prophylaxis of the dis- 
ease there is a unity of opinion between the contagion- 
ists and non-contagionists on the importance of the com- 
plete separation of the diseased from the healthy. 
During the past five or ten years much progress has 
been made in this direction.19 In 1884, the government 
of the Cape of Good Hope passed a Leprosy Repression 
Act. In Norway, segregation was made compulsory in 
1885. 
Under an act to facilitate the segregation of lepers in 
the Hawaiian Kingdom, 821 lepers had been removed to 
the asylum, between July 17, 1887, and March 12, 1889. 
For some years in New South Wales lepers have been 
kept in a lazaretto near Sidney, and quite recently a bill 
has been passed by the New South Wales Legislature to 
empower the authorities to compulsorily segregate lep- 
ers.19 In San Francisco also a stringent act has been 
adopted. 
In many parts of the world, however, as Dr. Thin ob- 
serves, great carelessness is still shown in this matter. 
James E. Graham. 
1 Bulletin Acad, de Med., Paris, 1889. 
2 Loc. cit. 
' Archives of Surgery, 1889. 
4 Dr. Thin : Leprosy. 1892. 
5 British Journal of Dermatology, 1888-89. 
8 De la Cellule geante dans la Lepre, Revue de Medecine, Paris, 1891, 
pp. 339, 344. 
7 Van Harlingen: Internation. Clinics, January, 1892. 
8 Deutsche Archiv fiir klin. Med., xliii., 4 and 5. 
9 Du diagnostic differentiel de la lepre anaesth6sique et de Syringo- 
myelie. Revue de Medecine, 1891, p. 781. 
10 Monats. fiir prakt. Dermat., 1891. 
569 Leprosy. 
Lungs. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
u Ibid.. 1885. 
i2 Ibid., 1888. 
13 New York Medical Journal, 1889. 
14 Transactions of the Medical Society of the State of New York, 1890. 
15 International Dermat. Congress, Paris, 1889. 
i' Ibid., 1889. 
17 Zambaco : Le Mercredi Medicale, August, 1892. 
18 London Practitioner, 1889. 
19 Dr. Thin : Leprosy, p. 245. 
goes by the name of " Wiesbaden Gichtwasser " and is pre- 
pared by putting extra quantities of bicarbonate of soda 
and lithion into the natural Wiesbaden Kochbrunnen. 
The patient takes about a quart of this water per diem, 
in divided doses, and with excellent results, as has been 
proved by recent statistics. 
The following analysis of the Wiesbaden Gichtwasser 
has been published : One thousand grammes of the water 
contain : 
Natr. bicarbon 7.500 
Natrii muriatic 6.828 
Calc, bicarbon 0.266 
Magnes, bicarbon 0.177 
Lith. chloric 0.023 
Potass, chloric 0.182 
Carbonic acid 9.296 
These are the principal ingredients of the water, and 
the therapeutic effects of the same are mainly produced 
by the relatively large amount of the soda and salt, and 
to only a small extent by the other salts. That an alkaline 
water thus prepared and drank in sufficiently large doses 
daily, and for a considerable period, will prove of excel- 
lent effect in gout and uric-acid diathesis I am ready to 
testify to from the observation of a large number of cases 
of that kind. The well-known Selters, Vichy, and Fa- 
chingen waters can readily receive additional quantities 
of soda and salt to bring them up to the required standard 
of about 3 ij. of each salt to a quart of water, and will 
then serve the same purpose as the Wiesbaden water. 
Leonard Weber. 
LLANDUDNO. A modern and fashionable watering- 
place in Wales. The climate is good, owing to its shel- 
tered position. It is more of a summer resort and sea- 
bathing place than a recognized winter station. It is 
situated under the promontory of the Great Orme's Head, 
and extends for over a mile along the shore, between the 
bays of Conway and Llandudno. The sanitary condi- 
tion of the settlement is good, the rate of mortality being 
about nineteen per thousand per annum. The winds com- 
ing over the water are generally tempered, but violent 
cold gales at times keep all invalids indoors. Dr. Yeo 
("Climate and Health Hesorts ") speaks of this place as 
follows : 
" Llandudno has pretensions also as a winter resort, 
especially for invalids who can support a certain amount 
of windy weather. Its annual rainfall-32.36 inches- 
is somewhat below the average rainfall of England and 
Wales, which is 35 inches. The mean humidity of the 
air in winter is 82', so that it has a drier winter atmos- 
phere than some of our southwest coast resorts ; this is 
partly due to the porousness of its subsoil, which is 
mostly gravel and sand. 
" During the five winter months (November to March), 
from observations extending over live years, it would 
appear that the mean winter temperature is 43.5° ; the 
mean maximum, 48.3°; the mean minimum, 38.8° ; the 
mean daily range, 9.5°; the mean monthly range, 28.3° F. 
North and east winds blow on 44 days, south and w'est 
winds, 107 days. There were 83 rainy days, and a rain- 
fall of 15.96 inches. 
"Nothing, perhaps, could show better the character of 
our (i.e., the English) winter climate than the fact that 
a place claims to have attractions as a winter resort, 
where, on an average of five years, there have been 
eighty-three wet days out of one hundred and fifty-one- 
more than one-half ! " 
Llandudno is twm hundred and thirty-six miles distant 
from London. 
The hotel accommodation is good, and the usual 
amusements are provided. The drinking-water is said 
to be excellent. There is a fine sandy beach. 
Edmund C. Wendt. 
LOSOPHANE (Tri-iodo-meta-cresylic acid). A new 
antiseptic preparation, obtained by the action of iodine 
upon oxy-toluylic acid in the presence of an alkali. Its 
formula is CeHLOHCHs, and it is said to contain eighty 
LEVULOSE (C6H12O6.). This form of sugar has, within 
the past year, been advocated as an article of diet for dia- 
betic patients. Its administration does not augment the 
amount of sugar in the urine, as it is thoroughly oxidized 
in the system, and acts as food by building up the body 
and supplying vital energy and strength. A preparation 
under the name of Diabetin has been placed in the mar- 
ket, which is said to be a perfectly pure levulose. It is a 
dry crystalline powder, easily soluble, and possessed of a 
remarkably sweet taste. 
Levulose exists in honey and in most fruits and vegeta- 
bles. It may be formed from cane sugar by heating with 
dilute acids, and is also produced by the action of yeast 
on pectase, the ferment peculiar to fruits. It is distin- 
guished from the ordinary forms of sugar or dextro- 
glucoses by its property of turning the plane of polariza- 
tion to the left, laevo-rotation, from which its name is 
derived. It generally exists with dextro-glucose, and is 
with difficulty obtained pure. It exhibits the same chem- 
ical reactions as other sugar, but is more easily altered by 
heat aud acids. A large percentage of dextro-glucose 
may be present without altering its rotatory action, as its 
power of polarization is much greater than that of the 
dextro-rotatory sugar. Beaumont Small. 
LIPANIN. A fatty compound formed by the addition 
of five or six per cent, of oleic acid to fine olive-oil. It 
has been proposed by Von Mehring as a substitute for 
cod-liver oil. Its use was suggested by the theory of 
Buckheim that the beneficial action of cod-liver oil was 
due to the fatty acids it contained. The proposed sub- 
stitute is more palatable and is easily retained by the 
weakest stomach, and when desired may be readily 
formed into an emulsion. It is freely absorbed, and un- 
doubtedly is a nutrient of some value. No diarrhoea or 
intestinal disturbance has been traced to its use. The 
dose for children is one teaspoonful before meals; for 
adults, one tablespoonful. Beaumont Small. 
LITH/tMIA. In the treatment of the uric-acid variety 
of lithaemia, the so-called uric-acid diathesis, as well as in 
true gout, piperazine has been extolled and freely adver- 
tised, in 1892, as a specific for that disordered state of the 
system. The remedy, a whitish powder of pungent taste, 
is prescribed in five-grain doses dissolved in carbonic- 
acid water, with or without bicarbonate of soda, and given 
three or four times in twenty-four hours. I have found 
it to be a fairly good palliative for an acute attack of 
gout, but a specific by no means, nor as good as Laville's 
liqueur antirheumatique, the active principles of which 
are colchicine and colocyntine. Laville's preparation I 
have often prescribed for acute attacks of gout, and 
found that twenty to thirty drops taken every three hours 
during the day, for a week at most, afford quick relief, 
and remove all acute symptoms effectually in almost 
every case. In cases of uric-acid diathesis neither La- 
ville's liqueur nor piperazine is ever indicated, but the 
plain and cheap bicarbonate of soda, with a little lithion 
and chloride of sodium, is all that is required when the 
patient needs a mineral water. 
Of German observers Dr. E. 'Pfeiffer, Dr. Mordhorst, 
of Wiesbaden, and Professor Ebstein, of Gottingen, have 
studied the question of gout and lithaemia, and the 
proper diet and medication for those affiicted with these 
disorders, and have written probably more about it of late 
than anybody else. The Wiesbaden doctors particularly, 
who undoubtedly see and treat a great many gouty pa- 
tients, have apparently proved that bicarbonate of soda is 
the remedy of all others which will promptly dissolve, and 
effectually keep in solution, the uric acid. They order now 
their patients to take it, dissolved in a mineral water that 
570 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Leprosy. 
Lungs. 
per cent, of iodine. It forms in white needles, insolu- 
ble in water, slightly soluble in alcohol, and readily 
soluble in ether, benzene, and water. At 140° F. it is 
freely soluble in fatty oils. 
It is particularly recommended in parasitic skin affec- 
tions. It may be used in tinea tonsurans, scabies, pity- 
riasis versicolor, also in prurigo, in chronic eczema, 
acne, and sycosis. It is contra-indicated in all acute in- 
flammatory conditions of the skin, as it is liable to in- 
crease the irritation and intensify the disease. The 
remedy may be applied in solution of the strength of one 
per cent., or in an ointment of one to three per cent. 
Beaumont Small. 
LOWESTOFT. A popular seaside resort on the Nor- 
folk coast. It is situated on the most easterly point in 
England, at a distance of about ten miles from Yar- 
mouth. The beach is much used for bathing, although 
it is only partly sandy and in part shingle. The little 
town is prettily built on the cliffs overlooking the sea. 
The air is claimed to be particularly pure and bracing at 
Lowestoft, but the place does not escape the humidity 
and abundant rainfall common to English resorts. The 
drinking-water is good, and the sanitary arrangements 
satisfactory. The death-rate is about eighteen per thou- 
sand. The hotel and boarding-house accommodation is 
moderately good. Edmund C. Wendt. 
LUNGS, ANATOMY OF THE. Historical.-The 
first account we find of the structure of the lungs is that 
given by Hippocrates,1 and is very incomplete. He com- 
pares them to a sponge interspaced with numerous small 
vessels. Aristotle2 also gives to the lungs a spongy 
nature, the canals receiving blood from the great vein. 
Celsus3 also describes the lungs as being spongy. Galen4 
had but little better idea of their structure ; he describes 
them as being made up of lobes, liver-like in substance, 
and containing many vessels. Vesalius5 describes the 
lungs as being divided into lobes, and says in regard to 
their structure that " the substance of the lung is soft, 
spongy, thin, light, airy flesh, as if formed of frothy 
blood, or bloody froth, and crowded with many branches 
of vessels." 
We now come to the time when Harvey6 announced his 
discovery of the circulation of the blood ; this had its effect 
on all anatomical research. Malpighi,7 profiting by this 
discovery, proved by means of injections that the air and 
blood were not contained in the same channels, but had 
separate systems of vessels, and that these did not commu- 
nicate with each other, but did communicate among 
themselves. He also saw the circulation of the blood in 
the vessels of the lung of a living frog. He recognized the 
presence of air-vesicles, and described them as opening 
into the trachea and communicating with one another. He 
also compares the lung to a sponge. Bartholin 8 defended 
the views of Malpighi. The next writer of note is Wil- 
lis.9 He is wrongly quoted by Williams in Todd's " Cy- 
clopaedia ; " he places Willis among those who describe 
the air-vesicles as communicating with one another. 
What he does say, directly opposite to the view of Mal- 
pighi, is, that the bronchial tubes give off numerous small 
branches which bear on their distal extremity little blad- 
ders, thus giving the lung the appearance of a bunch of 
grapes. Helvetius 10 returned to the older idea and main- 
tained that the lung was spongy in its nature. He de- 
nied that the spongy tissue of the lung was formed by 
the expansion of the bronchial tube, but asserted that the 
bronchus simply penetrated into the spongy tissue. His 
description of the lung is not very clear. Soemmering11 
describes the lungs as made up of small, irregular polygo- 
nal cells grouped together into lobules. The cells of the 
lobule communicate, but those of one lobule do not com- 
municate with those of adjoining lobules. 
Early in the present century, Reisseissen 12 published a 
very important paper, in which he advanced views quite 
opposite to those accepted by the anatomists of his day. 
His method consisted in pouring mercury into a bron- 
chus and, by applying gentle pressure, forcing it on until 
it appeared beneath the pleura. He describes the bron- 
(SUPPLEMENT.) 
chi as dividing into branches which in turn divide 
quite rapidly, becoming at the same time much small- 
er, until eventually each small branch ends in a single 
rounded extremity. This was apparently a revival of 
the theory of Willis. Magendie 13 wrote two important 
papers on the lungs. In the first he denies that the 
bronchi terminate in air-vesicles, but affirms that the 
air-cells of one lobule communicate with one another, but 
do not communicate with those of adjoining lobules. In 
his second paper he states that those grape-like structures 
described as hanging on to the end of a bronchus do 
not exist in nature, but are to be found only in books. 
His conclusion is that the lung is made up of " spongy 
tissue formed by the arrangement of the vessels, which 
have between them small spaces into which the air pene- 
trates freely." 
In 1832 Bazin14 wrote supporting the views of Reiss- 
eissen, and was followed a few years later by Lereboul- 
let,15 who in quite a lengthy essay also supported Reiss- 
eissen. Addison 16 failed to find "any tubes ending in 
culs-de-sac ; on the contrary, I always saw air-cells com- 
municating -with one another in every section I made." 
He describes the bronchi as dividing, within the lobule, 
into numerous minute branches which terminate in 
"branched air-passages and freely communicating air- 
cells." Huschke,17 however, writing about the same time, 
described the bronchi as ending in fine branches, which 
bore on their free extremity small sacs which did not 
communicate with one another. 
Rainey 18 wrote several excellent memoirs on the lung. 
He says " they are made up of bronchial tubes, bronchial 
intercellular passages, and air-cells." These air-cells com- 
municated with one another, and with the bronchi or 
bronchial intercellular passages, by means of large circu- 
lar openings. Moleschott19 published an excellent bro- 
chure in which he combats strongly the opinion of those 
who hold to the communication of one vesicle with 
another. In no instance did he find the bronchi forming 
anastomoses ; he also distinctly states that the air-vesicle 
contains no opening except that by which it communi- 
cates with its proper bronchial tube. 
Rossignol20 gave us a very valuable treatise on the 
structure of the lungs. He introduces the term "infun- 
dibulum." According to this author the bronchi give off 
numerous branches which cross each other repeatedly in 
all directions, but do not communicate ; from the ultimate 
division of the bronchial tube arises a dilatation in the 
form of a funnel, which he terms " infundibulum." The 
walls of each infundibulum are lined with numerous air- 
cells or alveoli. Rossignol compares each infundibulum 
with its alveoli to the lung of the batrachians, and says : 
" The human lung looked at from this point of view can 
be defined as the assemblage or concentration of innumer- 
able small lungs, held together by means of a common 
bronchial tree." In an inaugural dissertation written by 
Adriani,21 he adopts the nomenclature of Rossignol. He 
also describes alveoli as existing on the walls of the bron- 
chial tubes just before they dilate into infundibula. He 
takes strong exception to Rossignol's statement that there 
are no communications between adjoining alveoli, declar- 
ing it to be without doubt false, and describes minute 
openings by which adjoining infundibula communicate. 
Kolliker 22 gives quite a valuable description of the 
finer structure of the air-passages. He considers the term 
"infundibulum" introduced by Rossignol unnecessary, 
and says, that "all the vesicles belonging to one lobule 
open, not into ramifications of the finest bronchial twig 
going to it, but into a common space from which the air- 
vessel is afterward developed." 
The " Cyclopaedia of Anatomy and Physiology" * con- 
tains an article on " Respiration " by Williams, in which 
he has embodied some of his personal investigations. 
He describes each lobule as being sacculated and receiv- 
ing a single bronchial tube ; this tube gives rise within 
the lobule to small branches which subdivide to the third 
or fourth order, and from these latter branches the air- 
* The Cyclopaedia of Anatomy and Physiology. Supplementary vol- 
ume. London : Robert B. Todd, editor. 
571 Lungs. 
Lungs. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
cells arise. He discards the term " infundibulum," and 
uses in its place that introduced by Rainey, " intercel- 
lular passage." Mandi 23 describes the bronchial tubes 
as ending in terminal cavities which have numerous de- 
pressions in their walls, the "vesicles." He compares 
the terminal cavities and their vesicles to the lung of the 
frog. 
In 1860, Waters 24 published a most excellent essay on 
" The Human Lung," in which he describes the " ulti- 
mate pulmonary tissue " as being made up of elongated 
air-sacs arranged in groups, called by him " lobulettes," 
which spring from the enlarged end of a terminal bron- 
chial twig ; the air-sacs bear on their sides and ends de- 
pressions varying in number, the alveoli. He failed to 
find any communication between the air-sacs. On this 
point he says, " I have never found, either in the lungs 
of man, or of the dog, or cat, or pig, or sheep, or of any 
other mammal I have examined, any lateral orifice of 
communication between the different sacs of each lobu- 
lette." 
Henle,25 in his systematic work on anatomy, gives a 
very good article on the lungs. He describes com- 
munications between air-cells, but considers them anom- 
alies. He found them in the lungs of old people, and 
attributed them to the result of atrophy and absorption 
of the lung-substance. Delafield26 advocates the theory 
of communication between air-cells. He says : " The 
air-passages seem to be made up of a succession of large 
vesicles which open into each other, or of an irregular 
larger canal made up of vesicles into which other vesicles 
open from all sides." He also describes anastomoses 
between the air-passages. Roosevelt27 agrees with Dela- 
field in regard to the communication of the air-cells. 
In other places 281 have described some of my own re- 
searches on the lung. 
Besides the authors quoted at length, I will refer the 
reader to the works of Milne-Edwards,29 and to that of 
Ewart.30 Those who are interested in the development 
of the lung should not neglect to read the article by His.36 
General Histology.-For the structure of the tra- 
chea I will refer the reader to the text-books on anatomy, 
mentioning especially Quain (tenth edition). 
At the hilus of the lung we find the artery, vein, and 
bronchus lying in quite close apposition, and it is only 
at this point that we find them in such close relationship. 
The arrangement differs on the two sides ; on the right 
side the bronchus lies behind, the artery in the centre, 
and the vein on the outside ; the bronchus occupying a 
higher level than the other two vessels. On the left side 
the vessels have the same order, but the artery occupies 
the higher plane. 
Taking up now each set of vessels, we will consider 
first the bronchus. 
About on the level of the fifth dorsal vertebra the 
trachea bifurcates into the right and left bronchi, which 
pass to their respective lungs. Of these two bronchi the 
right is the shorter and wider, and is usually described 
as having a more horizontal direction than the left. 
Aeby,31 in his admirable monograph, has shown, how- 
ever, that it is the more oblique. The left bronchus is 
longer, but at the same time smaller in diameter, than 
the right ; its lower termination being about twenty-five 
millimetres below that of the right bronchus. The 
shortness of the right bronchus is due to the fact that, 
just before it penetrates into the depth of the lung, it 
gives off a branch which supplies the upper lobe of the 
right lung. This branch is given off above the point 
where the pulmonary artery crosses the bronchus on its 
way into the lung. On the left side we find no corre- 
sponding branch in man. 
Below the point where the pulmonary artery crosses 
the main bronchus, the arrangement of the bronchi is 
quite similar on each side. This peculiarity of the 
bronchi leads to the formation of three lobes for the right 
lung, but only two for the left lung. Aeby calls those 
that branch above the point where the artery crosses, 
eparterial ; those below, hyparterial bronchi ; he reasons 
that as the eparterial bronchus is not present on the left 
side, the lobe to which it is distributed is also absent, and 
(SUPPLEMENT.) 
that the upper lobe of the left lung and the middle lobe 
of the right lung are homologous. Occasionally in man 
the eparterial branch arises directly from the trachea ; 
this point of origin is constant in sheep and in the ox. 
Some of the lower animals possess eparterial branches 
on both sides, and in others no eparterial branches are 
found. Monkeys have an accessory lobe, termed by 
Owen 32 the azygos lobe ; this is supplied by an acces- 
sory bronchus, which arises from the right bronchial 
trunk near the point where the first branch is given off. 
Immediately after penetrating into the lungs the bron- 
chi undergo division, not in a dichotomous manner; 
neither is the arrangement axial, but rather arborescent. 
Aeby,31 by his investigations, proved conclusively that 
the old idea of dichotomy was erroneous ; and while at 
first I was inclined to the view of an axial arrangement, 
more careful investigation of the subject satisfied me of 
the untenableness of this view. 
The bronchi, in their finer structure, have the same 
arrangement as the trachea up to their entrance into the 
lung. With the division of the bronchi we find changes 
in the structure. The cartilage which has been in the 
form of incomplete rings is now found in the form of 
angular plates, which are placed at longer and longer in- 
tervals, until at last it is only found as a small plate at 
the fork of the smaller branches. Bronchi which have 
a diameter of one millimetre, and under, have no carti- 
laginous plates. At the same time that the cartilage be- 
gins to disappear, the smooth muscle-fibres which have 
been in the form of rings gradually spread out into an 
uniform layer, which diminishes in thickness with the 
diminution in the calibre of the bronchus. Beyond the 
terminal bronchus the muscle-fibres are not found. In 
the larger bronchi the mucosa is arranged in longitudi- 
nal folds and consists of at least two layers, the inner- 
most of which is made up of ciliated epithelium and 
scattered goblet-cells. In the finer bronchi these disap- 
pear, and we find in their place a single layer of respira- 
tory epithelium. Outside the cartilage, and extending 
the whole length of the bronchi, there is found a layer of 
connective tissue which forms a sheath surrounding the 
bronchi and contains elastic fibres, and in which the ves- 
sels and nerves run. 
When the divisions of the bronchus have reached a 
diameter of about 0.5 mm. they break up into the proper 
parenchyma of the lung. The last division of the bron- 
chus before this breaking up takes place is called the 
terminal bronchus, and it forms at the distal extremity a 
club-shaped cavity. 
At this point the structure of the lung changes, and 
what lies beyond this has been a much disputed point, 
as I have shown in my account of the history of the sub- 
ject. As a preliminary description, I will quote the fol- 
lowing from a previous paper :28 " The last division of 
the bronchus, before breaking up into the parenchyma of 
the lung, is known as the terminal bronchus, and from this 
arise a number of passages which widen out into an ex- 
pansion. From this other passages lead out which open 
into a central cavity set about with small irregular cells. 
A good idea of this arrangement may be obtained if we 
compare it to a Pompeian house. The passage leading 
off from the terminal bronchus is the ' vestibulum,' 
w'hich opens into the 'atrium.' From this arises the 
' faux ' or air-sac passage, which leads into the ' peri- 
stylum' or air-sac. This air-sac is set about with 
' cubicula ' or air-cells. 
" From this description it will be seen that the air-sacs 
do not communicate directly with the terminal bronchus, 
as is usually described, but between each air-sac and ter- 
minal bronchus there is a cavity constant in all parts of 
the lung, which I shall term atrium. The communica- 
tion between the atrium and the bronchus I shall call 
vestibulum ; that between the atrium and air-sac, air- 
sac passage, or, simply sac-passage." (Fig. 381.) 
The terminal bronchi do not have a smooth cylin- 
drical surface, but we find projecting from all por- 
tions small cells (Fig. 381), the air-cells of the bronchus, 
which have an average diameter of 0.047 mm. The 
opening by which these cells communicate with the 
572 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Lungs. 
Lungs. 
■bronchus is surrounded by the smooth muscle-fibres lin- 
ing the bronchus. In a section of the lung the terminal 
bronchi may be recognized by their diameter, by their 
walls being thicker than that of the surrounding paren- 
chyma, by the presence of smooth muscle-fibres, and by 
their having a lining of cylindrical epithelium. 
Leading out of the dilated end of the terminal bron- 
chus we find from three to six openings, the vestibules. 
These are circular in outline, or nearly so ; they are sur- 
rounded by the muscle-fibres which line the bronchus, 
and have an average diameter of 0.2 mm. These open- 
ings do not all take the same direction ; usually one 
of them appears as if it were a continuation of the 
bronchus, while the others open out at various angles or 
may take a course nearly recurrent to that of the bron- 
chus. As these openings are surrounded by smooth 
muscle, should the section lie in such a plane that we 
look directly into a vestibule, it will appear as a quite 
small terminal bronchus, but can be distinguished from 
one by its size. I have already stated that the smooth 
tain a mass which cannot he pulled apart ; if now we 
break off a small portion from the completely injected 
part and pick it to pieces under a dissecting microscope, 
we may obtain casts of the atria which present several 
freshly broken surfaces. These indicate the points of at- 
tachment of the air-sacs, and also their attachment to the 
bronchus. The presence of these broken surfaces has 
been misinterpreted by a recent writer, and used as an 
argument for the communication between air-sacs. That 
such is not the case will, I think, be readily understood 
from the above description. 
In Fig. 382, I have represented a terminal bronchus to 
which are attached five atria. The air-sacs communicat- 
ing with them have been removed. The specimen was 
prepared by cutting a small block from the lung of a dog 
(treated by the corrosion process) into serial sections, and 
then reconstructing by Born's33 method a terminal bron- 
chus and the parts attached to it. Two models were 
made, in one of which the air-spaces were cut out and the 
plates piled together. This gave an exact model of the 
air-spaces. At the same time the plates were piled to- 
gether the pieces cut out were piled also, and I thus ob- 
tained the second model-a "corrosion" of the first. It 
is this corrosion deprived of its air-sacs that is figured. 
The sections were cut 20 n thick, and the power used was 
one hundred diameters. 
The air-sac passages connecting the atrium with the 
air-sacs are somewhat smaller than the vestibule, having 
an average diameter of 0.143 mm. The air-sac passages 
(Figs. 382 and 383, P) can always be distinguished from 
the vestibule by the absence of smooth muscle-fibres. 
The air-sacs present a great diversity of forms ; they 
are very irregular and adapt themselves to the space they 
have to occupy. As seen in sections of the lung, they 
vary in diameter from 0.313 mm. to 0.511 mm. Fig. 383 
shows a corrosion model, prepared in the same manner 
as Fig. 382, of an atrium with a single air-sac attached, 
the others having been removed. 
Fig. 384 shows an air-sac removed from its atrium ; 
the irregularity of form is well shown. Some air-sacs 
have a deep partition extending into them, nearly divid- 
ing them into two. The irregular contour of one air-sac 
fits into corresponding irregularities in adjoining air-sacs, 
making it impossible to pull complete wax or Wood's 
metal corrosions apart. The walls of the air-sacs are 
quite thin, and are made up principally of the capillary 
network of the blood-vessels and connective tissue. 
Mall35 has shown the presence of " reticulum " in the 
walls of the air-sacs. In sections of lung lying parallel 
with, or perpendicular to, the pleura, the large irregular- 
shaped openings bounded by thin walls are the air-sacs. 
The small openings grouped about them are the air- 
cells. 
The air-cells are about one-fourth the size of the air- 
sacs ; their walls are thin and have the same structure as 
those of the air-sacs. Air-cells are found in three situa- 
tions : arising from the bronchus, from the atrium, and 
from the air-sacs (Fig. 385, C). Those arising from the 
air-sacs are the more numerous, the entire periphery of 
the air-sacs being covered with them. The air-cells 
arising from the air-sacs and atria have the same average 
diameter of 0.113 mm., while those air-cells which are 
found on the bronchus are smaller, having an average 
diameter of 0.047 mm. 
It is not uncommon to find in sections made parallel to 
the pleura that the plane of the section is such that it di- 
vides longitudinally as a vestibule opening into an atrium, 
and in rare instances it may pass through all the parts. 
Fig. 381 is an example of such a section. Usually, it is 
quite difficult to determine the atria and air-sacs, unless 
we have a complete series of sections to examine. I 
have already mentioned several points of distinction, but 
for general purposes attention to the following points 
will help one to decide: The bronchi may be recognized 
by their containing smooth muscle-fibres, and by their 
diameter ; lying in more or less of a circle about the 
bronchus may be seen three, four, or five openings, nearly 
circular in outline and separated from the bronchus by 
a number of smaller openings ; the first are the atria, the 
Fig. 381.-Camera Tracing of a Section through the Terminal Bron- 
chus, Atrium, and Air-sac. Enlarged about 65 diameters. 13, terminal 
bronchus; A, atrium ; S, air-sac ; K, vestibule : P, sac-passage ; C, 
air-cells arising from terminal bronchus, atrium, and air-sac. 
muscle-fibres do not extend beyond the terminal bron- 
chus. That this ring surrounding the openings of the 
vestibules is the last found is shown in sections which 
lie in such a plane that a vestibule is cut at right angles. 
In such a section we find the bundles of muscle-fibres 
cut transversely, lying on either side of the mouth of the 
vestibule, but not in the least entering into the formation 
of the walls of the cavity lying beyond. 
The cavity into which the vestibule opens I have called 
the atrium (Figs. 381, 382, 383, 385, A). This is irregularly 
spherical in shape, about half the size of a terminal bron- 
chus, and has leading out from it three to six openings ; 
of these, one is that of the vestibule, and the remaining 
openings lead into the air-sacs with which it communi- 
cates. There are also numerous projections from its 
surface, the air-cells. The walls of the atrium differ in 
no respect from those of the air-sacs. 
If we make a complete injection of the air-passages 
with wax and corrode in hydrochloric acid, we shall ob- 
573 Lungs. 
Lungs. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
second are air-cells. Lying peripheral to these may be 
seen large irregular openings, the air-sacs, and grouped 
around each a number of 
smaller openings, the air- 
cells. 
A much disputed ques- 
tion in the histology of the 
siderable period the question was vigorously discussed 
on both sides ; but gradually the view that there were no 
communications prevailed. The two most recent writers 
on the subject in this country, however, have returned 
to the old view of communication. I cannot agree with 
them on this point, for both comparative study and re- 
construction of the mammalian lung show the contrary 
to be true. 
In studying the lung from a compara- 
tive standpoint, we find that the sim- 
plest form is found in the Proteida. 
The specimens I have used for exam- 
ination have all been obtained from 
Necturus maculatus, the common mud- 
puppy of the Mississippi Valley and the 
great lakes of the West. The lungs in 
this animal consist of two elongated, 
cylindrical-shaped bodies, smooth on 
the outer and also on the inner surface ; 
they have both an arterial and venous 
supply, the ultimate distribution of 
which is so arranged that the course of 
the vein is nearly at right angles to that 
of the artery. 
Passing on now to Anura, we find in 
Rana catesbiana that the lungs are two 
thin-walled ellipsoid sacs, terminating 
posteriorly in bluntly-pointed ends. The 
inner surface is crossed by large bands, 
which, extending into the central cavity, 
form a coarse network ; between these 
bauds smaller bands are found which 
also form a network, thus giving 
the lung a honeycombed appear- 
ance. Between the lung of 
Necturus and that of Rana all 
grades of division of the inner 
surface may be found. 
In Ophidia, the lung (for they 
possess only one, the right) is 
much elongated; the posterior 
two-thirds is perfectly smooth, 
externally and internally, but the 
anterior third of the inner surface 
becomes more and more subdi- 
vided, until we find in the anterior sixth that we have the 
inner surface divided into many small air-sacs, which com- 
municate with the central cavity by a nearly circular 
opening. If we look down into one of these sacs with a 
low-power lens, 10-20 diameters, we shall see that each sac 
is divided into a number of shallow depressions, the air- 
cells. A careful examination of specimens prepared by 
cutting open previ- 
ously blown-up and 
dried lungs, and 
sections of h a r d - 
ened s p e c i m ens, 
failed to show any 
communication be- 
tween neighboring 
air-sacs. | 
Thus far the' 
lungs we have ex- 
amined have con- 
sisted of a large cen- 
tral cavity, having 
its wall either 
smooth or beset 
with larger or small- 
er cavities, which possess a more 
or less complex structure. The 
bronchus has entered the ante- 
rior end of the lung, but has not 
extended into its interior. There 
have been no partitions across 
the central cavity and extending 
the entire distance, dividing the 
lung into independent cavities. 
In Heloderma suspectum, one of 
Fig. 382.-Reconstruction Corrosion of a Terminal Bronchus with 
Five Atria Attached. Enlarged 100 diameters. A. atria ; B, 
bronchus ; P, sac-passage. The three atria which have no special 
letter attached are easily made out by the cut surface of the sac- 
passages. 
lung is whether there exist communications between the 
air-sacs. As I have shown in my brief account of the His- 
tory of the sub- 
ject, the opin- 
ion of the older 
authors was 
that such com- 
munication 
did exist. For 
a long time no 
one doubted 
the point; then 
it was denied, 
and for a con- 
Fig. 383. - Reconstruction 
Corrosion of an Atrium, 
with a Single Air-sac At- 
tached. E n 1 a r g ed 100 
diameters. A. atrium ; 5, 
air-sac ; P, an air-sac pas- 
sage divided transversely ; 
V, vestibule divided trans- 
versely. The atrium in 
this Figure is the same as 
the one in the upper left- 
hand corner of Fig. 382. 
Fig. 384. - Reconstruction 
Corrosion of an Air-sac, 
Showing the Irregularity of 
Form. Enlarged about 50 
diameters. 
574 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Lu ngs. 
Lungs. 
the Lacertilia, we find the central cavity divided by par- 
titions which extend across the entire distance, dividing 
the lung into larger or smaller cavities, which are in 
their1 turn subdivided into smaller spaces, just as we saw 
in the frog's lung. The surfaces of these partitions are 
also covered with fine bands which divide them into 
small cells. 
The bronchus enters the lung at the inner and upper 
sixth, and terminates in the partition which divides the 
posterior cavity from those in front of it. It occupies 
very nearlv a central position. Lateral openings, more 
or less oval in shape, are found in the wall of the bron- 
chus ; these communicate with the different cavities. 
This opening is the only one which opens into any single 
cavity. Nowhere do we find an opening through the 
partition wall. The only medium of communication be- 
tween one air-sac and another is that of the bronchus. 
The posterior sac which occupies the entire posterior 
third of the lung is much simpler in structure than those 
situated anterior to it. We shall find, as we continue the 
comparative study, that this posterior sac is slow to take 
on the complex structure found in those lying more an- 
terior to it. 
The lungs of the Chelonians show beautiful gradations 
in their division into cavities and in the complex sub- 
division of these cavities. In many forms the posterior 
sac is quite simple in structure, resembling the lungs of 
Necturus and of Rana ; but we find the primary divisions 
extending deeper and deeper into the centre, until, in 
Macrochelys, we find that it has a similar structure to 
those lying anterior to it. The bronchus extends cen- 
trally to the posterior sac ; the openings from the bronchus 
into the different sacs are nearly circular, and they are the 
only opening which each sac possesses. We found in 
Heloderma that there were no openings through the parti- 
tion walls of the sac ; the same is true of all Chelonians. 
The only means of communication between neighboring 
air-sacs is through the bronchus. 
In Crocodilia the bronchus enters the lung near its 
centre and on its inner side ; it passes somewhat obliquely 
into the lung, and at the junction of the lower and middle 
thirds breaks up into six to twelve tubular passages. The 
point where the bronchus breaks up forms a terminal 
bronchus; the tubular passages are elongated atria; 
opening out of them are numerous small air-sacs, which 
are subdivided into air-cells. There are no communica- 
tions between one atrium and another, or between ad- 
joining air-sacs. I have used in my study specimens ob- 
tained from the crocodile of the Nile, and from our 
representative of the group, the Florida alligator. 
In Aves the type of the lung presents marked differ- 
ences from that of reptiles on tlie one hand, and of mam- 
mals on the other. The lungs are closely attached to the 
ribs and their interspaces. The bronchus penetrates into 
the lung and breaks up into elongated tubular passages, 
which, in some instances, communicate with each other 
by means of short branches. These tubular passages are 
not true bronchi, because their structure shows a marked 
difference, and they do not give rise to terminal bronchi. 
They are to be considered as atria, and the alveoli, or true 
lung structure, arise from them just as we have found to 
be the case in the lung of the crocodile. By tracing the 
principal bronchi through the lungs we find that they 
communicate, by means of openings more or less circular 
in outline, with large air-bags situated in the abdominal 
cavity, or with air-spaces in the bones, etc. These air- 
bags must be considered as a portion of the lung, for 
they are directly continuous with the bronchi and are 
developed from them.35 There are no communications 
between air-sacs. 
The lungs of mammals I have studied by resorting to 
Born's " method of reconstruction.* In no instance have 
I found any communication between neighboring air-sacs 
or between one atrium and another. As was seen in the 
lungs of the lower animals, the only mode of communi- 
cation was through the bronchus. I have examined care- 
fully specimens taken from the lungs of man, the dog, 
the cat, and several other mammals, both in adult life, in 
the growing period, and in foetal life, but have invariably 
failed to find any communication. 
Blood-vessels.-We have to consider three vessels, 
the pulmonary artery, the pulmonary vein, and the bron- 
chial artery. The relations of the pulmonary artery and 
vein before entering the lung can be found in all sys- 
tematic works on anatomy. The position occupied by 
the bronchus, artery, and vein at the hilus of the lung 
has been already stated. 
Within the lung the pulmonary artery follows closely 
the bronchi throughout their entire course. The divisions 
of the artery correspond to those of the bronchi ; so if one 
knows the number of bronchi in a given lobe, the num- 
ber of arteries is also known. 
With the division of the bronchus into terminal bron- 
chi and their breaking up into the parenchyma of the 
Fig. 385.-Scheme of the Lung Lobule. B, terminal bronchus ; A, 
atrium; N, air-sac ; F, vestibule; P, air-sac passage; C, air-cell. The 
shaded vessel is the artery, the vein is in outline. 
lung, changes take place in the distribution of the artery ; 
it penetrates into the centre of the lobule until it reaches 
a position beyond the terminal bronchus ; there it breaks 
up into as many branches as there are atria, and from 
these branches are given off which pass to the air-sacs. 
There are also branches which correspond in size to those 
given off within the lobule, that arise from the artery just 
before entering the lobule, and supply the air-sacs winch 
lie close to the terminal bronchus. As a rule, these air- 
sacs arise from an atrium which has taken a recurrent 
course. 
On reaching the air-sac the artery divides into small 
radicles which run on the central side of the air-sac in the 
sulci between the air-cells, and finally are lost in the sys- 
tem of capillaries to which they give rise. 
The capillaries anastomose with those of adjoining air- 
sacs, but the arteries do not anastomose with each other. 
There is, therefore, but a single system of capillaries in 
the wall of an air-sac or atrium. The capillaries have a 
* Reconstruction methods have, so far as I have been able to learn, 
been made use of by Born, His, Seienka. Zimmerman, His, Jr., Piersol, 
Fol, and Mall in the study of embryos, and by Spelteholtz, Mall, and my- 
self in histology. 
575 ImilgK. 
Luxeuil. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
diameter of about 7 being slightly larger just beneath 
the pleura and somewhat smaller deeper in the lung. In 
length they are rather more than twice their diameter, 
and the space between the capillaries, the mesh, is a trifle 
more than the diameter of the vessel. 
After the capillaries have formed from twenty to 
twenty-four loops they unite to form small venous radi- 
cles which are situated on the peripheral side of the air- 
sac. These radicles do not lie in the sulci between the 
air-cells, but run directly over their centre ; they eventu- 
ally form a small vein, several of which, uniting together, 
form the veins of the lobule. These larger veins run in 
the interlobular spaces and are situated as far away from 
the bronchus as possible. 
We have therefore an artery on the central side of 
each air-sac, a vein on the peripheral, and between the 
two a rich capillary network, thus giving an arterial and 
venous side to each air-sac. 
The bronchial arteries are distributed to the walls of 
the bronchi and run throughout their entire length ; they 
are also distributed to the areolar tissue of the lung, the 
walls of the blood-vessels, and the lymphatics. 
I have been unable to find any veins accompanying 
the artery. The bronchial artery forms a long-meshed 
capillary network that unites to form short veins which 
open into the pulmonary vein. 
The question whether the bronchial artery opens into 
the pulmonary artery or vein, has been much discussed. 
I cannot here enter on a full description of my work on 
the subject, but will give the results. 
The bronchial artery is distributed to the bronchus 
throughout its entire length, to the walls of the blood- 
vessels, the lymph-vessels, the connective-tissue sheaths 
and septa. 
From the walls of the expanded end of the terminal 
bronchi two small vessels arise, which are formed by the 
capillary system, into which the bronchial artery breaks 
up ; these pass out from opposite sides of the bronchus. 
Each vessel receives a small number of venous radicles 
from neighboring air-sacs, and in this way a short but quite 
large vein is formed which empties itself into the nearest 
pulmonary vein. As these two veins arise from the 
expanded end of the bronchus, they lie within the lobule, 
and form an exception to the rule that all veins lie on the 
periphery, while the arteries occupy the central portion 
of the lobule. In a few instances I have found small 
veins coming from the bronchus just before entering into 
the lobule ; in other words, small veins may arise from 
the walls of the last forked division of the bronchus. 
They follow the same course as those within the lobule. 
IF. S. Miller. 
27 Roosevelt: Medical Record, Feb. 22, 1890, and The New York 
Medical Journal. March 7. 1891. 
28 Miller : The Lobule of the Lung and its Blood-vessels. Anatom- 
ischer Anzeiger, vii., No. 6 ; The Structure of the Lung. Journal of 
Morphology, vol. viii. 
29 Milne-Edwards: Leyons sur la Physiologie et 1'Anatomie com- 
paree. 
30 Ewart: The Bronchi and Pulmonary Blood-vessels. London, 1889. 
31 Aeby : Der Bronchialbanm, etc. Leipzig, 1880. 
32 Owen : Anatomy of Vertebrates. London, 1868. 
33 Born : Die Plattenmodelirmethode, Arch. f. Mikro. Anat., Bd. 22 
p. 584. 
34 Mall : Das Reticulirte Gewebe, p. 40. Tab. xi. Leipzig, 1891. 
35 Weldon : Proceedings of the Zool. Society, 1883 ; Mall: Journal of 
Morphology, vol. v., No. 1. 
36 His: Zur Bildungsgeschichte der Lungen beim menschlichen Em- 
bryo, Archiv fur Anatomie, 1887. 
LUNGS, CROUPOUS AND OTHER INFLAMMA- 
TIONS OF. Consideration of this subject is here limited 
mainly to etiology in reference to the agency of microbes. 
Weichselbaum (1887) holds that the bacteria found in 
the different forms of pneumonia are to be regarded as 
the cause of the inflammation, and taking cold as only a 
predisposing event. He considers the diplococcus as the 
most frequent cause. 
Perret and Rodet (1887) have together made experi- 
ments of injecting microbes (presumably under the 
epithelial surface of the air-passages), and conclude that 
pneumonia may be produced by a variety, including those 
of typhoid fever, measles, scarlatina, etc. 
Weichselbaum (1888) found bacteria constantly present 
in the different forms of pneumonia, and most active and 
abundant in early stages. In his opinion the virus is not 
a unity, but the croupous form itself may be due to sev- 
eral different organisms. The distinction of lobar and 
lobular, croupous and non-croupous, he believes to be ana- 
tomical merely-not etiological. Frankel's diplococcus is 
the most common microbe found, Friedlander's being 
rare. This diplococcus (Frankel's) is found in all the 
cavities about the nose ; also in the brain, spinal cord, 
pleura, pericardium, interior mucosae and submucous tis- 
sue. The same organisms are sometimes found in endo- 
carditis and suppurative arthritis. 
Monti (1888) withdrew the exudation of pneumonia 
from the lungs during life by means of Koch's syringe, 
and in twenty instances failed only once in obtaining 
micro-organisms. Frankel's diplococcus was always 
found (Friedlander's never), sometimes associated with 
other micrococci. Inoculation of rabbits with the sputum 
always gave positive results, but produced pneumonia 
only when thrown into the trachea. Under the external 
skin it caused septicaemia ; into the pleura, pleuritis and 
pericarditis, but never pneumonia ; into the dura mater 
of a dog, after trephining, it caused meningitis. 
Netter (1888) holds that pneumonia is transmissible 
through specific pathogenic micro-organisms, which mul- 
tiply in the diseased foci, and leave the body chiefly in 
the sputa. The contagium resists desiccation and retains 
its activity for a long time outside the body. 
The examination (1889) by Prudden and Northrup of 
seventeen children who died of diphtheria complicated 
with pneumonia, disclosed similar streptococci in both the 
diphtheritic membranes and the lungs of all but one of the 
cases. By using intra tracheal in jections of pure cultures 
of these streptococci, obtained from the lungs of the chil- 
dren, they uniformly produced lobular or broncho-pneu- 
monia in rabbits. 
Netter (1889) reports an infant born of a woman while 
ill of pneumonia. The child lived five days, and autopsy 
revealed pneumonia at the apex of the right lung, double 
pleurisy, suppurative pericarditis, and cerebro-spinal 
meningitis, associated with microscopic appearance of 
micrococci. It is presumed that the child was infected 
by the mother before birth ; and similar observations have 
been made in rabbits, guinea-pigs, and mice. 
According to Sternberg, Frankel's diplococcus (called 
by him micrococcus Pasteuri) is widely distributed, and 
is often found in the sputum of healthy persons. 
Mosier, of Greifswald (1890), gives a series of cases in 
one family. The father apparently contracted pneu- 
monia outside and communicated it to the others. The 
1 Hippocrates : De Carnibus, Op. om„ Kuhn's trans. 
2 Aristoteles: Hist. Animal., lib. I., cap. 16, 17. 
3 Celsus : Lib. iv., cap. i. 
4 Galenus : De Usu Partium Corp. Hum., lib. vi., cap. 3. 
6 Vesalius (1543) : De Corp. Humani Fab., lib. vi., cap. 7. 
6 Harvey (1628) : Exercitatio Anatomica de Motu Cordis et Sanguinis 
in Animalibus. 
7 M. Malpighi: De Puhnonibus, Epistolae ii. ad Borellum. Bonon, 
1661. 
8 Bartholin : De Pulmonum Substantia et Motu Diatriba (s. p. 355 of 
the edition added to the works of Malpighi). Op. om., etc., 1687. 
9 Willis : De Respirationis Organiset Usu, Om. op. Lugd., 1676. 
10 Helvetius : Memoires de 1'Academic Royale des Sciences, 1718. 
11 Soemmering: De Corporis Humani, Anat., vol. vi., pp. 14, 15, 35. 
13 Reisscissen : De Pulmonis Structura. Argent., 1803. 
13 Magendie : Lemons sur les Phenomcnes Physiques de la Vie. Paris, 
1836-37, t. ii. 
14 Bazin : Comptes-Rendus de ['Academic Royale des Sciences, sur la 
Structure intime du Poumon. Paris, 1832. 
15 Lereboullet: Anatomie comp, de l'Appareil Resp. Strasbourg, 1838. 
16 Addison: Phil. Transactions, 1842. 
17 Huschke: Soemmerings Lehre von den Eingeweiden, 1844. 
18 Rainey : On the Minute Structure of the Lungs, Medico-Chirur. 
Trans., vol. xxviii., 1845. 
19 Moleschott : De Malpighianis Pulmonum vesiculis. Heid., 1845. 
20 Rossignol: Recherches sur la Structure intime du Poumon de 
FHomme et des principaux Mammiferes. Bruxelles, 1846. 
21 Adriani: Dissertatio Anatomica inauguralis de subtiliori Pul- 
monum Structura. Trajecta ad Rhenum, 1848. 
23 Kolliker: Microscopische-Anatomie, Leipzig, 1850 ; Handbuch d. 
Gewebelehre d. Menschen, Leipzig. 1852. 
23 Mandi: Anat. Micros., t. ii., chap. vi. 
24 Waters : The Anatomy of the Human Lung. London, 1860. 
26 Henle : Handbuch d. System. Anatomie d. Menschen, Bd. ii., Art. 
Lungen. 
35 Delafield : Studies in Path. Anat., vol. i., p. 102. 
576 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Lung's. 
Luxeuil. 
fluid from the lungs contained bacilli resembling those of 
septicaemia in the rabbit, but no micrococci of Frankel 
nor of Friedlander. 
Levy reports, in a Paris journal (1890), a case of congen- 
ital fibrinous pneumonia complicated with pleurisy and 
pericarditis. Sero-purulent fluid aspirated from the 
chest gave cultures of the diplococcus of Frankel and 
Weichselbaum, and inoculations of the same proved their 
potency. The child was born thirty-six hours before the 
mother's death, and died, two days after birth, of broncho- 
and lobar fibrinous pneumonia combined. Fluid was 
drawn from the left ventricle of the heart and right lung, 
and cultures from the same gave Frankel's diplococcus. 
This microbe was also found abundantly in the blood. 
Platini (1890) found that inhalation of the pneumo- 
coccus failed to cause pneumonia, while the mucous sur- 
face of the respiratory tract maintained its integrity. 
After traumatism through the thoracic walls, or inhala- 
tion of ammonia or hydrochloric acid, infection took 
place. It was found that the animals after inoculation 
had more elevated temperature and more extensive pneu- 
monic lesions, and succumbed more rapidly when sub- 
jected to refrigeration, than other animals similarly inoc- 
ulated but not exposed to cold. On the other hand, 
exposure to cold without the inoculations failed to induce 
pneumonia. 
Debove (1890) reports having found pneumococci in a 
case of meningitis complicated with peritonitis, but there 
was no pneumonia. 
Netter observes that pneumococci are rare in peritonitis, 
but occur in most cases of meningitis. Cultures of pneu- 
mococcus have been made from the fluids of cerebral and 
spinal meningitis and encephalitis ; also from those of 
pleurisy and empyema, both independently of pneumo- 
nia and complicating it. 
Devoto, in many examinations of those dead from 
pneumonia, never found Frankel's diplococcus in the 
kidneys. Luccatello generally found the blood free of 
them. But Canfield, at the pathological laboratory of 
Johns Hopkins Hospital, has found them in the blood and 
tissues of rabbits killed with Sternberg's sputa and with 
the prune-juice expectoration of pneumonia. Bozzolo 
reports the discovery of diplococci in the milk of a woman 
ill of pneumonia. 
Several French physicians (Mosny, Laboulliere, Strauss, 
and Brouardel) report fatal cases of pneumonia, in which 
they attribute the infection to the streptococcus of ery- 
sipelas solely. In like manner pneumonia coexisting 
with typhoid fever, scarlatina, small-pox, influenza, or 
dysentery, might be referred to the action of the mi- 
crobes of one of these diseases on the lungs. 
Assuming the correctness of the above observations, 
the following conclusions seem to be justified : 
1. The most prevalent forms of pulmonary inflamma- 
tion hitherto enumerated (croupous or lobar, and ca- 
tarrhal or lobular) differ in degree and extent rather than 
in nature and cause. 
2. Pulmonary inflammation is always accompanied by 
micro-organisms, and may be regarded as directly de- 
pendent on their action. The most common is the diplo- 
coccus of Frankel, but several others are found operating 
singly or mixed. 
3. The same micro-organisms affect other anatomical 
parts, producing inflammation in all instances. Various 
parts may suffer at the same time from the same kind of 
bacteria. Several species of bacteria may be found in 
the lungs at the same time, all concerned in the inflam- 
matory process. Pneumonia, therefore, is not a specific 
disease, in the usual sense of the word specific. 
4. A solution of continuity in the mucous surface of 
the respiratory tract is a necessary antecedent. Bron- 
chial catarrh with cough is the most common predispos- 
ing cause ; inhalation of an irritating vapor, gas, or dust, 
and violent injury of the pulmonary structure in any 
manner, are efficient causes also. 
5. The common atmosphere near the ground habitually 
carries in suspension the necessary micro-organisms to 
excite inflammation in lungs susceptible to their action, 
and such susceptibility is most usual in the seasons of 
(SUPPLEMENT.) 
coughs and colds. One or more cases of pneumonia in a 
dense population, where colds and coughs are prevalent, 
may then light up an epidemic of this disease. 
6. That condition of the respiratory tract which ren- 
ders a person liable to pneumonia, probably exposes one 
to the infection of pulmonary consumption, wherever the 
bacillus tuberculosis may be present in atmospheric dust; 
and this accords with the frequent sequence of phthisis 
to pneumonia, the bacillus tuberculosis being slower in 
propagation and growth than most other disease germs. 
As to treatment, intra-pulmonary injections of solu- 
tions of corrosive sublimate, potassium iodide, sodium 
benzoate, and iodoform have been tried, but the results 
have not been encouraging. Petresco claims extraordi- 
nary success from large doses of digitalis-the disease 
aborting in two or three days, and the physical signs dis- 
appearing altogether in three days. In some cases he 
avers that the subject has resumed work in twenty-four 
hours. A reasonable explanation is, the drug strength- 
ens the heart's action and thus promotes the removal of 
the products of inflammation by the blood-current. Blis- 
ters over the chest may be supposed to increase the flow 
of blood through the parenchyma of the lungs, and so 
produce the same effect. In this view the earliest appli- 
cation is the most efficient, and such has been the experi- 
ence of the present writer. S. S. Herrick. 
LUXEUIL. This " almost unique" spa, situated in the 
Vosges region of France, has already been briefly referred 
to in Vol. IV. of the Handbook. Owing to its impor- 
tance, the following additional information may be found 
useful. The ancient town wears a picturesque aspect, and 
if the thermal establishment and casino are not so pre- 
tentious as are those of the more fashionable resorts, they 
are nevertheless supplied with all essentials for the cure 
of invalids. The chalybeate waters being freely " digest- 
ible," are taken with impunity by delicate women and 
even children. It is claimed that the surprisingly good 
results obtained in the treatment of anaemia at Luxeuil 
are due to the admixture of arsenic and manganese with 
the iron compounds. Of the eighteen springs found at 
this spa, fifteen are exploited. Bathing and drinking go 
hand in hand at this resort, few patients being subjected 
to only one kind of treatment. A so-called "crisis" is 
commonly produced by a course of Luxeuil waters. Mr. 
Wolff (" The Watering-places of the Vosges ") describes 
this phenomenon as follows : " Even the saline waters 
produce this-a combination of all sorts of unpleasant sen- 
sations, describable and indescribable-insomnia, debility, 
palpitations, constipation (aggravation of constipation is 
a very usual first effect), cutaneous eruption, sometimes, 
and in acute cases even fever. When the water taken is 
the chalybeate, the ' crisis ' appears in an aggravated 
form. However, all this does not last very long, and the 
doctors rather like to see it, on the principle that it shows 
the waters to be doing good. Sometimes, however, there 
is a recurrence of the same symptoms in the third or 
fourth week. Whenever that happens it is held to show 
that the treatment has been carried far enough and should 
be discontinued. On its cessation the unpleasant symp- 
toms subside almost at once, and give place to an im- 
provement which in some cases is described as really 
astonishing." 
The same author also states that " the marked dif- 
ference in the Luxeuil waters is attributed to the dif- 
ference in the triassic strata from which they spring. 
There are, first, the rather warm springs, ranging from 
95° to 132° F., which are alkaline and saline, but of rather 
slight mineralization, the total of solid matter in the litre 
not exceeding 1.17 gramme. These resemble, generally 
speaking, the Plombi&res waters, and are of course con- 
sidered useful for much the same classes of cases- 
rheumatism, liver complaints, dyspepsia, diabetes, affec- 
tions of the respiratory organs, and some female mala- 
dies. They share with the waters of PlombiSres the 
peculiarity that, however hot they be, flowers (or other 
vegetable matter) thrown into them do not at once 
shrivel up and fade, but rather assume at first a brighter 
coloring. Secondly, there are the chalybeate waters, 
577 Liiixeiiil. 
Magneto-Therapy. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
which are less warm, indicating from 72° to 86c F., even 
less mineralized-having but 0.9 gramme of solids in 
the litre-but remarkable for holding their iron in com- 
bination with a strong dose of manganese. (This really 
applies to the saline waters as well, only the quantity of 
iron is much smaller). The chalybeate waters, as might 
be expected, contain a very much larger proportion of 
free carbonic acid-it is said about six times the quantity. 
In both varieties of waters there occurs a fair amount of 
nitrogen, and some arsenic. It is the ferruginous water 
which makes Luxeuil almost unique, and so wonderfully 
effective in women's and children's anaemia, hypochon- 
dria, the malaria urbana, rheumatism-articular, mus- 
cular, or fibrous, more particularly rheumatism in the 
intestines,-neuralgia, uterine complaints, anaemia (pre- 
tendue), palpitations, scrofula, etc. The water is held 
to be contra-indicated only where anaemia arises from 
organic degeneration." 
Analysis.-The subjoined table gives a fair average 
of the different springs. In one thousand parts there are 
contained : 
(SUPPLEMENT.) 
The disinfectant and deodorizing properties are un- 
doubted. They are such as would be expected from a 
solution of cresol of such a strength, and experiments have 
shown that a 0.3 per cent, solution is capable of arresting 
the growth of the staphylococcus pyogenes aureus. It 
is also perfectly harmless and devoid of any toxic action. 
For surgical purposes it is used in different degrees of 
strength. For disinfecting the hands and cleansing the 
body of the patient a live per cent, solution is used by 
rubbing into the parts thoroughly, and then washing it 
off in a solution of one or two per cent. For disinfect- 
ing instruments and for irrigation during an operation 
a one or two per cent, solution is prepared, and for gynae- 
cological and obstetrical purposes a solution of one-half 
per cent, is sufficient. 
Lysol is indicated and may be used in all forms of in- 
flamed and ulcerated surfaces in which a disinfectant is 
required. On mucous surfaces, when used in stronger 
solution than two per cent., it causes a burning and pain- 
ful sensation which lasts for some time, but otherwise is 
perfectly unirritating. 
Lysol has recently been administered internally {Ther- 
apeutic Gazette, November, 1892), in the treatment of 
scarlet fever. In doses of three to ten drops, of a mixt- 
ure of lysol one part to two parts of sherry wine, three 
times a day, the temperature of the patient was rapidly 
lowered, the albumin disappeared from the urine, and 
the general condition of the patient improved. In dys- 
entery and choleraic diarrhoea it was serviceable when 
used as a clyster in the strength of a one per cent, solu- 
tion. From the satisfactory results thus obtained it is 
suggested as a remedy in Asiatic cholera, by giving im- 
mediately 2.5 grammes of lysol mixed with a stimulant, 
and thoroughly washing out the intestines with a one 
per cent, solution. Beaumont Small. 
MAGNETO-THERAPY. Magnetism is known to be a 
remarkable force, and it is not strange that from time to 
time the occult power of magnets has been brought to 
bear upon certain disorders by physicians in the hope, 
and often with the belief, that it would be efficient as a 
remedial agent. We need not seek far in medical litera- 
ture for matter relating to magneto-therapy. For in- 
stance, Roberts Bartholow, in the third edition of his 
work on " Medical Electricity," published in 1887, says : 
" We know that a current circulates in a magnet. If 
a powerful magnet is brought near to the skin, oppo- 
site electricities are attracted to the poles and currents 
are induced. About the point of application, there- 
fore, the skin will be acted on directly by the magnetic 
current and by an induced current. The production 
of physiological effects, which can be recognized, is 
therefore merely a question of magnetic strength." He 
then quotes Dr. Vansant, as assuming the body to be 
diamagnetic : " By applying north and south polarity to 
different parts, very extensive subjective impressions are 
experienced ; they are of two classes of heightened or- 
ganic activity and the opposite condition." 
He then adds : " That impressions of a very decided 
kind are produced by the application of strong magnets is 
evident in the experience of Dr. Proust and Dr. Ballet, 
who continued a course of investigation begun by Char- 
cot at Salpetriere." They ascertained that magnets could 
not be applied with impunity, for, if applications were 
prolonged, pains were felt in the epigastrium and thorax, 
making respiration painful, digestion was disordered, and 
boulimia brought on. These results were so uniform 
that there seemed to be no doubt of their genuineness in 
the minds of the investigators. 
Under the heading " Therapeutical Application of Mag- 
nets," Dr. Bartholow quotes Dr. Hammond as preferring 
a horseshoe magnet, and advising that several of the same 
size be kept, so that by clamping them together more 
power can be obtained. The author adds : " Hammond 
insists on the necessity for the application of both poles 
in many cases, and therefore uses the horseshoe magnet." 
" Hammond has used magnets in nine cases of chorea, 
in two ' complete cures being produced in a few min- 
utes.' " 
Sources Thermales. 
Parts. 
Silica 0.0360 
Phosphate of iron 0.0027 
Carbonate of iron 0.1093 
Carbonate of manganese ... 0.1074 
Carbonate of magnesia 0.0136 
Carbonate of lime 0.0810 
Chloride of sodium 0.0369 
Chloride of potassium 0.0240 
Chloride of magnesium .... 0.0240 
Chloride of calcium 0.0296 
Salts of arsenic traces 
Organic matter and loss.... 0.4169 
Total of solids 0.9005 
Temperature 70° to 86° Fahrenheit. 
Sources Hyperthermales. 
Parts. 
Silica 0.0988 
Carbonate of lime 0.0732 
Carbonate of magnesia 0.0075 
Carbonate of maganese 0.0023 
Carbonate of iron 0.00311 
Sulphate of soda 0.1646 
Chloride of sodium 0.7512 
Chloride of potassium 0.0585 
Chloride of lithium 0.0096 
Carbonate of soda 0.0216 
Arseniate of soda 0.0006 
Boracic acid, fluorine traces 
Organic matter and loss.... 0.0757 
Total of solids 1.1684 
Temperature 95° to 133° Fahren- 
heit. 
Accommodation.-The hotels and boarding-houses of 
Luxeuil are not in all respects first-class. Nevertheless 
most patients can be made tolerably comfortable for the 
few weeks time which the " cure " calls for. The peo- 
ple of the place are very obliging to foreigners. 
Edmund C. Wendt. 
LYSOL. This is a proprietary preparation of cresol 
introduced to supersede creolin, the best known solution 
of this valuable disinfectant. Since the discovery of the 
active antiseptic properties of cresol various methods 
have been adopted to secure a solution suitable for prac- 
tical purposes, and numerous patented preparations have 
been supplied to the profession. Many disadvantages 
attend these solutions, the most common being a precip- 
itation of the constituents when added to water, which 
produces turbid mixtures, and an annoying soapiness 
that renders the instruments and the hands of the oper- 
ator slippery and unpleasant. The advantages claimed 
for lysol over the other cresol compounds are that it 
forms a clear solution when mixed with water, contains 
a greater amount of cresol, and is perfectly free from in- 
jurious qualities. It is said to be prepared by dissolving 
the cresols, which distil between 190° C. and 200° C., in 
fatty matter and subsequently saponifying by the addi- 
tion of alcohol. It is a brown, oily-looking, clear liquid, 
with a feeble, aromatic, creasote-like odor. It is said to 
contain fifty per cent, of cresol. Its solution forms a 
soapy, frothing fluid, which only becomes turbid when 
mixed with hard water, the extent depending upon the 
quantity of lime-salt present; this turbidity increases 
upon standing for some time. Lysol mixes freely with 
alcohol, glycerine, chloroform, and benzene. The sapo- 
naceous character is claimed as an advantage, as it facil- 
itates cleansing and disinfecting the site of the operation 
and the hands of the operator. It acts in a manner equal 
to the best soap, and readily removes all dirt, fat, and 
resinous matter. In order to avoid the annoyance of the 
soapy instruments and to facilitate the tying of sutures, 
the hands and instruments may be rinsed in sterilized 
water to remove the lysol solution. 
578 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Lu xeutl. 
Magneto-Therapy. 
(SUPPLEMENT.) 
"In two cases of hemiplegia with hemiangesthesia 
Hammond had very surprising results from the applica- 
tion of horseshoe magnets, the sensibility returning im- 
mediately, and in one the hemiplegia was recovered 
from in a few hours." 
Professor Benedikt, of Vienna, who has made much 
use of the magnet in nervous affections, has taught that 
erethitic forms of hysteria are better treated by the mag- 
net than by electricity, hydrotherapy, or drugs. A 
magnet being applied to the sensitive vertebrae, without 
removal of the dress, the irritable patient soon becomes 
quiet and even quasi-paralyzed. The magnet, therefore, 
" increases the resistance to conduction in the motor 
nerves." The muscles gradually relax, the respiration 
becomes sighing, consciousness slowly disappears ; the 
resistance to conduction in motor nerves "could easily 
become absolute." The two poles have different effects. 
Sometimes one pole to a hyperaesthetic ovary fails to re- 
lieve pain, whereas a change of the poles causes its 
speedy disappearance. According to him the magnet 
must be employed with due caution, since patients may 
be injured by it. 
Of late years Luys has in Paris brought to the atten- 
tion of the profession some of the marvellous effects of 
magnets upon the human body, but it is plain that Luys 
has been carried away by his own imagination as well as 
by the imposition and simulation of his patients. Where 
not directly due to feigning, the facts in his experiments 
can readily be explained by the phenomena of sugges- 
tion. 
The magnets made use of by physicians are generally 
those of a horseshoe shape, varying in length from a few 
inches to a foot. They are the so-called permanent mag- 
nets. 
They exert a traction force equivalent to several 
ounces and in some instances to as much as three or 
four pounds. But electro-magnets may be made infi- 
nitely more powerful. Some may sustain two hundred 
pounds to each square inch, or fourteen kilogrammes 
to the square centimetre of active surface on either pole, 
that is to say, twenty-eight kilogrammes to the square of 
active surface on either pole if both poles are alike and 
share the load. 
A propos of the effects of the magnet upon the human 
body, some experiments were recently made by Dr. 
Frederick Peterson and Mr. A. E. Kennelly, at the Edi- 
son Laboratory at Orange, N. J. (" Some Physiological 
Experiments with Magnets at the Edison Laboratory," 
New York Medical Journal, December 31, 1892). Sev- 
eral of the largest magnets known to modern science 
were made use of by the experimenters. In one of them 
the intensity of the magnetic field between the poles was 
about five thousand centimetre-gramme-second lines to 
the square centimetre, a field twenty-seven thousand 
seven hundred and seventy-eight times that of the earth's 
horizontal component that aligns the compass needle. 
A microscope was properly arranged so that substances 
might be examined when exposed to the operation of 
this force. Iron by hydrogen, dry or placed in water, 
was observed to act as do iron-tilings when similarly 
treated. 
Dry powdered haemoglobin exposed to this magnetic 
field was not visibly affected by it. 
Human and frog blood-corpuscles similarly examined 
showed not the feeblest traces of polarization, move- 
ment, or vibration. 
Living ciliated epithelium from the pharynx of a frog 
was absolutely unaffected by the magnet as it was mag- 
netized and demagnetized by the making and breaking 
of a one hundred and twenty volt current in the huge 
coils. The delicate ciliary movement continued without 
change of any kind. 
The circulation of the blood in the web of the foot of 
a curarized frog was observed under the microscope in 
the same way, and it was demonstrated that the magnet 
had not the faintest influence upon the blood or its 
movement. 
A small dog was placed in the cylinder of a set of idle 
field magnets and kept for five hours exposed to a mag- 
netic field with an intensity of 1,000 to 2,000 c.g.s.* 
lines to the square centimetre, and not the slightest visi- 
ble effect was produced upon the animal. 
The next experiments were directed to studying the 
influence of magnetic fields on the human brain. The 
machine employed for the purpose converts about 70 
horse-power at full load. The armature and one journal 
were removed, leaving the space between the pole-pieces 
free. This cavity is 35 ctm. (fourteen inches) in diam- 
eter and 60 ctm. deep. The weight of this electro-mag- 
net is over five thousand pounds, and the intensity of 
the magnetic field produced within the polar cavity after 
removal of the armature, though not uniform, may be 
estimated at a mean of 2,500 c.g.s. lines to the square 
centimetre. A long board was placed upon the base 
plate leading into this polar cavity, and the subject ex- 
perimented upon lay on his back upon the board with 
his head and shoulders in the cavity between the poles, 
and exposed thus to the full influence of the magnetic 
field. There would be comparatively feeble residual 
magnetism with no current in the coils. A switch so 
nearly silent in action as to be inaudible to the subject 
was arranged to close and open the exciting current 
circuit through the field coils. On closing the switch 
nearly the full magnetic intensity would be active and 
permeate the head within one second, and on opening 
the switch the whole intensity would disappear in one 
second. 
Five men, the authors being among the number, were 
subjected to trial, and the following description of one 
case serves for all, since the results were precisely the 
same : 
The subject lay back upon the board and concentrated 
his attention upon his sensations. His right wrist was 
extended and was grasped by one observer, who took 
sphygmographic tracings of the pulse. A second ob- 
server placed a hand on his chest to observe any irregu- 
larity that might occur in respiration. A third observer, 
in view of these two, but unseen by the subject of the 
experiment, opened and closed the switch that excited and 
relaxed the field, signalling to the first two observers as 
he did so. The strong magnetic influence was therefore 
turned on or off at will and without the knowledge of 
the subject. Several sphygmographic tracings were 
taken in each of our subjects, and in one the knee-jerk 
was tested continuously. 
The sphygmographic tracings taken continuously dur- 
ing the seance show no change in regularity, in spite of 
the making and breaking of the enormous magnetic in- 
fluence during its registration. The respirations were 
not changed in the least. The knee-jerk also presented 
absolutely no change. As to common sensations, there 
were none that could be attributed to the magnetic influ- 
ence, and the subject could not discover when or whether 
the field had been excited. The testimony of all five 
subjects was alike. In one experiment the subject held 
a steel screw in his mouth, and was then able to tell 
when the poles were magnetized or demagnetized, but 
only by the pulling of the screw to one side or another, 
not by any peculiar sensation or taste. 
Experiments wrere then made with reversed magnetism. 
A huge coil of stout, cotton-covered copper wire, about 
30 ctm. high and 25 ctm. internal diameter, weighing 70 
kilogrammes and composed of nearly 2,000 turns, was 
so arranged that the head of the subject could be freely 
introduced within the coil. Its resistance was 10 ohms, 
and an alternating current of 1,200 volts, making 280 
alternations per second, was passed through this coil. 
The magnetic field would thus be reversed 280 times per 
second. Each of the authors acted as subject in this 
experiment. No appreciable effect of any kind was pro- 
duced when the head was introduced. 
The authors concluded that the most powerful magnets 
known at the present time have no effect whatever upon 
the organism, neither upon the iron of the blood, upon 
the circulation, upon ciliary or protoplastic movements, 
upon the sensory or motor nerves, nor upon the brain. 
* c.g.s. = centimetre, gramme, second. 
579 Magneto-Therapy. 
!Hal lor matioiis. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
The ordinary magnets used in medicine by Hammond, 
Benedikt, Charcot, Luys, and others have a purely sug- 
gestive or psychic effect and would be quite as useful if 
made of wood. Frederick Peterson. 
MALFORMATIONS, PRODUCTION OF. Among the 
invaluable services of embryology in adding to the gen- 
eral fund of biological knowledge none have been more 
signal than the removal of developmental anomalies from 
the domain of fanciful speculation and the establishment 
of a rational teratology based upon the laws of develop- 
ment. Not only has embryology indicated the lines along 
which the production of anomalous development pro- 
gresses, but, likewise, it has indicated the broader mor- 
phological significance wdiich in many cases exists, 
emphasizing especially the fact that not infrequently 
deviations in the higher types correspond to the normal 
and usual condition of lower forms. 
Notwithstanding the advances in the comprehension of 
the true significance of variations which the progress and 
increased accuracy of our knowledge of the course of 
normal development have rendered possible, there are 
still numerous deficiencies in our understanding of the 
primary causes producing malformations-breaks which 
renewed investigations and further observations alone can 
supply. The most rational teratological classification, it 
is evident, would be that in which malformations were 
grouped according to the various methods of their pro- 
duction ; unfortunately, however, with the present limi- 
tations and uncertainty of our knowledge of these pro- 
cesses all attempts at such grouping must be imperfect 
and provisional. 
Defects arising from the mechanical effects induced by 
diseased and unusual conditions of the foetus, as accumu- 
lations of fluid in abnormal quantity within the body- 
cavities or the undue size of organs, which may, in an 
adverse manner, directly influence the development of sur- 
rounding parts, must be distinguished from those distor- 
tions resulting from inflammatory processes, these latter 
falling under the category of pathological changes rather 
than of developmental deviations. 
A few words concerning the much-vexed question as 
to the responsibility of maternal impressions in the pro- 
duction of malformations may here, at the beginning of 
the consideration of our subject, find place. While fully 
appreciating the sincere convictions of not a few in the 
belief of the sufficiency of such impressions, and in the 
sometimes apparently convincing testimony adduced in 
support of such views, the writer must confess his in- 
ability to attach much importance to these influences. In 
this connection attention must once more be called to the 
significant fact that in the majority of cases the affected 
parts are already well advanced in their development be- 
fore the supposed impression takes place ; in fact, not in- 
frequently the developmental deviations necessary in the 
production of the malformation attributed to the mater- 
nal impression take place before the existence of preg- 
nancy is even suspected. While it may be conceived 
that certain defects may result from nutritive changes 
induced as the consequence of profound nervous impres- 
sions on the mother, yet to those familiar with the embry- 
ological significance of malformations the basis of the 
popular belief in the potency of maternal impressions 
will appear as depending more upon the very natural dis- 
position to find an explanation for otherwise unintelligi- 
ble misfortunes in coincidental circumstances, rather than 
upon well-established or accurately observed phenomena. 
The various headings here introduced make no pre- 
tence to systematic arrangement, but are simply provi- 
sional, as affording convenient groups for the considera- 
tion of nearly-related forms of deviation. Bearing these 
limitations in mind, malformations may be classed, with 
regard to their mode of production, into : 
I. Those produced by variations in nutrition and 
growth-either excessive or arrested. 
II. Those produced by defective union of component 
embryonic parts. 
III. Those produced by cleavage-either partial or 
complete-of the primary embryonic cell-mass. 
I. Malformations produced by variations of growth. 
a. The manifestations of excessive growth may be pres- 
ent in all parts, resulting in a general increase of the en- 
tire organism, or they may be limited to some particular 
region, as half of the body, a simple extremity, or a special 
finger or toe, While slight deviations from the normal 
average length (50.5 ctm. or about twenty inches) and 
weight (3,250 grammes, or about 7.2 pounds) of the new- 
born infant constantly occur, yet well substantiated in- 
stances where these figures are exceeded to any marked 
extent are by no means frequent. A height of over 200 
ctm. may properly be considered as gigantic. 
It is worthy of note that individuals conspicuous by 
reason of their extraordinary proportions quite usually 
were children of ordinary size, whose parents, likewise, 
were of average stature. * The case reported by Beach 1 
is a striking exception, since the father measured seven 
feet seven inches, and the mother seven feet nine inches. 
Their first child, immediately after birth, was twenty- 
four inches long and weighed eighteen pounds, while 
the second measured thirty inches and weighed twenty- 
three and three-fourths pounds. The assumption of an 
excessive amount of formative material, in the attempt to 
find an explanation of these instances of unusual growth, 
must be unsatisfactory when it is remembered that in 
some cases almost ten years have elapsed before the child 
evinced any disposition to excessive size. It must be ad- 
mitted that our knowledge extends little beyond surmise 
as to the cause of these cases. 
Equally uncertain are the causes leading to the curious 
excessive growth limited to some particular part of the 
body, as when one extremity, a hand, or even a single 
finger, attains inordinate dimensions without participa- 
tion of the adjacent parts. It is evident that such in- 
stances of excessive growth must be carefully distin- 
guished from enlargement the result of inflammatory 
processes or other pathological conditions. As with the 
instances of general increase, so here, also, the affected 
parts may for some time after birth present no unusual 
characteristic, the tendency to extraordinary growth first 
becoming noticeable at a later day. The subcutaneous 
connective tissues share with the osseous, vascular, and 
lymphatic tissues in the participation of the changes in 
question. 
b. Variations due to defective growth may be grouped 
into : 1, those in which a general decrease in size is ac- 
companied by uninterrupted development ; 2, those in 
which the diminution is dependent upon arrested or 
anomalous development. 
The first group is represented by true dwarfs, in which 
physical development has taken place to completion al- 
though the resulting organism is of unusually small 
dimensions, owing to insufficient growth. Individuals 
greatly reduced in size, and, at the same time, completely 
developed, are of rare occurrence ; concerning their eti- 
ology nothing is known. True dwarfs are, of course, to 
be carefully distinguished from the not infrequent cases 
where the diminished size depends upon the effect of 
pathological processes, as caries or inherited constitu- 
tional vices. Heredity plays as unimportant a role in 
the production of dwarfs as in that of giants, since, gen- 
erally, the parents are of normal size ; and, further, not 
infrequently the dwarfs during early infancy differ but 
slightly, if at all, from other children of similar age, the 
diminutive size, which later renders them conspicuous, 
attracting attention only as age advances. 
The second group, including those diminutions depend- 
ent upon arrested development and subsequent atrophy, 
embraces malformations varying greatly in degree, from 
a rudimentary finger to a shapeless acardiacus. The im- 
paired nutrition, to ■which the production of these mal- 
formations is due, may be the expression of general causes 
affecting the development of the entire organism and re- 
sulting in general atrophy, or of but local causes exerting 
their unfavorable influence within a very limited area ; 
in these latter cases they may be mechanically induced as 
the result of undue pressure, either from without or from 
within the embryo. The investigations of Kollmann2 
and His3 render it highly probable that general malnu- 
580 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Magneto-Therapy. 
Malformations, 
trition of the embryo in its earliest stages, resulting in the 
production of the "abortive" forms, to which the last- 
named author has recently again called attention,4 is much 
more frequent than is generally supposed. These abortive 
embryos, which may be either nodular, cylindrical, or 
contorted in outward form, may remain stationary in 
their development within their membranes for weeks or 
even months without decomposition or absorption. This 
fact affords the explanation for the not unusual, apparent- 
ly irreconcilably small size of the product of conception 
and the length of time during which pregnancy has ex- 
isted. These stunted embryos are often the seat of a 
peculiar proliferation of wandering cells, which invade 
the entire organism and obscure its histological details. 
The group of "acardiac" monsters, likewise, fur- 
nishes conspicuous examples of interrupted development 
brought about by impaired general nutrition. In such 
cases an atrophic foetus frequently is associated with a 
well-developed, and possibly entirely normal, mate, a 
common placenta, with double cords, being generally 
shared by the two. 
Regarding the manner in which these malformations 
are produced opinions are by no means in accord. The 
older view of Claudius6 attributes the atrophic changes 
primarily to the reversal and impairment of the circula- 
tion, brought about by the overpowering vigor of the 
stronger foetus. This doctrine has been warmly defended 
and further elaborated by Ahlfeld,6 according to whom 
the production of an acardiac monster is largely acci- 
dental. 
The development of an ovum containing two embryonic 
areas ordinarily results in the formation of " homologous " 
twins, in which great physical similarity is very pro- 
nounced. In any event the development progresses with 
regularity until the formation of the allantois at about the 
twelfth to thirteenth day ; if the growth of this organ 
proceeds with equal pace in both embryos the available 
space for attachment offered by the false amnion will be 
equally shared, and both embryos will be provided with 
allantoic, and later placental, circulations fully sufficient 
for their nutrition. The slight communication between 
the circulations, established by the anastomosis of the 
allantoic capillaries, which is usually found in such 
homologous twins, exerts no untoward influence on either 
embryo, both being born, at the close of gestation, fully 
capable of maintaining post-embryonic life. 
When, on the other hand, the connection between the 
two circulations involves large vessels, unequal propelling 
forces in the two embryos may lead to the gradual sup- 
pression of the normal blood-current of the weaker foetus, 
resulting in its death, followed by the subsequent disap- 
pearance of the amniotic fluid and cavity, and the pressing 
of the unfortunate foetus against the uterine walls, where, 
by the continuous pressure exerted by the increasing bulk 
of the stronger surviving foetus, the dead product is re- 
duced to the thickness of stout parchment, producing an 
atrophic mass to which the term/teZws papyraceus is some- 
times applied. In those cases where the allantois grows 
with unequal rapidity in the two embryos the fate of the 
weaker embryo is somewhat different. The allantois of 
the more vigorous attaches itself to the partial or com- 
plete exclusion of the less fortunate embryo, the latter 
being thus compelled to seek attachment for its allantois 
in the remaining unappropriated part of the area destined 
to form the placental attachment or chorion frondosum. 
Where, however, all of the placental area is already 
secured by the allantois of the first embryo, a secondary 
attachment to the united allantois of the first embryo is 
all that remains for the second foetus to secure. Em- 
bracing this last source of nutrition, the weaker foetus 
forms anastomoses with the allantoic or placental cir- 
culation of the stronger, and thus becomes directly de- 
pendent for its nutrition upon the circulation of the latter, 
constituting an allantoic parasite (Ahlfeld). 
Owing to this dependence, according to the views of 
the followers of Claudius, a reversal of the blood-current 
within the vessels of the weaker feetus takes place, and 
is the prime factor in the production of omphalositic 
monsters, with the accompanying imperfections in many 
organs. The heart, naturally, is greatly affected by the 
changed conditions of circulation, becoming, in numer- 
ous instances, reduced in function to constitute but a part 
of the vascular channel. The atrophy and frequent dis- 
appearance of the heart was formerly regarded as an al- 
most constant characteristic of these malformations, -as 
expressed by the commonly applied term "acardiac;" 
that such condition, however, need not necessarily be 
present has been pointed out by Ahlfeld, who has col- 
lected fourteen cases where "acardiac" monsters pos- 
sessed more or less developed hearts. The young organ 
may adapt itself to the reversed blood-current to an ex- 
tent sufficient to enable it to take part in the propulsion 
of the stream. The quite usual relatively much better 
developed condition of the posterior, lower, or caudal 
half of the foetus, is generally attributed by the supporters 
of Claudius to the more favorable situation of these parts 
to secure nutrition sufficing for at least partial develop- 
ment, while the upper portions of the foetus are denied 
nutrition adequate to prevent the atrophy and disappear- 
ance so commonly observed. That sometimes, however, 
the reverse may occur is shown in the case recorded by 
G. W. Koch,1 in which the neck, trunk, and upper ex- 
tremities were well developed without even a trace of a 
heart being present. In those instances where the avail- 
able blood-supply is insufficient for the nutrition of even 
the lower part of the foetus the entire organism becomes 
converted into a shapeless mass, retaining but little re- 
semblance to the human form, and representing the so- 
called amorphous acardiac monsters. 
Opposed to the foregoing views, ably supported by 
Ahlfeld, are those of Dareste,8 Panum,' Peris,10 Breus,11 
Koch, and others, who maintain that the reversed blood- 
current and accompanying changes are secondary and 
dependent upon an inherent primary defect in the em- 
bryo of so grave a nature that development beyond a cer- 
tain stage becomes impossible. The destruction, which 
otherwise would be the inevitable fate of such embryo, 
is partially averted by the opportune assistance derived 
from the anastomosis of its allantoic circulation with that 
of its more fortunate companion, from whose more vig- 
orous circulation a donation is received capable of main- 
taining the partial nutrition of a larger or smaller por- 
tion of the affected embryo. 
The view advanced by Cleland 15 as to the origin of 
acephalic and other lowly developed types of monstrosi- 
ties corresponding to the acardiaci, opposes that of Clau- 
dius, and refers the origin of these forms to changes 
which follow primary posterior or " abcaudal " fission. 
According to this author, in the cases in question, one of 
the two segments resulting from such division develops 
with less vigor than the other, and, in consequence of 
the unequal growth of the segments and their external 
allantoic attachments, becomes subjected to greater and 
greater stretching, until finally separation takes place. 
One part of the weaker embryo remains attached to, and 
often within the stronger, while the other portion be- 
comes free, and, where the allantoic circulation is estab- 
lished, capable of maintaining an imperfect existence, 
resulting in the well-known types of acardiac monsters. 
Should the weaker embryonic segment fail to form ex- 
ternal attachments, it remains connected with the more 
robust mate, and probably becomes one of the more or 
less pronounced parasitic forms of double monsters. 
Whatever be accepted as the detail of the immediate 
process by which these highly aborted forms of mal- 
formation are produced, it seems certain that their ori- 
gin depends on a primary impairment of vitality of one 
of the embryos, as the result of which tardiness in secur- 
ing adequate allantoic attachments, and failure in main- 
taining a successful and independent circulation follow. 
Weighed by the standard of our present knowledge, the 
changes observed in the circulation of such malforma- 
tions can no longer be regarded as of the same primary 
significance as claimed for them by Claudius and his sup- 
porters, but rather as secondary phenomena, depending 
upon more deeply lying fundamental causes. 
In seeking the interpretation of those examples of ar- 
rested development and incomplete differentiation af- 
581 Malformations. 
Malformations. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
fecting the lower extremities in various degrees, from 
the suppression of a single digit to the rudimentary de- 
velopment and fusion of both lower limbs, as in sireno- 
melus, it is difficult to determine to what extent such 
developmental arrest depends upon external mechanical 
influences as contrasted with deficiencies of formative 
material and force. 
Peris, Dareste, Gebhard,13 and others concur in ascrib- 
ing to an abnormally narrow amnion the principal role 
in the production of such arrests of development. Ad- 
mitting, as we must, that important modifications may 
undoubtedly be referred to the direct limitations of the 
enveloping membranes, yet the symmetry frequently 
observed in the defects under consideration, together 
with the fact that sometimes, as in phocomelus, those 
parts most directly and continuously exposed to external 
pressure are much better developed than those which 
are more deeply placed and less exposed, strongly em- 
phasizes the inadequacy of referring to merely mechani- 
cal influences the production of such anomalies, and 
renders imperative the assumption of the presence of a 
much more deeply seated cause of the arrest of develop- 
ment encountered. 
II. Malformations produced by the defective union of 
component embryonic parts. 
The limits of the second group of malformations, de- 
pending upon the imperfect union or fusion of parts orig- 
inally distinct but normally uniting in the course of 
development, are very wide, and include an extended 
series of defects, which vary in their significance from 
slight inconvenience, as simple harelip, to great deficien- 
cies incompatible with life, as extensive spina bifida. 
These defects naturally fall under two heads : a, those 
arising from imperfect union of embryonal parts, origi- 
nally separated ; b, those resulting from incomplete clos- 
ure of foetal passages. 
In connection with the anomalies embraced within the 
first sub-group, the early embryonic relations and pro- 
cesses must be recalled, especially the fact that the em- 
bryo largely develops by the fusion of two symmetrical 
halves. These halves, at first lateral tracts, differentiate 
into two sets of folds-dorsal and ventral. The former 
unite above the embryonic axis, as defined by the noto- 
chord, to form a dorsal tube, the neural canal ; the ven- 
tral folds join below the axis to form an imperfectly 
defined primitive digestive tube, whose ventral wall, 
throughout a variable distance, is incomplete for a time, 
opening directly into the umbilical vesicle or its duct, 
the last trace of this connection usually disappearing 
only at birth. The lateral parts of the dorsal or neural 
folds are continued into the marked duplications form- 
ing the amniotic folds, which gradually cover in, at first 
the dorsal, later, the ventral surface of the embryo. By 
the elongation ventrally of the root of the primary am- 
niotic folds, the tissues embraced within the latter (the 
ectoderm and the parietal layer of the mesoderm) grad- 
ually encompass the primitive digestive tube and form 
the ventral body-walls, the umbilicus marking the posi- 
tion where the last communications between the cavities 
of the foetus and external structures exist ; likewise, at 
the umbilicus, the embryonic parietes and the amnion 
are continuous. 
On comparing the normal union of the dorsal and ven- 
tral folds it will be seen that while the dorsal line of 
fusion is unbroken the ventral line of closure is incom- 
plete, being interrupted by the mouth and umbilicus 
primarily, and by the genito-urinary and anal openings 
secondarily. As is to be anticipated from these relations, 
malformations due to defective union along the anterior 
or ventral line of closure exceed in frequency those of 
the posterior or dorsal surface. 
Without entering into a detailed account of the mode 
of production of the numerous defects included within 
the first of the above sub-groups, a brief consideration of 
the most important of such defects may claim attention. 
The region of the face and neck is a favorite seat of 
such imperfect unions, a tendency readily appreciated 
when we recall the manner in which these parts are so 
largely derived from the tissue supplied by the visceral 
arches, together with the adjoining portions of the head. 
The most frequently observed defect of this group, the 
lateral labial cleft or harelip, results from the faulty 
uniou of the central naso-frental, or intermaxillary, pro- 
cess with the superior maxillary or upper division of the 
first visceral arch. Harelip may be uni- or bi-lateral, 
and may be associated with defective development of the 
adjacent bony structures, as maxillary and palatal cleav- 
age. When unilateral, harelip is more frequently lim- 
ited to the left side, in explanation of which the tendency 
of the embryo to lie upon the left side in its early stages 
has been assumed to predispose to the formation of dis- 
turbing amniotic folds. Conspicuous anomalies are pro- 
duced when the intermaxillary process fails to develop, 
the space between the ends of the superior maxillary 
processes appearing as a wide central labial cleft. Open 
naso-lachrymal ducts and oblique facial clefts are other 
forms depending upon defective union of the margins of 
corresponding embryonic furrows, while fissures of the 
cheeks, clefts, fistulae, and cysts of the lower lip and de- 
fective inferior maxilla are further instances of imper- 
fect fusion, or of insufficient formative material. The 
visceral furrows, as is to be anticipated, offer a product- 
ive field for defects of this class, as illustrated in the 
deviations about the external ear resulting from the im- 
perfect development of the first outer visceral furrow 
and its secondary tubercles. Persistence of the low'er vis- 
ceral furrow's gives rise to the laterally situated cervical 
fistula, those occupying the median plane resulting from 
the imperfect fusion of the visceral arches at their inner 
ends. The question as to the existence of a delicate epi- 
thelial'partition separating the external furrow from the 
corresponding inner pharyngeal pouch is still a subject of 
non-agreement. A number of authors agree with His14 in 
denying the existence of a free communication between 
the outer and inner furrows, unless artifically produced, 
while many others hold that secondary rupture of the 
epithelial partition takes place spontaneously and with- 
out violence after a variable length of time. Notwith- 
standing the retention of the epithelial septum during 
embryonic life, which condition the writer must con- 
tinue to regard as the usual one before birth, there seems 
to be no reason why this delicate partition may not dis- 
appear subsequently, especially when viewed in the evi- 
dence of such cases as those recorded by Sutton16' 16. 
The production of a complete median cervical fistula has 
been attributed by Marshall11 to the persistence of a rudi- 
ment of the median portion of the thyroid body, the 
thyro-glossal duct, which enlarges and subsequently 
opens on the free cutaneous surface. As opposed to this 
view, Kostanecki and Mielecki18, Kauthack19' s0, and 
others refer the fistula in question to a breaking through 
of the pharyngeal pouches into the still present remains 
of the sinus cervicalis. Diverticula and cysts also arise 
within the pharyngeal walls as vestiges of the visceral 
pouches. 
Imperfect approximation and fusion of the parietal 
plates, to which the ventral, body-wall owes its origin, 
results in defects varying from slight sternal clefts to 
gaps involving the entire line of ventral union. The 
causes leading to these defects are various and by no 
means free from complexity ; in addition to the more 
mechanical influences opposing the normal union, as the 
disturbing presence of intruding amniotic folds or of the 
unusual interposition of excessively enlarged, displaced, 
or abnormally adherent viscera, the effects of insufficiency 
or distortion of formative material, together with devel- 
opmental inertia, must likewise be recognized as active 
factors in causing the arrested unions. 
Excessive size of the heart is frequently the cause of 
imperfect closure of the thoracic walls, cardiac ectopia 
being sometimes associated with these defects. Likewise 
abnormal adhesions may limit the development of the 
ribs, forming lateral clefts through which a pulmonary 
hernia may appear. The same influences which prevent 
the perfect union of the anterior thoracic walls may 
affect the diaphragm to the extent of permitting the for- 
mation of diaphragmatic hernia, which may include the 
migration of a large part of the intestinal tract. 
582 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Mal formations. 
Malformations 
While the thoracic clefts not infrequently are prolonged 
into the upper portion of the abdomen, it is in the lower 
or caudad part of the line of ventral union that the defects 
of closure occur with greatest readiness, a tendency find- 
ing its stimulus in the passage through the body-wall, at 
the umbilicus, of the several structures connecting the 
fretus with its external attachments. The normal con- 
ditions thus favoring incomplete union, the supervention 
of causes retarding closure, as amniotic adhesions or ex- 
cessive bulk or abnormal position of the abdominal vis- 
cera, may readily prevent the approximation of the ab- 
dominal walls and produce permanent fissures through 
which more or less extensive extrusion of the viscera may 
take place. 
Such imperfections of slight degree, involving only the 
umbilical ring, are of frequent occurrence ; especially re- 
lated to the patulous condition of the umbilical ring are 
the protrusions of the gut, either as the result of abnor- 
mal retention within the cord of that part of the intestine 
which, until the tenth week of foetal life, lies without the 
abdominal cavity, but subsequently is drawn within, or, 
more seldom, as the result of later secondary protrusion 
of the gut through the still open ring. A familiar ex- 
ample of the persistence of these foetal relations, to a 
slight and imperfect degree, is presented in the occurrence 
of Meckel's diverticula, where the retention of the lumen 
of the proximal end of the vitelline or umbilical duct 
may establish a communication extending between the 
lower portion of the ileum and the free surface at the 
umbilicus. In the majority of such cases, however, the 
diverticulum ends before reaching the umbilicus, being 
continued to the parietes as an impervious fibrous cord. 
The production of the various forms of funicular hernia 
probably follows the abnormal attachments of the vitel- 
line duct, which then, as pointed out by Ahlfeld, induces 
a continuous drag upon the loops of intestine within the 
cord, thereby preventing its retirement within the abdom- 
inal cavity. 
Closely associated with an abnormal position and con- 
sequent downward traction of the umbilical cord, clefts 
of the lower part of the abdominal wall, and even pelvic 
bones, may occur. Ectopia of the urinary bladder, re- 
sulting from the rupture of the allantois, due to over- 
distention, following the obstructed exit of the accumu- 
lated excretions owing to closure of the urachus without 
the formation of the usually substituted cloacal passages, 
is connected with these abdominal lesions, the vesical 
defect being frequently associated with abnormal adhe- 
sion of the gut. 
The altered relations of the parts involved in these 
malformations exert widely extended impressions, result- 
ing in secondary anomalies. Among such induced mal- 
formations are obstructed fusions of the Mullerian ducts 
due to the interposition of a gut attached to the bladder 
or of a distended allantoic stalk, and resulting in double 
uteri and vaginae in all grades of separation, from the 
mere suggestion of division, as expressed by a cleft uter- 
ine fundus, to completely isolated tubes extending from 
the oviducts to the vaginal orifice ; cleft pubes, with the 
attendant faulty development of the external genitalia, 
also follows the lesions in question. Imperfect \inion of 
the parts going to form these organs may produce the 
various fissures, as epi- or hypo-spadia, divided scrotum, 
etc., from which arise the conspicuous forms simulating 
hermaphrodites. Displacements of the abdominal vis- 
cera and even abnormal curvature of the vertebral col- 
umn, which latter may induce modifications in the forma- 
tion and position of the lower extremities, are, likewise 
members of the train of misfortunes referable to the 
clefts of the lower abdominal wall. 
Interruptions in the closure of the neural canal along 
the dorsal line of fusion occur, as already stated, less 
frequently than along the corresponding ventral line. 
Two localities-the cervical and lumbar regions-exhibit 
an inherent weakness in the walls of the neural tube, 
being the points at which union is last completed and at 
which, therefore, the tissues are least capable of resisting 
undue pressure from within ; the sharp flexures which 
occur at these positions of the canal are probably, as 
(SUPPLEMENT.) 
pointed out by His, responsible for the tardy closure and 
accompanying weakness. Corresponding with this pre- 
disposition, spinse bifida? are more frequently observed 
in these particular portions of the neural canal than else- 
where, those occupying the lumbar region, moreover, 
preponderating. Where the protrusion is small in size, 
the stretched and thinned out integument still suffices to 
invest the tumor ; with the enormous increase in the di- 
mensions of the latter sometimes seen, the skin no longer 
is capable of covering the protruding tumor, the sac in 
such cases being composed of the distended membranes 
of the cord alone. 
Concerning the mode of formation of spina bifida 
opinions vary ; the older and widely accepted view re- 
gards augmented intra-spinal pressure, referable to pri- 
mary hydrops, as the active factor, and the ununited 
arches and protruding Sac as results of a process of dis- 
placement largely mechanical. Other observers, on the 
contrary, regard these defects as the expressions of 
arrested development which owes its origin to deeply 
seated causes affecting the skeletal axis. The symmetry 
of the vertebral defects shows that they must originate 
at an early period of foetal life when formative processes 
were active in the differentiation of the primary material. 
The experimental investigations of Richter,21 likewise, 
do not support the view that the spinal dropsy or amni- 
otic pressure is to be regarded as the fundamental cause 
of spina bifida. 
The malformations involving the cephalic expansions 
of the neural tube are also the subject of divergent opin- 
ions. The older view, supported by Dareste, Marchand, 
Peris, and others, attributes to the amnion, as the result 
of the pressure and obstruction caused by its abnormal 
adhesions and constriction, the most important role in 
the arrest of development. Ahlfeld, on the other hand, 
considers that the primary condition is one of abnormal 
intracranial pressure which results in the rupture of 
the very early cerebral vesicles, followed by the absorp- 
tion and disappearance of the ragged edges of ruptured 
sac, so that later, when these cases usually first come 
under observation, the cranial basis lies exposed and the 
original conditions are masked. 
Opposed to these non-mechanical theories as to the mode 
of these malformations are the views of Ackermann," 
Quicken,23 and others, who regard these imperfect ce- 
phalic developments rather as the results of defective for- 
mative energy and insufficiency of formative material than 
as secondary defects induced by pressure. In view of the 
frequent association of these cephalic defects with those 
of the neural canal, it is highly probable that similar 
forces are responsible in both localities for the arrested 
development. As consequences of the imperfectly ex- 
panded cranial base, and the not infrequently associated 
vertebral defects, the proportions of the face and the 
direction of its axis are materially changed, thereby pro- 
ducing the striking "frog-headed" physiognomy so 
characteristic of an encephalic monster. 
Closely related to these deviations in the cephalic de- 
velopmental processes stand the variations in the closure 
of the anterior end of the neural tube which produce the 
conspicuous series of cyclocephalic monsters, whose brief 
consideration may here find place. Both the view that 
cyclocephali result from the fusion of two eyes originally 
distinct, and that ascribing them to failure of differentia- 
tion of the two eyes from a condition of primary unity, 
have been superseded by the more recent explanation by 
Dareste,24 by whom the cyclopian features are regarded 
as directly dependent upon the primary imperfect devel- 
opment of the anterior cerebral vesicle. 
The differentiation of the lateral diverticula, or optic 
vesicles, which under normal conditions are formed, is 
but partially accomplished, owing to the imperfect devel- 
opment of the anterior cerebral vesicle in consequence of 
the premature closure of the neural plates forming this 
portion of the nervous tube. As a result of this closure, 
an insufficient involution of ectoderm takes place where- 
by the amount of material available in the formation of 
the optic vesicles is greatly reduced. When this closure 
of the cerebral vesicle occurs very early but a single me- 
583 Malformations. 
Malformations. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
dian optic vesicle is formed, resulting in the production 
of the characteristic feature of these monsters. In cases 
where the closure takes place later, affording greater 
opportunity for advanced development, two imperfectly 
differentiated optic vesicles are present, from which two 
eyeballs, more or less closely approximated, arise, the 
degrees of proximity atld fusion depending upon the 
completeness of the differentiation of the optic vesicles 
as separate sacs. The cause of the primary arrest of de- 
velopment affecting the anterior cerebral vesicle, Dareste 
is disposed to attribute to anomalous growth of the am- 
nion, in consequence of which the expansion of the brain 
vesicle is unable to proceed to the usual extent. 
As secondary defects, dependent upon the abnormally 
situated central optic vesicle and the faulty development 
of the anterior cerebral sac, deviations and displacements 
of the naso-frontal process take place with corresponding 
conspicuous changes in the face. The absence of the 
central process allows the approximation of the superior 
maxillary divisions of the first visceral arch, by whose 
fusion the oval opening assumes a characteristic trian- 
gular form. Immediately above the mouth the closely 
approximated, or single, visual organs take up their po- 
sition, the displaced naso-frontal process lying higher 
and often resulting in the development of the character- 
istic proboscis. 
The anomalies owing their production to the abnormal 
persistence of canals whose function ceases before or at 
the time of birth are usually inconspicuous, but, at the 
same time, may induce conditions incompatible with 
post-foetal life. The peculiarities of the foetal circulation 
are not infrequently retained as a patulous foramen 
ovale or pervious ductus arteriosus. Variations in the 
plan of suppression among the aortic arches of embry- 
onic life give rise to the conspicuous anomalies of the 
great vessels near the heart; not only are transposed 
aortae, double aortse, and deviations in the origin of the 
subclavian and carotid arteries to be referred to devia- 
tions from the usual fate of the embryonic aortic bows, 
but, likewise, the transposition of the associated viscera. 
Instances of the retention of the embryonic arrangement 
of the venous system are also occasionally seen, as in 
many anomalies of the great veins near the heart. The 
presence of Meckel's diverticula, and, in extreme cases, 
the formation of an artificial anus, find their explanation 
in the persistence of the lumen of the vitelline duct. 
Likewise, the retention of the allantoic stalk in a pervi- 
ous condition, instead of the usual transformation into 
the fibrous urachus, may establish an unnatural exit for 
the contents of the urinary bladder ; such conditions are 
usually induced by obstruction, during fcetal life, of the 
more usual channels. Partial retention of the lumen of 
the allantoic stalk may result in the formation of cysts. 
Imperfect obliteration of the thyro-glossal duct may con- 
tribute to the production of cervical fistulse. 
III. Malformations produced by fission, either partial 
or complete- 
a. Of the primary embryonal cell-mass ; 
b. Of the partially differentiated individual organs. 
The malformations comprising the third group-those 
derived by fission-include the most conspicuous results 
of developmental deviation, forming a series beginning 
with the limited fission implicating a single digit, and 
ending with the extreme division presented by those 
double monsters in which union is alone maintained by 
the limited isthmus of attachment, as between the ster- 
num, pelvis, or head. 
The production of double monsters has long been a 
subject of diligent study and ingenious speculation, and 
even at present it constitutes a biological problem re- 
garding many details of which there is still much differ- 
ence of opinion. 
The once generally accepted and brilliantly supported 
theory, that double monsters result from the fusion of 
two separate and independent embryos, may be regarded 
as now entirely obsolete, modern embryologists agree- 
ing, at least so far, that multiple monsters arise from a 
single ovum. 
Regarding the further question, however, as to whether 
(SUPPLEMENT.) 
these monsters originate by the union ot two originally 
distinct embryonic areas upon a single ovum, or whether 
they result by the cleavage of a single blastoderm, opin- 
ions still fail to accord. The former supposition recog- 
nizes primitive duality, followed by fusion, the latter 
primitive unity undergoing subsequent 
fission. 
In addition to the older authorities 
upholding the fusion theory, B. 
Schultze, Panum, and especially 
Dareste, have given this view their 
support, while Rauber, Gerlach, and 
others accept it with more or less im- 
portant modifications. Dareste, while 
accepting the doctrine of primitive 
duality, insists that union can only 
take place in the very earliest stages, 
and then only as the expression of a 
special inherent predisposition. 
The supporters of the fission theory 
number many of the most distin- 
guished older investigators, and prob- 
ably the majority of the embryologists 
of to-day. The fission theory, as pre- 
sented by Ahlfeld, one of its most 
ardent advocates, suffices for the ex- 
planation of all forms of double mon- 
sters. The primitive undifferentiated 
embryonic cell-mass may undergo 
cleavage, in the direction of the future 
embryonic axis, in varying degrees. 
When the division is complete, the 
two resulting halves lie at first paral- 
lel, and are capable, under favorable 
conditions, of developing into homo- 
logous twins ; when incomplete, the 
divided parts may subsequently separate, while the at- 
tached portions constitute the common bond of union 
either anterior, posterior, or middle, as illustrated ir 
the accompanying drawings (Figs. 386 to 389) of act 
ual double monsters of dif- 
ferent types of fission ob- 
served in the development 
of avian ova. By the vari- 
ations in the intensity of 
these forces all degrees of 
deflection, from a position 
of almost parallelism to 
one of extreme divergence, 
as head to head, is possible. 
Ahlfeld regards the fission 
theory as sufficient for the 
explanation of all forms of 
double monsters, and does 
not admit the necessity of 
seeking aid from other 
theories. 
Gerlach25 regards the 
production of double mon- 
sters as far more variable, 
and opposes the passive 
cleavage ascribed to the 
embryonic cell-mass by 
Ahlfeld, attributing, on 
the contrary, to the embry- 
onic trace an active partici- 
pation in the division, the 
controlling predisposition 
to which must reside with- 
in the cells even before 
differentiation. This " bi- 
furcation " Gerlach c o n - 
siders especially active in 
producing anterior or 
cephalic duplications ; the 
corresponding posterior or 
caudal cleavage is referred by this author to the partial 
union or "copulation" of separate but converging traces 
proceeding from the posterior margin of the germinal 
Fig. 386.-Chick Em- 
bryo of about Forty 
Hours, showing 
limited anterior 
cleavage. (Dareste.) 
vAf, hAf, cephalic 
and caudal folds of 
amnion; h, heart; 
o. primary otic vesi- 
cles. 
Fig. 387.-Goose Embryo of Seventy- 
two Hours, indicating the effects 
of coincident anterior and pos- 
terior cleavage ; the two resulting 
divisions are connected by the isth- 
mus of undivided tissue. (Reich- 
ert.) Ap, area pellucida: vh, an- 
terior brain vesicles; o, primary 
otic vesicles ; Mf, medullary folds ; 
ch, chord® of the divided parts. 
584 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Malformations. 
Mal for (nations. 
area. Debierre26 and Klaussner21 also hold the fission 
theory as inadequate to account for all forms of double 
monsters; the former concludes that both fission and 
fusion may take part, while Klaussner declares that the 
genesis of such monsters depends upon primary plurality 
of the embryonic area, and upon fission with post-gener- 
ation. 
The inadequate observations on early mammalian 
double monsters, together with the fact that the young- 
est human double monster was already four weeks old 
(Ahlfeld), still farther adds to the uncertainty of conclu- 
sions regarding man and the higher types. Notwith- 
standing the incompleteness of our knowledge in many 
points concerning these interesting questions, it must be 
admitted, we believe, that to fission of the primary em- 
bryonic trace must be referred the origin of the great 
majority of the double monsters encountered, and that, in 
the present state of our knowledge, we are warranted in 
onic segments, thereby producing a third, which, in the 
case of complete fission, would form one of the group of 
homologous triplets; partial cleavage of one of the seg- 
ments would produce a composite monster of the triple 
type. Such cases must, obviously, belong to the rarest 
of anomalies, and when occurring would be prone to 
unequal development with the suppression of the weaker 
embryos. Multiple human monsters in excess of triplets 
have never been observed. When the almost entirely 
separated embryonic segments undergo equal develop- 
ment and growth, the resulting individuals may be capa- 
ble of maintaining an almost independent existence, as in 
the case of the celebrated Siamese twins ; not infrequently, 
however, the segments are affected by unequal develop- 
ment and growth, the disparity becoming more marked 
with time. From a condition of equality, the weaker 
embryo becomes more and more dependent upon its 
stronger mate, until the relations become pronounced as 
some form of parasitic monster* In the observation of 
the later stages of growth, when the condition of inequal- 
ity is already well emphasized, sight must not be lost of 
the fact that at an earlier period both embryos were of 
equal dignity, although the possible presence of a shape- 
less acardiacus attached to a moderately well-developed 
foetus at first glance seems little in accord with such 
condition. 
The explanation of the series of obscure parasitic mon- 
sters, represented by the different " inclusions," is found 
in the assumption of duplications, either posterior or an- 
terior, where, as pointed out by Cleland, the two seg- 
ments are primarily united at a point variably distant 
from the upper end of the vertebral column. With the 
subsequent unequal growth of the two embryos, the less 
developed finally comes to lie within the body of the 
stronger to an extent dependent upon the position of the 
primary union, and upon the stage of development and 
growth to which the weaker part attains. Where the 
" parasite " remains relatively free and well nourished, 
the relations between the two may approach those pre- 
sented by the classic example of the Genoese Colloredo, 
and by the young Hindoo, Laloo, now living and about 
twenty years of age. These " inclusions " present their 
extreme in the obscure tumors attached to some part of 
the head, as the hard palate (epignathus), lower jaw 
(polygnathus), orbit, and 
other parts of the cranium, 
in which cases the union ol 
the two embryonic segments 
is situated at the anterior ex- 
tremity of the vertebral axis, 
and the weaker segment has, 
either from the first under- 
gone but slight development, 
or, as advocated by Cleland, 
suffered a separation. The 
part remaining attached to 
the main stem becomes en- 
veloped within the tissues of 
the stronger embryo to con- 
stitute the contents of the 
tumor, the position of whose 
external attachments deter- 
mines the designation which 
it receives. In the case of the 
'congenital sacral" tumors 
i somewhat modified pro- 
cess must be recognized, 
since, as held by Cleland, the 
jony parts within these tu- 
nors are the remains of the 
'used adjoining lower limbs 
)f, at one stage, double sets 
)f extremities, resulting from 
ission involving the embryo 
is far as the sacrum. The adjacent left and right limbs 
>f the duplications remain undifferentiated and fused, 
ind, undergoing subsequent atrophy, remain as the con- 
ents of the sacral tumor ; it follows, therefore, that the 
imbs which develop really represent the right and 
Fig. 388.-Double Chick Monster of Forty-eight Hours. Marked an- 
terior cleavage has taken place, with subsequent divergence. (Gerlach.) 
Ap, area pellucida ; Av, area vasculosa ; V, V', if, M', II, IV, respectively 
the anterior, middle, and posterior primary brain-vesicles ; iff, the still 
widely open medullary folds; Ur, the somites or primary segments. 
accepting, provisionally at least, the explanations offered 
by this theory. 
The most pronounced effect of the cleavage forces re- 
sults in the complete division of the cell-mass into two 
separated portions. Each of these may undergo inde- 
pendent development, the two, under favorable condi- 
tions, developing into homologous twins, characterized by 
remarkable physical similarity and the same sex. 
In those cases, however, where the cleavage forces effect 
but partial division of the original embryonic mass, the 
production of the conspicuous double monsters takes 
place. The degree of the duplication varies from the 
slight splitting of the cephalic end of the notochord, the 
resulting condition presenting no external evidences of 
its existence and being only accidentally discoverable, to 
the almost unrestricted separation resulting from the co- 
incident anterior and posterior cleavage where, as in 
xiphopagus, a narrow bridge of remaining tissue alone 
establishes continuity. 
As an extremely rare occurrence, a repetition of the 
cleavage may take place in one of the separated embry- 
Fig. 389. - Chick Embryo of 
Thirty-six Hours, showing pos- 
terior or caudal cleavage. (Ahl- 
feld.) Mf, medullary furrow di- 
vided toward its caudal extrem- 
ity into the diverging grooves, 
separated by the median fold 
(amniotic (?) ), Zw; vAf, an- 
terior or head fold of amnion. 
585 .malformations. 
Malformations. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
left members, not of the same, but of two pairs of ex- 
tremities. 
The included foetus ordinarily lies enclosed within a 
sac closely united with the 
surrounding organs ; from 
these latter blood-vessels 
form communic ations 
which supply the nutri- 
tion requisite for the exist- 
ence of the parasite. 
Should the remaining 
parts of the included em- 
bryo come to rest upon 
the actively growing tis- 
sues destined to form the 
sexual glands, these para- 
sitic structures become 
surrounded by the tissues 
of the future testicle or 
ovary, and later give rise 
to inclusions within these 
organs. These rare condi- 
tions must be clearly dis- 
tinguished from the rela- 
tively frequent dermoid 
cysts occurring within the 
testicle and ovary : while 
in the former cases the re- 
mains are parts of the atro- 
phic supernumerary em- 
b r y o n i c segments, ar- 
ranged with, at least, a 
suggestion of order, the 
contents of the dermoid 
cysts represent heteroge- 
neous, isolated, and usu- 
ally ectodermic, tissues of 
limited variety. 
Contrasted with the 
foregoing results of complete or partial dichotomy in- 
volving the entire embryonic cell-mass stand the limited 
duplications arising from the fission of the cell-areas 
forming the individual organs. Such duplications 
affect almost 
every important 
v i s c u s in the 
body. 
The assumption 
that the obstruc- 
tion caused by 
the folds of an 
abnormally a d - 
herent amnion is 
chiefly responsi- 
ble for the fre- 
quently observed examples 
of fission in polydactylism 
seems insufficient in ex- 
planation of these anom- 
alies. While, no doubt, 
such mechanical forces 
may result in important 
modifications, yet when 
we recall the dispropor- 
tionate infrequency of 
cleavage of those parts of 
the limb-buds most ex- 
posed to external influ- 
ences, together with the 
fact that numerous in- 
stances of polydactylism 
occur among the anam- 
niota, as the amphibians, 
and the conspicuous trans- 
mission of such anomalies 
by heredity, through sev- 
eral generations, it is evi- 
dent that the production of 
these anomalies lies in a 
(SUPPLEMENT 
much more deeply seated and less local cause. As ob- 
served by Pott,29 the conditions producing polydacty- 
lism, adactylism and syndactylism are closely related, 
being the variously modified expressions of the same in- 
herent differential forces that, under usual conditions, 
result in the separation of the common cell-area into the 
normal number of well-defined digits. Where these 
forces of differentiation and separation, which seem to be 
possessed by all parts of the embryo during some stage 
of embryonic life, are stimulated as by excessive pres- 
ence of formative materials, their action may be exerted 
far beyond the usual limits, resulting in repeated and 
extensive more or less perfect cleavage. These divisions 
commonly are limited to the distal segment of the em- 
bryonic limb, producing the frequently encountered 
supernumerary digits, fingers or toes ; much less frequent 
are divisions implicating the remaining segments, dupli- 
cations of the entire arms and legs being extremely rare. 
A remarkable example of cleavage of the upper extrem- 
ity is recorded by Burnett,28 where the entire arm has 
suffered repeated partial division. 
Excessive activity of the differentiating forces results 
in the cleavage of the cell-areas destined to become vari- 
ous parts of the body ; examples of such excessive ac- 
tion are particularly noticeable in the formation of such 
series as the ribs and vertebrae, as well as the muscles, 
vessels, and nerves, their production supplying the 
"variations" of the anatomical text-books. Many or- 
gans occasionally present more or less complete duplica- 
tions, either as the result of early fission of the primary 
cell-mass, or of secondary division induced by encroach- 
ments of neighboring tissues. Among the organs occa- 
sionally undergoing such cleavage are the tongue, uvula, 
epiglottis, bronchiae, pulmonary lobes, stomach, intes- 
tines, liver, gall-sac, pancreas, spleen, kidney, ureter, 
urinary bladder, sexual glands, and mamma?. In con- 
nection with the production of supernumerary mammary 
glands, the recent investigations of O. Schultze30 are 
very suggestive, since it is shown that special embryonic 
areas, or " milk-lines," extend on either side as far as 
the groin, the permanent glands resulting as the devel- 
opment of certain limited areas along these tracts. While 
the occurrence of mammary glands on the anterior sur- 
face of the body thus finds suggestive embryonal condi- 
tions, the instances of mammae situated on the thigh 
being also readily regarded as extensions of the primary 
milk-lines, the occurrence of supernumerary glands on 
the back, as sometimes observed, seems to call for fur- 
ther explanation. The assumed transplantation of the 
divided original gland-area seems less plausible than 
to regard the appearance of these glands in such unusual 
positions as the expression of perverted differentiation of 
widely distributed epidermal structures, the mamma 
arising as but the higher specialization of the ectoder- 
mal tissue producing sebaceous glands. Supernumerary 
mammary glands occur in men with far greater frequen- 
cy than is usually supposed, as showm by the examina- 
tions by Bardeleben31 ; the apparently greater frequency 
in women arises from the fact that the secretion of milk 
within these structures, after childbirth, calls attention 
to the existence of anomalies never before suspected. 
The Artificial Production of Malformations. - The 
origin of double and other monsters has always pre- 
sented so much of interest, but at the same time of un- 
certainty, that the hope of adding to our understanding 
of the methods and conditions of their production long 
ago induced observers to undertake the artificial produc- 
tion of such malformations. For evident reasons, these 
attempts at experimental investigations have been limited 
to the lower forms. While the results of such investiga- 
tions cannot be directly applied to man, yet they are of 
value in pointing out facts which possess a probable 
bearing upon similar processes taking place in the 
higher mammalian types. In applying the deductions 
derived from experiments with the lower classes of ver- 
tebrates, the inherent differences in the processes as af- 
fecting the totally segmenting alecithal mammalian 
ovum and the partially segmenting telolecithal eggs of 
the fishes and birds, must not be forgotten. 
Fig. 390.-Double Chick Monster Re- 
sulting from Posterior Cleavage 
and Subsequent Great Deflection 
of the Separated Segments. (Rau- 
ber.) Such monsters suggest to 
some authorities the assumption 
of the possible occurrence of the 
fusion of at first isolated em- 
bryos. Mr, medullary furrows ; 
o, primary otic vesicles; Ap, 
area pellucida. 
riG. 491.-Multiple Embryos Con- 
tained within two Closely Ap- 
proximated Arete Pellucid® Oc- 
curring in Chicken's Ovum, 
after sixty Hours' Incubation. 
The smaller area contains a sin- 
gle embryo, the larger an embryo 
which has undergone complete 
posterior cleavage. (Rauber.) 
Mf. medullary furrows ; pr, pr', 
pr", primitive streaks ; etc, me- 
dian ridge: Av, area vasculosa. 
586 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Mal lor matiou s. 
Malformations. 
The possible causes influencing the production of mal- 
formations may be arranged in three groups : 
I. Anomalous conditions of the sexual elements : 
a, Of the female element-the ovum ; b, of the male 
element-the spermatozoon ; c, of the union of sexual 
elements, resulting in abnormal fecundation and seg- 
mentation. 
II. Direct mechanical impressions. 
III. Anomalous conditions of environment of the em- 
bryo, including thermic and respiratory changes. 
it is evident that the experimenter has little control 
over the modifying conditions embraced in the first 
group, and that these, for the purposes of his attempts at 
artificially inducing the production of malformations, 
must be largely ignored. Of interest are the observa- 
tions of Born32 on fish eggs, since the fact seems estab- 
lished that the ova of certain females showed especial 
tendency to yield double monsters, the predisposition re- 
maining practically constant and unchanged notwith- 
standing variations in the source of the fertilizing male 
elements. The segmentation of these ova appeared to be 
normal. 
So far, there is no reliable evidence pointing to anom- 
alous conditions of the male sexual elements as being 
responsible for abnormal development. The double- 
headed spermatic filaments not infrequently seen, and 
to which the production of double monsters has some- 
times been attributed, are to be regarded as variations in 
the development of the spermatic elements themselves, 
rather than as cells endowed with unusual powers of 
fertilization. 
The connection between the entrance of more than a 
single spermatozoon into the ovum at the time of fer- 
tilization, and the induction of abnormal segmentation 
and subsequent maldevelopment. has been maintained 
by Fol,33 and formerly also by O. Hertwig ; the more 
recent investigations of the Hertwig Brothers,34 however, 
do not support the supposition that polyspermia produces 
double monsters. The relation between double sper- 
matozoa and the imperfect expulsion of the second polar 
body as anticipating the formation of double monsters, 
as suggested by Windle,35 lacks further confirmation ; 
and so does, likewise, the hypothesis advanced by Da- 
reste,36 that multiple pronuclei follow the penetration of 
more than one spermatic element. 
The possibility of influencing development by the ap- 
plication of mechanical impressions early invited the 
consideration of experimenters. These mechanical in- 
fluences, brought to bear upon the ovum with a view of 
modifying development, have been : 
a, Abnormal position ; b, disturbed equilibrium ; c, 
direct mechanical injury. 
The elder Geoffroy Saint-Hilaire, by his success in 
producing malformations by incubating eggs placed in 
abnormal positions, has merited the distinction of being 
regarded as the founder of experimental teratology. 
Thirty years later, Liharzik 37 succeeded in distinctly 
modifying chick embryos by change of position during 
the latter half of incubation, when the chick normally 
lies with its axis corresponding with the longer diameter 
of the egg, the head usually occupying the broader end 
of the egg. Recognizing this normal relation, Liharzik 
placed the eggs vertically, in some cases with the larger 
end uppermost, in others with this extremity down. The 
increased nutrition affecting those parts, whether head or 
tail, which were dependent and, therefore, aided by 
gravity, was manifested by the distinctly recognizable 
increase in size of those portions which had occupied the 
lower end of the egg. Dareste 38 also obtained positive 
evidence of influenced development by adopting the ver- 
tical position, while, more recently, Strahl and Gasser 39 
fixed the yolk so that development proceeded while the 
germinal area lay beneath, and thereby produced a par- 
tial inversion of the viscera which, apparently, depended 
upon the abnormal position for its cause. 
The disturbing influences of violent agitation have 
long been known and successfully applied to the pro- 
duction of malformations by Valentin, Knoch, both the 
elder and younger Geoffroy Saint-Hilaire, Lombardini, 
(SUPPLEMENT.) 
and Dareste. The latter experimenter observed that when 
eggs are incubated immediately after violent agitation, 
as after railroad transport, they usually soon die, while, 
on the contrary, if a period of rest intervene before in- 
cubation development proceeds normally. Eggs vio- 
lently shaken by a machine for some twenty minutes 
before incubation gave rise to many malformations, in- 
cluding exencephalus, cyclocephalus, spina bifida, etc. 
Some eggs, however, notwithstanding their maltreatment, 
passed through the cycle of normal growth. 
Attempts at still more profoundly influencing the 
course of development have been made by the direct in- 
jury or mutilation of the early embryonic cell-mass. 
Schrohe40 incised and punctured the germinal area with 
the hope of producing double monsters, but with the 
results of inducing but single deformities. Rauber's 
attempts at causing the formation of double monsters by 
division were also negative ; his conclusions, that it is 
not possible to produce such malformations by mechani- 
cal injuries, are endorsed by Panum and Dareste. In this 
connection the quite recent experimental investigations 
of Driesch41 on the segmentating ova of echinus, and, 
still later, of Wilson 42 on the earliest stages of amphioxus, 
are extremely suggestive. In these experiments, by the 
separation of the blastomeres of the earliest stages of 
segmentation, it was possible to obtain multiple embryos, 
either as isolated individuals, or, as often happened in the 
experiments on amphioxus, as double monsters in various 
stages of separation. These investigations are important 
as emphasizing the primary differential equality of the 
early blastomeres, a single segmental element, in some 
cases observed by Driesch, sufficing to produce a perfect 
individual of diminished size. 
Further attempts to produce anomalous embryos have 
been carried out by Warynski and Fol, who applied the 
thermo-cautery to embryos, and concluded that coelosomia 
and symelia are the only malformations directly referable 
to the amnion ; Gerlach 43 also cauterized the anterior 
end of embryos with the view of producing exencephalus, 
but with only partially satisfactory results. Electricity 
in various forms has been employed by Lombardini, 
Maggiovani, Windle, and others, but this agent seems 
capricious and uncertain in its results. 
The experiments whereby the supply of heat and oxy- 
gen has been affected have yielded the most important 
results. As long ago established by Reaumur, the most 
favorable temperature for incubation is about 40° C. By 
keeping eggs at a temperature of 41° to 42° C., Dareste 
was able to obtain in twenty-four to thirty hours, em- 
bryos which had attained a development corresponding 
to that usually reached only at the third day; on the 
other hand, a reduction to 30° C. retarded development 
fully one-half. Variations in the form and development 
of the germinal, and especially the vascular, area seem 
frequent accompaniments to these thermal changes. A 
continuous slight elevation above the normal temperature 
hastens development but retards growth, and often re- 
sults in the production of dwarfs. Out of seventy-eight 
eggs incubated at a reduced temperature, Richter44 ob- 
tained five malformations, three spinae bifidae with exen- 
cephalus, and two exencephali alone. 
Modifications in the amount of oxygen having access 
to the egg have been carefully studied by a number of 
experimenters. While the effect of an abnormally abun- 
dant supply of oxygen must be regarded as still unde- 
termined, the deleterious influences of a diminished 
supply are conclusively established. In the experiments 
affecting the respiratory interchange of gases, advantage 
has usually been taken of the fact that through the po- 
rous egg-shell the air gains access to the ovum. Various 
devices for rendering the shell more or less impervious to 
gases have been employed, the favorite method being the 
application of varnish. Dareste has called attention to 
the precaution of coating freshly-laid eggs, since after 
the formation of the air-space the contained oxygen suf- 
fices for development for a certain length of time. The 
elaborate experiments of this author confirmed the in- 
vestigations of the earlier observers as to the efficiency of 
these methods of influencing development, especially" the 
587 Malformations. 
Malt. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
development of the vascular area and the blood-corpus- 
cles, thereby establishing an anaemic condition. Dareste 
concluded, moreover, that the restricted supply of air 
bore no direct relation to the malformations. 
The methods adopted by Gerlach in his experimental 
investigations are of especial interest from the fact that 
the results are more nearly positive than those of any 
former experimenter. Recognizing that the growth and 
proliferation of cells are always influenced by the supply 
of oxygen, Gerlach assumed that by restricting the inter- 
change of gases to a V- or Y-shaped area, so placed that 
it would correspond to the anterior part of the germinal 
area, it might be possible to alter the arrangement of the 
cells', by compelling a new disposition in their search 
after oxygen, to the extent of producing an anterior bi- 
furcation. Of sixty eggs so treated, nineteen exhibited 
variations which Gerlach attributed directly to the modi- 
fied conditions of respiration. Of these deviations, two 
were unmistakable anterior duplications. It is to be re- 
membered, however, that such malformations probably 
occur, under ordinary conditions, more frequently than 
supposed, and the direct causal relation between the two 
fissions and the especial treatment of the eggs is by no 
means beyond question. 
Gerlach and Koch,45 and later Koch,46 studied the con- 
nection between restriction of air and the production of 
dwarfs, but they conclude that the retarded growth con- 
sequent upon such conditions results not in true dwarfs, 
but only in poorly developed embryos. 
Review of the foregoing experiments in the artificial 
production of malformations emphasizes the fact that 
certain disturbing influences, as violent agitation, marked 
thermic variations, and restricted supply of oxygen, are 
all forces capable of profoundly impressing the early 
embryonic cell-mass, and of secondarily inducing more 
or less conspicuous malformations. And further, as 
pointed out by Dareste, and more recently emphasized 
by Windle,41 that there is no definite relation between the 
nature of the disturbing influence and the character of 
the resulting malformation, the same anomalies being 
produced by various methods. On the other hand, not- 
withstanding a wide variation in the nature of the dis- 
turbing agents, the deviations of development are largely 
those referable to impaired nutrition, as expressed by the 
defective development of the vascular system. 
Whatever may be the success of future investigators in 
producing at will certain types of malformations, it must 
be admitted that at present, at least, experimental tera- 
tology is capable of yielding results which are suggestive 
rather than definite. George A. Piersol. 
(SUPPLEMENT.) 
22 Ackermann : Die SchMeklifformitat bei der Encephalocele congen- 
ita. Halle, lb82. 
3'Quicken: Zur Genese der Hemicephalie. Halle, 1885. 
1811 ^lllCSte ' formation de la cyclopie, Ann. d'Oculistique, 
28 Gerlach : Die Enstehungsweise derDoppelmissbild. d. hbheren Wir- 
belth. 1882. 
36 Debierre : La theorie de la monstruosite double, Arch, de Physiol, 
norm, et patholog., 1890. 
27 Klaussner : Mehrfachbildungen bei Wirbelthieren. Miinchen, 
1890. 
28 Charpentier: Wood's Cyclopaedia of Obstet. and Gynaec., vol. iii„ 
p. 327. Figured also in article " Teratology " in this Handbook. 
29 Pott : Ein Beitrag zu den symmet. Missbild. d. Finger u. Zehen, 
Jahrbuch f. Kinderheilk. Bd. xxi., 1884. 
30 Schultze, O.: Ueber die erste Anluge des Milchdrtisenapparates, 
Anat. Anzeiger, Bd. vii., 1892. 
31 Bardeleben : Hypertheile bei Mannern, Verhand. d. anatom. Ge- 
sellschaft, 1892. 
32 Born : Ueber die Furchung des Eies bei Doppelbiklungen, Breslauer 
arzl. Zeitschrift, 1887. 
38 Fol: Sur le commencement de l'henog6nie chez divers animaux, 
Archiv. d. sci. phys. et anat. de la bibl. univ. Revue Suisse, tome Iviii., 
1878. 
34 Hertwig, O. und R. : Ueber die Befrucht. u. Theil. d. thiersch. 
Eies unter dem Einfluss ausser Reagentien. Jena, 1887. 
35 Windle : On the Origin of Double Monstrosity, Journal of Anatomy 
and Physiology, vol. xxiii., 1889. 
36 Dareste : Nouvelles recherches sur le mode de formation des mon- 
stres doubles, Coinpt. rend., tom. civ., 1887. 
37 Liharzik : Das Gesetz des mensch. Wachsthums, u.s.w. Wien, 1858. 
38 Dareste : Production artiticielle des monstruosites. Paris, 1876. 
32 Strahl und Gasser: Ueber kiinstliche Production von Situs in- 
versus beim Vogel, Anatom. Anzeiger. 1888. 
40 Schrohe : Untersuch. iib. d. F.influ,ss median. Verletzungen auf d. 
Entwick. d. Embryo. Giessen, 1862. 
41 Driesch : Entwickelungsmechanisches, Anatom. Anzeiger, Bd, vii., 
1892. 
43 Wilson, E. B.: Artificial Production of Twins and Multiple Embryos 
in Amphioxus, Proc. New York Acad, of Sciences, October. 1892. 
43 Gerlach : Ueber die Entstehungsweise d. vordern Verdopplung, 
Deutsch. Archiv f. klin. Med., Bd. xlii., 1887. 
44 Richter : Ueber die experiment. Darstell. der Spina Bifida, Anatom. 
Anzeiger, 1888. 
45 Gerlach und Koch : Ueber die Production von Zwergbildung in Hiih- 
nerei auf experiment. Wege, Biolog. Centralblatt, 1883. 
43 Koch, H.: Ueber die kiinstliche Herstell. von Zwergbildungen im 
Hiihnerei, Inaug. Diss.. Erlangen, 1884. 
47 Windle: Investigations in Artificial Teratology, Proc, of Birming- 
ham Philosoph. Society, vol, vii., pt. ii., 1890. 
MALT (Maltum, U. S. Ph., 1880). The official direc- 
tions given in the United States Pharmacopoeia for the 
preparation of this product are as follows : 
"Malt, in coarse powder, not liner than No. 12, one 
hundred (100 )parts ; water, a sufficient quantity. Upon 
the powder, contained in a suitable vessel, pour one hun- 
dred (100) parts of water and macerate for six hours. 
Then add four hundred (400) parts of water, heated to 
about 30° C. (86° F.), and digest for an hour at a tem- 
perature not exceeding 55° C. (131° F.). Strain the mixt- 
ure with strong expression. Finally, by means of a 
water-bath, or vacuum-apparatus, at a temperature not 
exceeding 55° C. (131° F.), evaporate the strained liquid 
rapidly to the consistence of thick honey. Keep the 
product in well-corked vessels in a cool place." 
The historical references, detailed description of the 
processes of manufacture and peculiarities of the finished 
product, as given by Professor Bolles (Reference Hand- 
book of the Medical Sciences, Vol. IV., 1887, p. 637), 
are sufficiently full for our present purpose, and need not 
therefore be touched upon. The almost universal em- 
ployment of malt preparations, especially liquid malt- 
extracts, by physicians and by the laity, however, seems 
to warrant a critical study of their value from a thera- 
peutic standpoint. This naturally implies an investiga- 
tion of the composition of malt, its properties as a food- 
substance from a physiological point of view, and finally, 
an estimate of its virtues alone, or combined with other 
medicaments, in the treatment of disease. And, inasmuch 
as there is a popular demand for these products, some 
reference should also be made to adulteration, and the 
addition of foreign substances-principally antiseptics, to 
prevent fermentation. 
Composition.-The manufacture of malt consists es- 
sentially of four different processes, viz. : Steeping, 
couching, flooring, and kiln-drying, which result in de- 
creasing the weight of the grain (about 20 per cent.), 
but are attended with an increase in bulk (3 to 8 per cent.). 
The entire manipulation should be considered as succes- 
1 Beach : A Giant Birth-the Child Weighing Twenty-three and three- 
quarter Pounds, Medical Record, March 22, 1879. 
2 Kollmann : Die Kiirperform mensch. normal, u. patholog. Embry- 
onen, Archiv f. Anat. u. Entwick., 1889, Sup. Bd. 
3His: Anatomie mensch. Embryonen, Theil ii., pp. 99, 1882. 
4 His : Offeue Fragen der path. Embryologie, Festschrift Rudolph 
Virchow, 1891. 
8 Claudius : Die Entwick. d. herzlosen Missgeburten, Kiel, 1859. 
3 Ahlfeld : Die Missbildungen des Menschen, 1880-82. 
7 Koch, G. W. : Ueber einen mensch. Acardiacus, Archiv f. Gynakol., 
Bd. xxvi., 1885. 
8 Dareste : Production artiticielle des monstruosites. Paris, 1876. 
9 Panum : Beitrag zur Kenntniss d. physiol. Bedeutung d. angebor. 
Missbildungen, Virchow's Archiv, 1878. 
10 Peris : Lehrbuch d. allgem. Pathologic, Theil ii., 1879. 
11 Breus: Zur Lehre von den Acardiacis, Wiener med. Jahrbiicher, 
1882. 
12 Cleland: On Birds with Supernumerary Legs, and on Abcaudal Fission 
and Acephalus, Memoirs and Memoranda in Anatomy. London, 1889. 
13Gebhard: Ein Beitrag zur Anatomie der Sirenbildung, Archiv f. 
Anat. u. Phys., 1888. 
14 His : Mittheilungen zur Embryol. d. Saugeth. u. des Menschen, Ar- 
chiv f. Anat. u. Phys., 1881. 
16 Sutton : Brachial Fistula, Cysts, Diverticula, and Supernumerary Au- 
ricles, Journal of Anatomy and Physiology, vol. xxi.. 1887. 
13 Sutton : Evolution and Disease. New York. 1890. 
17 Marsh all: The Thyro-glossal Duct, or "Canal of His," Journal of 
Anatomy and Physiology, vol. xxvi., 1891. 
18 Kostanecki und Mielecki: Die Angebor. Kiemenfisteln d. Menschen, 
Virchow's Archiv, Bd. 120 u. 121, 1890. 
19 Kanthack : The Thyro-glossal Duct, Journal of Anatomy and Phy- 
siology, vol. xxv. 
20 Kanthack : Complete Cervical Fistulas, Journal of Anatomy and 
Physiology, vol. xxvi. 
21 Richter: Ueber die experimentelle Darstell. d. Spina Bifida, 
Anatom. Anzeiger, 1888. 
588 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Malformations. 
Malt. 
sive steps of the same operation, since the malt contains, 
in somewhat altered arrangement, the substances found 
in the grain ; malting merely effects the transformation 
of these substances, through the influence of heat, moist- 
ure and the amylolytic action of diastase, an unformed 
ferment (enzyme) which is a constituent of malt to the 
extent of from one to two per cent. (Hagar). Through 
the action of diastase-manifested within an hour after 
grain is put to steep-whose properties are similar to that 
of ptyalin from the saliva and amylopsin from the pan- 
creas, the insoluble starch of barley is converted into 
dextrin and glucose - sometimes called grape-sugar. 
Thus, the outline of Proust (loo. cit.) shows that malt 
contains nineteen per cent, less starch and cellulose than 
barley, ten per cent, more sugar, eleven per cent, more 
dextrin, while the amount of gluten is lessened by two 
per cent. It should be stated in this connection that, 
while the object of " malting" is to produce the maxi- 
mum of sugar by the action of diastase, it is not desirable 
that this action should be entirely exhausted, and there- 
fore, at a certain stage of the operation, this process is 
arrested by kiln-drying; under favorable circumstances 
-heat and moisture-this fermentation is re-kindled. 
Qualitative tests for diastatic activity are extremely 
simple. A quantity of malt is added to hot water and 
dissolved by constant stirring ; then a small portion of 
starch is added in like manner, and in the course of a few 
minutes the iodine test is applied. 
The soluble extract in a good malt suitable for brewers' 
use, is, according to Ure, 66.8 per cent. ; it contains in 
addition, insoluble matter, 26.7, and moisture, 6.5 per 
cent. To determine the proportion of insoluble matter, 
a definite quantity is measured by weight and dried by 
heat from boiling water ; the remaining powder is then 
put in cold water and heated. The soluble extract is 
then decanted off and the residue dried and weighed and 
the percentage calculated. 
The process of diastatic fermentation is by hydration 
(Hoppe-Seyler), as will appear later on. The amylolytic 
power of diastase is about the same as the proteolytic 
power of a good pepsin ; that is, diastase will convert 
starch into glucose in the proportion of 1 to 2,000, while 
pepsin converts albumin into peptone in the same pro- 
portion, although recent improvements in the manufac- 
ture of pepsin enable manufacturers to produce a much 
more concentrated article (I to 6,000). 
Liquid malt-extracts are simply weak solutions of ordi- 
nary malt, very much like beer, and usually contain a 
variable proportion of alcohol, a small percentage of 
carbonic acid, with more or less solid extract, but for 
none of them can be claimed any distinct diastatic prop- 
erty. These preparations hold in solution the products 
of diastatic activity, dextrin and sugar, which renders 
them " sweet" and palatable, while the alcohol is not in 
sufficient amount to interfere materially with the proper 
performance of the digestive functions; indeed, in the 
case of elderly persons, it may prove a decided benefit. 
Carbonic acid is also acceptable to the stomach ; but the 
percentage of " solid extracts " in these products furnishes 
no criterion as to their intrinsic value, as will be shown 
presently. 
From an examination and analysis of thirteen different 
samples of liquid malt-extracts, Leffmann (Medical News, 
January 28, 1893) found that all save one contained 
alcohol in small proportion-none as high as eight per 
cent., and that the solid extract ranged from 5.1 grammes 
to 16.06 grammes for each 100 c.c. Moreover, three of 
the samples contained appreciable amounts of salicylic 
acid. 
Adulteration.-The temptation to sophisticate malt 
arises from the great care required in the process of 
malting ; if the diastatic power be destroyed by excessive 
heat, the malt possesses no nutritive or digestive value. 
Again, in sections of the country where malting is 
extensively carried on, manufacturers may employ 
"ungerminated" grain, i. e., grain that has been sub- 
jected to " heating," and has thus lost its vitality. As 
a result of wet seasons, therefore, malt may be of a 
very inferior quality - possessing but slight diastatic 
(SUPPLEMENT.) 
power, yet showing a large percentage of insoluble 
matter. 
Most serious objections are urged against the employ- 
ment of salicylic acid as an antiseptic, since it is harmful 
if taken in too large quantities or too long continued, and 
besides, like all other antiseptics, it arrests or suspends 
diastatic activity. Now, while this is true in general, it 
may not apply uniformly to malt-takers and beer-drinkers, 
because we know that even in the absence of diastatic 
power this class generally present a rotund, florid, some- 
times a bloated appearance-due to the deposit of fat 
from the absorption of sugar-and frequently suffer from 
rheumatic affections ; hence the introduction of salicylic 
acid free from impurities may possess negative value, (1) 
by enacting the role of an antiseptic in the alimentary ca- 
nal, (2) by lessening the diastatic activity, thereby prevent- 
ing the rapid conversion of starch, and (3) by its influence 
upon the rheumatic diathesis. This leaves, then, for the 
liquid malt-extracts containing salicylic acid, nothing of 
special value except the converted sugar and a small pro- 
portion of alcohol. 
Incompatibles.-The following table (after Hermann 
Meyer and Brunton) is introduced to show the strength 
in watery solution of the different drugs which arrest the 
action of diastase, from which it will be observed that, 
while chloroform and creasote, even in saturated solution, 
have very little or no deleterious effect, corrosive subli- 
mate in a solution so weak as 1 to 50,000 destroys the fer- 
ment. Thus salicylic acid in the proportion of one grain 
to ten ounces (approximately) is sufficient to arrest the 
action of diastase : 
Alcohol. 1 to 3. Corrosive sublimate, 1 to 50,000. 
Benzoate of soda, 1 to 100. Creasote, no action in sat. sol. 
Benzoic acid, 1 to 1,025. Eucalyptus oil, acted only in ex- 
Borax, 1 to 100. cess. 
Bromine, 1 to 5,070. Glycerine, 1 to 2. 
Carbolic acid, 1 to 30. Iodine, 1 to 4,125. 
Chloride of lime, 1 to 6,613. Mustard oil, only lessens action 
Chlorine, 1 to 7,411. in sat. sol. 
Chloroform, slight action in sat. Salicylic acid, 1 to 5.100. 
sol. Sulphurous acid, 1 to 8,600. 
Copper sulphate, 1 to 6.500. Thymol, slight action in sat. sol. 
Physiological Action.-From the preceding remarks 
it will be apparent that there is comparatively little to add 
in regard to the physiological action of malt, either from 
the standpoint of the clinician or from that of the physi- 
ologist ; and yet that little is of paramount importance. 
Malt performs a twofold action in that it is a digestive 
and nutrient, its virtues being augmented by hydration. 
Digestibility is the prime element in all food-stuffs, but 
concentration may seriously interfere with absorption ; 
hence the importance of dilution by water, which is the 
most efficient medium for the transmission of pabulum 
through the secreting structures of the alimentary tract 
(endosmosis). Thus, while concentration is an impor- 
tant factor entering into questions relating to the manu- 
facture and transportation of food products, the very 
opposite is essential to insure rapid absorption and easy 
assimilation. But the increased consumption of carbohy- 
drates, while it increases the amount of fat, is at the ex- 
pense of muscular structures which require nitrogenous 
material for the maintenance of their integrity, and 
therefore, too much dependence must not be placed 
upon the apparent gain secured by the administration of 
malt and predigested foods of this character. Indica- 
tions of their unfavorable effects will be manifested by 
acidity, hepatic and cardiac derangements, and constipa- 
tion, along with mental hebetude and other evidences of 
imperfect metabolism. 
Contra-indications to the employment of malt prepara- 
tions in the treatment of children's diseases, more especial- 
ly those peculiar to summer and autumn, should be no- 
ticed, viz.: evidences of fermentation in the stools. 
When this condition is present, carbohydrates must be 
omitted and nitrogenous food substituted. 
The dangers arising from the small percentage of alco- 
hol in the liquid malt-extracts have been unduly magnified, 
as we have ample evidence of its value as a reconstructive. 
In suitable amounts-with meals-alcohol improves the 
589 malt. 
Massage. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
appetite, favors digestion, lessens the elimination of phos- 
phorus and promotes the excretion of urea, thus en- 
hancing muscular capacity ; but we must bear in mind, 
also, that alcohol lessens oxidation-a conservative process 
in certain wasting diseases-although an effect to be 
avoided in health. Its obtunding influence upon the 
nervous system is likewise of medicinal importance, and 
in the administration of malt preparations we should 
never lose sight of the physiological functions of the 
organism, our sole object being to restore and maintain 
its integrity by the exhibition of remedies adapted to its 
wants. 
There is still another important factor to be considered 
in connection with the physiological functions of malt. 
For example, a considerable percentage of cod-liver oil 
can be incorporated with it in such a manner that the 
compound is tolerably stable while freely miscible with 
water, and, therefore, readily assimilable by the digestive 
apparatus. Now, bearing in mind that malt contains 
more or less gluten, perhaps a little dextrin, together with 
some unconverted starch and insoluble extract, it is not 
unreasonable to believe that under normal conditions the 
contents of the intestine may approach the type of a mu- 
cilaginous substance, possessing cohesive properties, and 
whose viscosity will prove of value in preventing the ab- 
sorption of poisonous products from the alimentary 
tract. Physicians readily appreciate the value of starch 
enemata in irritable conditions of the lower bowel, al- 
though but few understand the modus operandi by which 
these benefits are secured. Starch enemata are of ser- 
vice, not merely because they have a quieting effect upon 
the terminal filaments of sensory nerves in the mucous 
structures, but rather on account of their adhesive quali- 
ties, which enable them to lay hold of poisonous sub- 
stances in the course of elimination, thus preventing 
them from coming into contact with the delicate and in- 
flamed tissues. While the old idea has long been accepted 
as a clinical fact, it was nothing more than a temporary 
hypothesis or make-shift, and is promptly set aside to 
make room for the scientific fact upon which it depends. 
And just here should be pointed out the marked simi- 
larity or analogy between the conditions which obtain in 
the small intestine when malt is administered and that of 
the lower bowel when a starch enema is introduced. 
This explanation not only sheds new light upon the inci- 
dental physiological action of malt, but it puts the entire 
theory of the therapeutic action of emulsions upon a sci- 
entific basis, in keeping with the results of clinical obser- 
vation, Heretofore the causes which were actually 
responsible for the wonderful improvement following 
the exhibition of comparatively small quantities of malt, 
cod-liver and petroleum oils, as well as other remedies in 
the form of emulsion, have been scarcely realized, be- 
cause the physiological functions of the emulsionizing 
agents were overlooked, or but imperfectly understood. 
Notwithstanding the fact of its being a negative virtue, 
it is, nevertheless, a factor of material significance. 
Therapy.-The most important therapeutic applica- 
tion of malt consists in its employment for the relief of 
intestinal affections dependent upon imperfect intestinal 
digestion of starchy foods and subsequent fermentation. 
In this class of cases the carbohydrates should be re- 
stricted, bread only being allowed, and the patient in- 
structed to masticate it thoroughly in order to incorporate 
with it the ptyalin of the saliva, which serves to break 
up the starch granules before entering the stomach. Oc- 
casionally amylopsin may be added with benefit. This 
method of treatment will be found available in a very 
large number of cases of intestinal indigestion associated 
with chronic disease, especially pulmonary affections, be- 
cause, as has already been shown, carbohydrates are fat- 
producers. They do not, however, increase the capacity 
of the muscular system, and may, therefore, do harm by 
lessening oxidation and obstructing elimination. Short- 
ness of breath, cardiac weakness, or hepatic insufficiency 
with acidity of the stomach and diminished urinary ex- 
cretion demand their prompt discontinuance and a com- 
plete re-arrangement of the dietary. 
Malt enjoys deserved popularity as an adjuvant in 
convalescence from protracted illness, as an auxiliary and 
digestive in the case of nursing women, and to a limited 
extent in the treatment of all debilitated conditions of the 
system, but its continuous or indiscriminate use will 
eventually result disastrously. Like all other remedial 
agents, its medicinal employment requires the discrimi- 
nating judgment of the conscientious and intelligent 
physician. 
In the treatment of summer diseases, in both adults and 
children, malt possesses a high degree of utility, but it is 
only adapted to the cases in which the stools are putrid 
and foul-smelling. Where the stools are sour-smelling, 
due to starchy fermentation, malt and malted products 
are of secondary importance, as they have no influence 
upon the micro-organisms or other poisons associated 
with the intestinal disorder. Indeed, there is good reason 
to believe that the popular method of treating this class of 
affections by the exhibition of "barley-water''' has been 
productive of greater mortality rates than would have 
occurred had all treatment been abandoned. Science ab- 
solutely condemns the practice, and clinical observation 
emphatically indorses her teachings. The personal ex- 
perience of Dr. Benjamin Ward Richardson, published 
in the ^Esclepiad about a year ago, covering the untoward 
effects of oatmeal and barley-water, should be critically 
studied by every general practitioner. 
Administration.-Malt (U. S. Ph.) may be given in 
doses of one or two drachms, either with meals or two 
hours later. Liquid inalt-extract should be given with 
meals-one or two wineglassfuls. 
To meet special demands in the case of malnutrition, 
malt may be combined with a number of reconstructive 
medicaments, as follows: Malt with quinine, iron, and 
strychnine ; malt with hypophosphites ; malt with pep- 
tone; malt with cod-liver oil-but not to exceed the 
proportion of ten per cent. John Aulde. 
MALVERN. A spa of ancient repute in Worcester- 
shire, England. 
Location.-Malvern is prettily situated in a beautiful 
part of Worcestershire, at an elevation of five hundred 
and twenty feet above the sea. Bradshaw says that the 
town of Malvern is beautifully situated on the slopes of 
the Malvern Hills, which rise to the height of fifteen 
hundred feet above the sea-level. These hills are tra- 
versed by roads and paths easy of ascent. From their 
summit a succession of the grandest and most picturesque 
views in the United Kingdom, embracing twelve different 
counties, can be obtained. 
The town consists of Great and Little Malvern, which 
are about three miles apart. The picturesqueness of the 
site and surroundings of Malvern have been celebrated 
in prose and verse by Byron, Walpole, Southey, Brown- 
ing, and Macaulay. 
The Malvern air is dry and bracing, the climate tonic 
and stimulating, and the temperature equable. The 
drinking-water is of absolute purity and softness. The 
death-rate is low, being only 18.85 per 1,000. The sani- 
tary arrangements are based on the best scientific prin- 
ciples. Over fifty thousand persons visit this spa during 
the season, which lasts from May to October. 
Access.-Malvern is one hundred and twenty-nine 
miles from London, and can be reached in about three 
hours by rail. 
Analysis.-The Malvern waters are faintly alkaline 
and earthy. Its brine baths are famous. The two 
springs of Malvern are St. Anne's and the Holy Well. 
Indications.-The waters and saline baths of Malvern 
find their chief employment in cases of rheumatic gout 
and rheumatism, and their various sequelte and compli- 
cations ; also in scrofulous disorders, neuralgia, sciatica, 
lumbago, etc. ; swellings of the joints, contractions and 
anchylosis, paralysis, morbus Brightii, bronchial affec- 
tions and chest complaints, skin diseases, old wounds, 
and ulcerations. Edmund C. Wendt. 
MARGATE. One of the best known and most popular 
seaside resorts in England. Margate was once fashion- 
able, but Ramsgate has outstripped this city by the sea in 
590 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Halt. 
Massage. 
that particular. Margate is in Kent. It begins in a valley 
and stretches up the slope of a hill. It has a famous 
pier, and in many other respects resembles our own 
Coney Island. Though quite open and exposed to try- 
ing winds, Margate is a healthy place, and the air there 
is remarkably keen and bracing. The famous Clifton 
baths, formed out of a cliff, are one of the main attractions 
of the beach, which is a fine sandy one. Margate is only 
two hours by rail from London, and about four hours by 
river steamer. Dr. Yeo speaks of Margate as follows 
(" Climate and Health Resorts") : 
''Although often associated in men's minds with the 
neighboring resorts on the south coast, it must not be for- 
gotten, in estimating the special qualities of the climate 
of Margate, that its aspect is not to the south, nor to the 
east, but to the north or northeast. Whoever will take 
the trouble to look at a map of this part of the coast of 
the Isle of Thanet will see that Margate has a decidedly 
northerly or northeasterly aspect. In this respect it dif- 
fers entirely from the neighboring coast town of Rams- 
gate, which is so placed in an indentation of the coast- 
line as to look southeast. From this difference of aspect 
it not infrequently happens that the local weather differs 
considerably in these two places, only a few miles apart, 
for a storm may be raging at Margate which is scarcely 
felt at Ramsgate. It happens also from this northerly or 
northeastely aspect of Margate that during the prevalence 
of the northeasterly winds of spring it is one of the very 
few conveniently accessible seaside resorts where, during 
that season, pure sea-air can be obtained. For the pre- 
vailing northeast winds blow directly over the North 
Sea and the northern portion of the British Channel on 
to Margate and the line of coast of which it forms a part, 
whereas during the same season the prevailing winds at 
the resorts on the southern coast are land winds and blow' 
off the land out to sea, driving off, as it were, the sea air 
-hence, I take it, the great value which Margate air is 
known to possess in scrofulous affections. 
" It has a chalk subsoil, and the ground quickly be- 
comes dry after rain. The water supply is abundant and 
pure. 
" The best residential part of the town is on the Cliff, 
where the Cliftonville Hotel stands ; but the cheaper 
hotels and lodging-houses are on the lower ground, near 
the harbor and pier. 
" The drainage of the higher ground is better than 
that of the lower level, which is not all that could be 
wished. 
" Margate is too windy for cases of chest disease, ex- 
cept in the summer months, but it is especially beneficial 
to cases of scrofulous disease in children and to those of 
convalescence after surgical operations. This fact has 
led to the establishment there of that excellent institu- 
tion, ' The Royal Sea-bathing Infirmary, or Royal Na- 
tional Hospital for Scrofula.' 
" The air of Margate is excellent for promoting the 
progress of slowly healing wounds and ulcers, and it is 
valuable in cases of debility from inherited feebleness of 
constitution. It is also said, from its dryness, to be good 
for rheumatism. 
" Its autumn climate is often very fine. In November, 
when London is foggy and the country damp, Margate 
rejoices in a clear, bright, and dry atmosphere. 
''Margate is celebrated for its sands, which are very 
extensive, owing to the shallowness of the water. They 
are therefore the delight of children and those who do 
not care for a plunge into the deeper sea." 
Edmund C. Wendt. 
MARTIGNY-LES-BAINS. A spa in the Vosges Moun- 
tains, France, which has recently acquired an excellent 
reputation. 
Location.-Martigny is a village situated in a pleas- 
ant valley surrounded by wooded slopes. It is not far 
from the spas of Contrexeville, Bourbonne-les-Bains, and 
Vittel. Although its growing reputation as a watering- 
place is of recent origin, the place itself is said to date 
back to the times of the Druids, and there are seen to 
this day remains of undoubted Celtic origin. 
The two principal springs of Martigny supply a cha- 
lybeate water rich in lithia. The waters are cold, clear, 
and slightly astringent to the taste. The climate is pleas- 
ant and bracing. 
Access.-Martigny-les-Bains (not to be confounded 
with Martigny in Switzerland) is a station on the Eastern 
Railway of France. It lies on the road from Contrexe- 
ville to Bourbonne-les-Bains. 
Analysis.-According to Wilm, one thousand parts 
contain : 
Parts. 
Bicai bonates of lime, of magnesia, and of iron 0.3918 
Sulphates of lime, of magnesia, and of lithia 0.8641 
Chloride of magnesium 0.0071 
Silicates of magnesia, of soda, and of potash 0.1383 
Silica 0.0018 
Organic matter and loss 0.0250 
Total 2.3281 
The more complete analysis of M. Jacquemin is as 
follows : One thousand parts contain : 
Source Source 
No. I. No. II. 
Parts. Parts. 
Bicarbonate of soda 0.0160 0.0120 
Bicarbonate of magnesia 0.1750 0.1800 
Bicarbonate of lime 0.1620 0.1580 
Bicarbonate of lithia 0.0320 0.0190 
Bicarbonate of iron 0.0090 0.0310 
Sulphate of soda 0.2290 0.2360 
Sulphate of magnesia 0.3300 0.3340 
Sulphate of lime 1.4240 1.4400 
Chloride of sodium 0.0950 0.1050 
Chloride of potassium 0.0120 0.01'40 
Phosphate of lime 0.0028 0.0019 
Silicate of soda 0.0532 0.0456 
Silicate of lime 0.0029 0.0014 
Fluorine, arseniate of lime, borates of 
soda, of manganese, of alumina traces traces 
Organic matter 0.1141 0.0681 
Totals 2.6570 2.6400 
According to Mr. Wolff (" The Watering-places of the 
Vosges") there is now a large new hotel with good ap- 
pointments, which includes the thermal establishment. 
But although baths are much used " the main use of the 
water is for drinking. The hours are the same as at 
Contrexeville and Vittel, and so is the number of glasses 
taken, generally from eight to ten. There are grounds 
adjoining, covering something like twenty-five acres, 
and very prettily laid out. One very useful feature is 
the large covered Promenoir, in which are housed the 
two springs, and which affords shelter alike for walking 
after drinking, and for pretty free exercise in wet 
weather." 
The older chalybeate spring is not much used now, 
and lies outside of the village. 
Indications.-The lithia springs of Martigny are em- 
ployed for the relief of gout, gravel, diseases of the blad- 
der' hepatic congestion, and the various manifestations 
of the uric-acid diathesis. But dyspepsia, anaemia, and 
chlorosis, gastralgia, diabetes, and some forms of rheu- 
matism and neuralgia are also said to be treated with 
advantage there. Those in search of a quiet watering- 
place, devoid of all the excitements of fashionable spa 
life, will find comforts that they will appreciate, amid 
surroundings that are interesting and agreeable at Mar- 
tigny. 
Accommodation.-In addition to the large modern 
hotel already mentioned there are a number of unpre- 
tentious establishments, with fairly neat and clean rooms 
and a modest bill of fare at decidedly reasonable rates. 
Edmund C. Wendt. 
MASSAGE. Physiological.-Experience has taught 
us that massage is a powerful tonic to the muscular sys- 
tem. But Professor Maggiora, of the University of 
Turin, has recently demonstrated this much more fully 
by a series of careful and pretty experiments, showing 
the rapidly restorative effects of massage upon muscles 
weakened'from various causes (Archives Italiennes de 
Biologic, tome xvi., 1891). 
591 Massage. 
Massage. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
1. The action of massage upon muscles in a state of 
repose was first studied. For this purpose the fatigue 
curves of the right and left middle fingers in voluntary 
flexion with a weight of three kilos (6.6 pounds) every two 
seconds were taken at 8 and 11 a.m., at 2 and 5 p.m. , and 
the following day the fatigue curves of the same mus- 
cles, with the same weight and rhythm, were taken at 
the same times of day after massage for three minutes.* 
The average result showed that the muscles did almost 
twice as much work after massage as they did before. 
The average for the left middle finger was 4,252 kilos 
without massage ; after massage, 8,019 kilos before ex- 
treme fatigue prevented further contractions. The right 
medius behaved similarly. Another series of experi- 
ments was made in which the same muscles were fa- 
tigued by the electric current applied to them or to the 
median nerve, and the same results were obtained as in 
the previous experiments, and showed that it takes much 
longer to fatigue muscles by electrical irritation after 
massage than before. 
2. The next experiments were undertaken in order to 
ascertain whether the beneficial effects of mixed massage 
(friction, percussion, and kneading) increased in propor- 
tion to its duration. At 8 a.m. the normal fatigue curves 
were taken, then every two and a quarter hours after 
this they were also taken, having been preceded by two, 
five, ten, and fifteen minutes of massage of the right and 
left middle fingers. Ten tracings were thus obtained, and 
the result showed that five minutes of massage produced 
almost all the useful effect possible. When the massage 
was continued longer, for ten and fifteen minutes there 
were slight variations in the amount of work shown, 
above and below that after five minutes. The same re- 
sults were obtained when electrical irritations were used 
to fatigue the muscles or applied through the median 
nerve. 
3. The third series of experiments were employed 
with a view to determine the effects of the main proced- 
ures of massage-friction, percussion, and petrissage. 
The methods were as before : first the normal fatigue 
curve was taken, then every two hours during the day 
fatigue tracings were taken after five minutes of friction, 
after five minutes of percussion, and after five minutes 
of petrissage or kneading, and finally after five minutes 
of these three manoeuvres alternating. There was little 
difference in the amount of work that could be done 
after five minutes of friction as compared with that after 
five minutes of percussion. There was a great increase 
in the force and duration of the contractions after 
petrissage, but the best effects were obtained after an 
alternation of all three. Like results followed when the 
contractions were produced by electricity, and these three 
procedures of massage employed separately and alter- 
nately. 
4. The effect of massage upon muscles weakened by 
fasting was such as to restore them temporarily to a nor- 
mal condition, so that they gave tracings of fatigue 
equal to normal tracingsnot preceded by fasting. The 
same result followed when the electrical current was ap- 
plied either directly to the muscles or to the nerve sup- 
plying them in place of voluntary contractions. 
5. The effect of massage upon muscles fatigued in an 
indirect manner, or as the result of general fatigue, was 
also studied. After a walk of ten miles, Professor Mag- 
giora took tracings of voluntary flexion of his right and 
left middle fingers. The amount of work of which they 
were capable was only about one-fourth of what they 
could do when there was no general fatigue. After 
massage for ten minutes they did nearly a normal 
amount of work, which, of course, was temporary. It 
has been found that the muscles of the fingers, fatigued 
in the manner mentioned by Professor Maggiora, by con- 
tractions with three kilos every two seconds, required 
two hours' rest in order that they might produce normal 
tracings of fatigue. (The massage was applied in this in- 
stance half an hour after the fatigue tracing was taken, 
so that making allowance for this extra work the infer- 
ence would be fair that ten minutes of massage brought 
about more recuperation than two hours of rest. When 
there was no general fatigue, five minutes of massage to 
the finger would then equal two hours of rest, as in the 
other experiments.-D. G.) 
6. After the loss of a night's sleep the fatigue curve 
was found to be very small, about one-fourth normal, 
but after ten minutes of massage it was temporarily re- 
stored to a natural curve, a result that was not obtained 
by nourishment nor by nerve tonics. In fatigue of mus- 
cles from fasting, rest alone will not restore them, and in 
muscular fatigue from wakefulness, food alone affords 
no appreciable relief. 
7. The effect of massage upon muscles weakened by 
excessive intellectual work was also noted. After the 
final examination of twenty students, which took five 
hours, Professor Maggiora was much exhausted, and then 
took fatigue tracings of both middle fingers. These 
represented only one-fifth of a normal amount of work. 
Half an hour later, after ten minutes of massage, the 
amount of work was little less than natural, and proba- 
bly would have been natural but for the extra work half 
an hour before. 
8. After a slight attack of fever of ten hours' duration, 
the muscles were weak the whole of the following day. 
The influence of massage upon the flexors of the fingers 
increased their aptitude for work so that they gave a 
tracing of fatigue nearly normal. 
9. Professor Maggiora showed that aneemia of a few 
minutes produced phenomena in muscles similar to fa- 
tigue. His brachial artery was compressed for three 
minutes, and a fatigue tracing was taken and found to 
be very small. Two hours later the brachial artery was 
again compressed for three minutes, and at the same 
time the forearm was subjected to mixed massage. Then 
another tracing was taken while the anaemia was kept 
up, and it was less than the previous one, showing that 
massage has no effect upon muscles when their blood- 
supply is shut off. 
In comparing this last experiment with the preceding 
ones, it is evident that the effect of massage consists es- 
sentially in reawakening the phenomena of the local cir- 
culation, in bringing to the muscles a greater quantity of 
material necessary for their contraction, and in removing 
the retrograde products of muscular work. 
Muscular Rheumatism almost invariably yields 
quickly to massage, and the result shows a fivefold in- 
fluence : 1. Thermal : From equalized and increased 
circulation and warmth imparted by the hands of the 
manipulator. 2. Electrical: The muscles contract much 
more vigorously and agreeably to a faradic current after 
massage in these cases than before. 3. Neural : Pain 
disappears, which is brought about by, 4, the mechani- 
cal changes produced by massage, which dispels the 
muscular rigidity and the partial and irregular contrac- 
tions of the muscular fasciculi, breaks up minute adhe- 
sions between muscular fibres, and thus restores flexibil- 
ity and suppleness to the muscles, and removes pressure 
and pulling from terminal nerve filaments. Kiihne has 
shown that the contractile substance of muscle is semi- 
fluid. The pathology of muscular rheumatism coming 
on suddenly is considered by Professor Busch to be a 
partial coagulation of the contractile muscular substance. 
The difference in the firmness of muscles lies not so much 
in the muscular substance as in the fascia that surrounds 
it. Where the fascia is thick the muscles seem hard ; 
where thin, the reverse. Ludwig has shown the fascia 
to be a pump-like arrangement by which lymph is sucked 
out of the muscles and propelled onward into the lym- 
phatics. Between the two layers of fascia are lymph 
spaces terminating in lymphatics. When the muscles 
contract, the inner layer is pressed against the outer and 
forces the fluid onward into the lymphatic vessels. When 
the muscles relax the inner layer falls away from the 
outer, and the lymph finds its way into it. Muscular 
contraction thus favors the removal of waste products. 
When muscles cannot contract without pain, as in mus- 
cular rheumatism, massage will more than make up for 
* The ergograph o£ Professor Morse was used to take the muscular 
curves. 
592 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
massage. 
Massage. 
the loss of contraction. The intermittent pressure of 
massage has been demonstrated to increase the flow of 
lymph in a remarkable manner (see my " Treatise on 
Massage," pp. 72-75). In this connection a very practi- 
cal hint is afforded us by those adhesions of the pleura 
which are frequently loosened by the rubbing together 
of the two membranes in respiration. 5. As to the chem- 
ical influence of massage in muscular rheumatism: It is 
pretty generally conceded that when a muscle or joint is 
impaired from fatigue, cold, injury, or rheumatism in 
the system, a deposit of uric acid takes place at the af- 
fected part. Therefore, when this gets well under mas- 
sage, it may be reasonably inferred that the uric acid, or 
other materies morbi, has been got rid of. Further ob- 
servations in this direction would be desirable. 
I think that massage may be of some value in the diag- 
nosis of doubtful cases of muscular rheumatism from 
neuritis. As ordinarily understood, muscular rheuma- 
tism is distinguished by rigidity of muscle, pain on mo- 
tion, and ease when at rest. The immediate effect of 
massage in such is apt to be painful, but speedy relief 
follows. But there are many cases of what, I think, are 
erroneously called " muscular rheumatism," where the 
patients are much more comfortable when up and mov- 
ing about, in which there is no perceptible muscular ri- 
gidity, but, on the contrary, there may be some flabbiness 
and slight atrophy of muscle, affecting either a single 
group of muscles or the same groups on each side of the 
body, and accompanied with some stiffness of motion, 
and in which pain is much aggravated after the patient 
has been warm and at rest in bed for some hours. In all 
probability these are cases of neuritis of the terminal 
nerve filaments supplying muscle, and the occasional ap- 
pearance of neuritis affecting a distinct nerve-trunk in 
such cases would strengthen such a view. But be they 
what they may, the relief afforded by judicious massage 
is great and immediate, but not so lasting as in the pre- 
vious class of cases. They quickly lose nearly all the 
comfort felt during massage, and it takes long to benefit 
them ; thus in every particular differing from what we 
have hitherto understood by muscular rheumatism. The 
recent epidemics of influenza or grippe left a legacy of 
these neuro-muscular disturbances. 
Pleuritic Effusions.-Ten cases of primary pleuritic 
exudations have been treated with massage of the chest 
by Dr. Poliakow (Wien. Med. Presse). Seven of these 
were purely serous, three sero-fibrinous. The manipu- 
lations were made in the direction of the lymphatics of 
the affected region. The treatment was begun with 
light stroking and soon brisk, deep massage was used, 
and this was followed by percussion, all occupying from 
ten to twenty minutes daily. The exudations disap- 
peared in from eight to twenty days, and the other symp- 
toms in from nine to thirty-five days. The chest pains 
were relieved, the muscles invigorated, and the respira- 
tory movements increased in volume, and thus a marked 
influence on the absorption of the exudation and the dis- 
tention of the compressed lung was obtained. Dr. Emil 
Schlegel has also reported several cases of pleuritic effu- 
sion where the absorption of the fluid seemed to be accel- 
erated by means of massage. This was used in the form 
of percussion only, with the ulnar border of the hand 
striking at the rate of two blows a second, or six hun- 
dred in five minutes, which made a sitting, and two of 
these were given daily. Dr. Schlegel's enthusiasm car- 
ries him a little too far, for he believes that percussion 
might be quite as useful for promoting absorption in the 
intra-cranial cavity, the spinal canal, etc., forgetting that 
the blows would have to be so hard, in order to be ef- 
fectual, that the patient would have reason to object. 
Neuritis.-Massage is becoming more generally ac- 
cepted as one of the proper measures to employ in cases 
of neuritis. In the early stages it may be used to push 
the blood out of the distended vessels and to create a free 
circulation in the adjacent tissues ; in the later, to pro- 
mote absorption of inflammatory products by spreading 
these over greater space, and for the relief of minute ad- 
hesions and thickening of the nerve-sheath. But the senti- 
ment largely prevails throughout the profession that cases 
(SUPPLEMENT.) 
of fully developed neuritis ought not to have massage. 
Nevertheless, testimony is accumulating that even here 
it may be beneficial. I have recently had two cases of 
acute neuritis of the sciatic nerve in previously healthy 
people, in which the result was all that could be desired. 
In one, massage was used in conjunction with galvan- 
ism and tonics ; in the other both medical and electrical 
means had been exhausted. It was the patient's third 
attack, the first having lasted for three months, then, 
after an interval of several years, came the second attack, 
which lasted for six months, and at this rate of increase 
we feared that the patient was in for a year of it with 
his third attack, which appeared several years after the 
second. But under massage alone the whole aspect of 
the case was speedily changed, and in the course of a 
few weeks the patient resumed his arduous professional 
duties. 
Dr. A. Symons Eccles, of London, has reported in de- 
tail three cases of highly acute neuritis1 of the sciatic 
nerve in previously well people, which he treated success- 
fully with rest, position, and massage (effleurage, knead- 
ing, and percussion). In the intervals between the mas- 
sage, the leg was suspended in a Salter's swing. It was 
contrary to all expectation that percussion could be used 
to advantage in such cases, but experience proved the 
value of it. In six other cases of sciatica that occurred 
in patients of an anaemic type the sciatic affection was 
evidently a concomitant of the general condition. In these 
general massage of the body, with frequent meals and the 
avoidance of all pressure upon the nerve-trunk, were 
kept up from four to ten weeks, with the result that not 
only was the sciatic pain removed but the patients all 
improved in appetite, weight, and strength. 
Local Neurasthenia.-Neurasthenia, as I under- 
stand it, may be either general or local, affecting the 
nerves or nerve-cells of all or any part of the cerebro- 
spinal or sympathetic system. Its manifestations are 
those of exhaustion or too easy exhaustibility of nerve- 
force ; and its pathology, malnutrition of the nerve- 
cells involved, with concomitant instability of their cir- 
culation in the form of anaemia or hyperaemia, or 
alternations of these. It predisposes to, it accompanies, 
it results from disease ; the nervous shock and the tedious 
recovery from injuries point to other sources, and it may 
be caused by overwork, worry, or sheer laziness. The 
agreeable fatigue after a satisfactory day's work that 
insures sound sleep may be regarded as a healthy form 
of neurasthenia, if the Hibernianism may be pardoned. 
It is a matter of common observation that those who 
are compelled to hard manual labor seldom suffer from 
nervous prostration, and among the more fortunate 
who may be predisposed to neurasthenia, those who are 
deeply interested in some hobby or occupation that keeps 
mind and body active, have found the best means of 
prophylaxis. The same means that serve for its pre- 
vention also supply us with a clue to one of the most 
valuable agents that can be employed for its relief or 
recovery. Exercise keeps the circulation active, but 
requires effort of brain, spinal cord, and nerves, as well 
as muscles, at a time when our object may be to afford 
rest to one or all of these parts of an overtaxed nervous 
system. Massage supplies this want, and will keep the 
circulation going with a minimum or no expenditure of 
nerve-force from the patient, and deep massage without 
friction will lessen the beats of the heart and afford it rest 
also. Nay, more, for it is getting to be the fashion not 
only among the laity, but also with some physicians, to 
say that massage imparts energy to the patient, though I 
confess I do not exactly understand what this means. 
Certainly many who submit to massage feel much more 
vigorous, light, and supple after even the first applica- 
tion than they did before it. But may not this rather be 
owing to the rousing of their latent energies and restor- 
ing the equilibrium of their forces by facilitating the cir- 
culation of blood and the flow of lymph and the trans- 
mission of nerve-force ? 
I have previously stated elsewhere that in cerebral 
exhaustion the relative value of massage was almost nil, 
and that out-of-door exercise was of paramount impor- 
593 Massage> 
Massage. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
tance ; but I have since found reason to modify this in 
favor of more massage and less exercise. In such cases, 
massage of the head alone daily, or every other day, is 
better than applying it all over the patient, unless there 
be a rare idiosyncrasy that will not allow the head to be 
manipulated. 
There are people, not a few, who, when using their 
brains, suffer from uneasy sensations in the lumbar or 
dorsal region, and these discomforts continue after the 
cessation of study, causing wakefulness. Generally, 
there is also some spinal irritation in the region affected. 
In such cases massage of the back alone will often in- 
duce sound sleep, and next day the patient feels inspired 
with faith, hope, and courage, in place of doubt, dread, 
and fear of meeting appointments. With these cases a 
much more marked effect is produced by local than by 
general massage, except when the tenderness of the mus- 
cles and spinal irritation are extreme, unfitting them for 
every kind of work, and then the massage should be 
general, omitting the back at the first seances, but grad- 
ually approaching it at subsequent ones. 
If space permitted I could give details of cases which 
would seem to justify the following conclusions : 
1. That massage induces sleep. 
2. That even when massage is applied in the forenoon 
its soporific effects may not disappear before bedtime, 
though in general the later in the day massage is used 
for promoting sleep the better. 
3. Disagreeable feelings of drowsiness and languor do 
not necessarily intervene between massage in the fore- 
noon and sound sleep at bedtime. Aptitude for rest or 
work generally follows massage. The mind is clearer, 
the mental faculties work easier and longer, the muscles 
are more supple, and do not tire so soon. 
4. When people are wakeful after massage they may 
not be restless nor feel the loss of sleep on the following 
day. Generally they do not. 
5. Spinal irritation is relieved or disappears under 
massage. 
6. For local neurasthenia there is no need of general 
massage unless the whole system be secondarily affected. 
7. When affections have come to a standstill under 
massage, improvement may yet go on after massage has 
been discontinued. 
8. For improving the nutrition of nerves and muscles, 
restoring natural sensation and motion, massage may 
succeed when other means have failed. 
9. Deep massage without friction has proved of more 
value in my hands than all other forms of massage put 
together. 
10. Massage can be overdone, producing opposite 
effects from a moderate application. 
11. Besides massage, carefully graduated exercises at 
regular times are valuable accessories in the restoration 
of motion. 
12. Massage is not the only means of treatment for 
neurasthenia. Its selection is usually decided upon after 
the failure or exhaustion of every other means; in the 
same manner that the shrewd old divine decided that it 
was not wise to let the devil have all the good tunes to 
himself. 
Diabetes.-Massage under the water, or douche-mas- 
sage, constitutes the peculiar mode of administering the 
warm hydro-sulphuretted water of Aix-les-Bains, where it 
has been in use from time immemorial. The water is too 
feebly mineralized to be rationally employed in any other 
way than externally, which is thought to favor the ab- 
sorption of sulphuretted hydrogen by the skin. 
Dr. H. Forestier, physician at Aix-les-Bains, has em- 
ployed this treatment in seven cases of saccharine diabe- 
tes in fat people, with the interesting result that there was 
an enormous decrease of the glycosuria without the.in- 
tervention of any change in the alimentary regimen or 
the administration of any medicine.'2 The patients lived 
A la table d'hote, eating a mixed diet of meats, sweets, 
fruits, and amylaceous substances. They followed their 
ordinary habits of exercise. The douche-massage was 
used with the patients seated or lying, while two mas- 
seurs occupied themselves, the one with the limbs, the 
(SUPPLEMENT.) 
other with the trunk, adroitly directing a jet from a noz- 
zle under the arm, douching with both hands and 
masseing at the same time. This occupied ten or fifteen 
minutes. The temperature of the water was from 37° 
to 40° C. (98.6° to 104° F.). 
The patients thus treated were classified as belonging 
to the clinical form of diabetes known as diabete gras of 
Lancereaux, or the slow diabetes of the English. All 
seven presented very similar features-age fifty to sixty 
years-embonpoint or confirmed obesity, extreme thirst, 
passage of excessive quantities of urine, and great mus- 
cular fatigue on slight exertion. These symptoms were 
overshadowed in four of the cases by arthropathies, and 
in two by neuralgia which had been mistaken for chronic 
rheumatism ; and in one of them this diabetic neuralgia 
seemed like that of tabes, affecting the crural and sciatic 
nerves. In those patients with a large quantity of sugar 
in their urine, as well as in those with a small quantity, 
there resulted the same modification in the excretion of 
urea. Before the douche-massage this was less than nor- 
mal, but under this treatment it increased, thus demons 
strafing increased oxidation and acceleration of retarded 
nutrition. The decrease in the sugar was great. In the 
first case, from 24 grammes in twenty-four hours to 1J 
grain after the twentieth massage, in twenty days. In 
the second case, from 117 grammes in twenty-four hours 
to G6 grains after the twenty-fifth massage, in twenty-five 
days. In the third, from 87 grammes to 18 grammes*after 
twenty massages, in twenty-two days. In the fourth, 
from 319 grammes to 101 grammes after nineteen mas- 
sages. In the fifth, from 42 grammes to 5 grammes after 
twenty massages. In the sixth, from 30J grammes to 
11$ grammes after twenty massages, in twenty-four days. 
In the seventh, from 291 grammes to 80 grammes after 
twelve massages. 
The quantity of urine also decreased. The general 
condition of the patients improved, appetite and sleep 
were also made better. The pain and stiffness of those 
whose joints were thus affected were greatly benefited, 
but the neuralgia affecting the crural and sciatic nerves 
in one patient was still troublesome, though his general 
condition had become excellent. 
The douche-massage would thus seem to be one of the 
most powerful means of hygienic therapeutics for fat 
diabetics, and can be used at the same time with other 
treatment, such as the internal use of the waters of Carls- 
bad and Vichy and Brides. But these are probably 
better adapted for diabetics with hepatic troubles and 
large livers, whereas the hygienic treatment of the douche- 
massage is rather indicated for cases where there is no 
appreciable trouble of the liver and where the general con- 
dition alone seems to be at fault. As to the duration of 
improvement after massage, but little is said except in two 
cases : in the one that had 319 grammes of sugar in 
twenty-four hours, after nineteen massages, this was 101 
grammes : and at the end of eight months at home, on mod- 
ified diet, this had still further decreased to 2 grammes. 
The following year he ■went to Vichy, and two months 
after he had left there the urine had 53 grammes every 
twenty-four hours. In another case that had been at 
Vichy for several years, the glycosuria had always in- 
creased to the same degree in the intervals between the 
seasons. After twenty massages, it decreased from 42 
to 5 grammes, but how long it remained thus we are not 
told. The results must probably have been more favor- 
able if the diet had been restricted, but in order not to 
obscure the results of the douche-massage, a full mixed 
diet was allowed. This might be a good course to pur- 
sue when the physician is obliged to use milder treat- 
ment than that of special diet, in order not to discourage 
the patient. 
Professor Finkler has tried general muscle-kneading 
in fourteen cases of diabetes. The patients were at first 
masseed daily, and later, morning and evening for twenty 
minutes, over all the muscles of their bodies. The diet 
at the same time was mixed. A few of the patients were 
confined to bed, others were able to go about, and some 
did severe manual labor. The result, on the whole, was 
favorable, as shown by decrease iu the quantity of urine 
594 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Massage. 
Massage. 
and of the sugar contained in the same, diminution of 
thirst, return of perspiration, and increase of body 
weight. After three months' treatment of one patient 
the sugar entirely disappeared from the urine, and this 
remained absent for three months after the last massage, 
then the sugar reappeared (Schmidt's " Jahrbucher," Bds. 
2 and 3, p. 218). 
As there was no external application used writh the 
massage in Professor Finkler's cases, the result would 
probably have been as good in Dr. Forestier's cases with- 
out the douching with the waters of Aix. 
Intermittent Fever.-Dr. Feroykovy, in the Inter- 
nationale klinische Rundschau, states that in the Austrian 
army about one thousand soldiers were treated for inter- 
mittent fever annually. One of these cases was that of 
a soldier in whom neither the hot nor the cold stage was 
observed. He suffered only from severe vomiting, which 
quinine alone could check. Another case was character- 
ized by severe sciatica. On one occasion when no qui- 
nine could be obtained, Dr. Feroykovy ordered these 
patients to be rubbed on the back with simple ointment. 
This was done twice in one day, and at the visit next 
day he found that the attack of fever which had pre- 
viously occurred regularly had not made its appearance. 
The massage was later carried out in seventy patients 
suffering from intermittent fever without the use of 
quinine, and in sixty cases of quotidian fever the attack 
did not recur any more, but in ten cases of tertian fever 
massage had no effect. The same treatment was then 
tried in over one hundred cases, and in the "vast ma- 
jority " the result was satisfactory. 
Massage of the Heart.-Massage of the heart is 
very much overestimated. General massage is of great 
aid to the peripheral circulation, lessens the work of the 
heart, tranquillizes the nervous system, and induces sleep, 
even in the worst cases of heart disease. In a recent 
work Oertel places altogether too much importance upon 
the mechanical effect of massage of the heart over the 
chest-walls. In order that massage might act upon the 
heart in the same way that it does upon the muscles of 
the extremities (which he claims), it would be necessary 
to remove the chest-walls, a procedure that would hardly 
be justifiable. While the patient is standing he directs 
that gliding pressure should be made upon the chest- 
walls, downward and inward from the axillary line, the 
benefits of which he states are not only referable to its 
influence in perfecting expiration, but also to the direct 
pressure upon the heart, influencing its nutrition pre- 
cisely as massage benefits the muscles of the extremities. 
It is indicated, he says : 
1. When the heart-muscle is weak from deficient nu- 
trition, anaemia, or corpulence. • 
2. When the arterial system is imperfectly filled and 
there is passive congestion as a result of insufficiency of 
the myocardium. 
3. When there are valvular lesions or obstruction to 
the circulation, the pressure of tumors, or constriction of 
the pulmonary orifice. Emphysema and curvature of 
the spine increase the demands of the heart. 
4. As an accompaniment of treatment of the heart by 
mountain climbing. 
It is contra-indicated in acute or recurring endocarditis 
or pericarditis, in acute or subacute myocarditis, the re- 
sult of sclerosis of the coronary arteries, and in general 
arterio-sclerosis. 
But the great authority in this matter, according to Dr. 
Sarah E. Post, is the renowned pugilist, John L. Sulli- 
van, of whom she says : "It is idle to fight with facts 
when a man like the great Sullivan insists upon being 
rubbed down and not up. . . . Horses, too, are 
rubbed down and not up " {Massage Primer, p. 27). The 
horses know' as much about this as Sullivan. A mo- 
ment's reflection will show that rubbing down would 
tend to produce engorgement of the venous and lym- 
phatic systems. 
Myxcedema.-I had never heard of massage being 
used in myxcedema prior to May, 1885, when Professor 
Robert T. Edes sent me a case. It was that of a man 
fifty-six years of age, who had suffered from the usual 
symptoms of myxoedema for four years. The result of a 
course of general massage every other day was most sat- 
isfactory. The boggy, brawny, waxy condition of the 
tissues gave place to suppleness and elasticity, freedom 
of motion, improved mental tone, and better hearing. 
Seven years have elapsed and the improvement has con- 
tinued. Since then several cases have been reported much 
improved or cured by means of massage and hypodermic 
injections of an extract of the thyroid gland of a sheep. 
A most interesting case of this kind has recently been 
published in the British Medical Journal by Dr. Wallace 
Beaty. The patient, a lady forty-live years of age, had 
for five or six years become more and more easily tired, 
speech had become slow, memory impaired, temper ir- 
ritable, walking difficult, constipation increased, suscep- 
tible to cold, etc. Her face was swollen, waxy-looking, 
and anaemic ; lips and alas nasi thickened, nose broadened, 
hair thin ; hands and feet, arms and legs were enlarged 
and clumsy. No trace of the thyroid gland could be 
made out. Examination of the blood showed haemo- 
globin to be seventy per cent, of the normal. Five 
weeks of massage brought some improvement, and then 
hypodermic injections of an extract of sheep thyroid 
gland were also used, and more rapid improvement fol- 
lowed. The patient was under this treatment for twelve 
weeks, continually improving. After treatment was dis- 
continued she steadily progressed. " Now she is prac- 
tically cured. The face looks natural, the skin of the 
face is no longer swollen, the lips and tongue are of nat- 
ural size, the speech is rapid and easy, the hands are no 
longer clumsy, she can give a hearty and firm shake- 
hands, her rings are loose and easily removable, her 
movements are active, her hair, which had become thin, 
is now growing thickly; her memory has returned, 
menstruation, which was absent, is natural." 
Massage of the Abdomen for Indigestion.-In 
dilatation of the stomach and chronic dyspepsia massage 
has proved of benefit, the distressing symptoms disap- 
pearing and the patients gaining flesh and strength. It 
should be applied as much as possible over the stomach, 
working from the left side upward and inward under 
the false ribs, so as to empty the stomach of its contents 
while stimulating the contractility of its muscular walls. 
The effect of gravity causes the food to lodge in the most 
dependent portion, in the greater curvature, and it needs 
to be pushed along toward the pylorus, at the same time 
that its peristaltic action is being increased. The 'whole 
abdomen should be masseed at the same sitting, as the 
bow^els are also usually sluggish in these cases. Ru- 
bens Hirschberg, of Odessa, reports many cases of this 
kind which he relieved or cured by means of massage, 
and lays special stress on the fact that massage has an 
ultimate chemical influence in causing the disappearance 
of sour, burning eructations, foul breath, and bad taste 
in the mouth, as well as of sensations of weight and ful- 
ness, which would indicate an improved state of the gas- 
tric juice and better contractions of the stomach. I 
have witnessed the same result in several cases under my 
care. Hirschberg invariably found in these cases what 
I have seldom met with, that massage of the abdomen for 
thirty minutes had a decidedly diuretic effect, the daily 
quantity of urine in some being increased to three times 
the usual quantity, without any other inconvenience save 
that of frequent micturition. When massage was dis- 
continued the urine fell to its former quantity. The 
increase of urine probably depends upon more active ab- 
sorption of fluids from the digestive tract, increased 
blood-pressure, and stimulation of the splanchnic and 
pneumo-gastric nerves below the diaphragm, caused by 
massage. Contra-indications to the use of massage over 
the stomach or bowels would be symptoms of cancer or 
ulcer, acute or febrile states, and a suspicion of a ten- 
dency to hemorrhage. If cicatricial contraction of the 
pyloric orifice existed, massage might increase the dila- 
tation, for the walls of the stomach would then in all 
probability yield more readily than the cicatrix. 
Salol serves a useful purpose in showing us when the 
contents of the stomach pass into the small intestine. 
Insoluble in the gastric juice, it is decomposed into its 
595 Massage. 
Massage. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
two constituents, salicylic acid and carbolic acid, in the 
small intestine, where it is subject to the action of the pan- 
creatic juice, which renders it soluble and easy of absorp- 
tion. Soon after absorption into the circulation it passes 
through the kidneys into the urine as salicyluric acid and 
sulpho-carbolic acid, its presence being shown by the pro- 
duction of a red-violet precipitate when the urine, after 
acidulation with hydrochloric acid and shaking witii 
ether, is tested with a solution of perchloride of iron. 
Professor Ewald tied the pylorus of a number of dogs, 
then gave them large quantities of salol, without obtain- 
ing the reaction of this in the urine. Dr. Sahli found 
that acute catarrhal conditions, as well as chronic dilata- 
tion of the stomach, delayed the decomposition and ab- 
sorption of salol. The experiments of Professor Ewald 
and Dr. Eccles agree in that they found, in most cases 
under natural conditions without massage, that salol 
could be detected in the urine in forty-five minutes 
after its administration ; but after massage upon the ab- 
domen for fifteen minutes the reaction of salol was ob- 
tained in thirty minutes. 
In two obstinate cases the addition of general massage 
had a more favorable effect in hastening the absorption 
of salol than did massage of the abdomen alone. 
After the administration of one gramme of salol to 
people suffering from chronic dyspepsia, Hirschberg, 
Brunner, and Huber found that it required from two 
hours to two hours and a half before the reaction of salol 
could be detected in the urine. But after a walk of fif- 
teen minutes or gymnastic exercises for ten minutes, the 
reaction was obtained in one hour and five minutes. 
Similar results were obtained from faradization, but 
massage proved more efficacious than any other means. 
Hopadze has made a series of observations showing that 
massage of the abdomen for ten minutes lessens the so- 
journ of the food in the stomach from fifteen to seventy- 
five minutes. He also made other observations upon 
healthy people, proving that the nitrogenous metamor- 
phosis in four persons to whom he gave daily massage 
for twenty-five minutes invariably increased and lasted 
for seven days after a week of massage. The assimila- 
tion of the nitrogenous substances of the food increased 
in all the cases, and lasted during the week following 
the week of massage ; but during the ■week of massage 
one gained in weight, two lost, and one was unchanged. 
The results obtained by Zabludowski were similar. 
Relaxation of Ligaments is often erroneously diag- 
nosticated after the improvement of a joint from the 
acute symptoms of disease or injury. It is much more 
frequently the case that the muscles moving it are atro- 
phied and relaxed in consequence of the necessitated 
disuse, which thus allows too great traction upon its liga- 
ments. Massage, carefully regulated movements, and 
faradization will restore the nutrition and tone of such 
muscles, and if the disturbance of the joint has disap- 
peared, the limb can thus be got well. In three cases of 
this kind I had the pleasure of training the affected mus- 
cles as mentioned, so that from being totally unable to 
extend the affected leg at all. in a few weeks they could 
hold it fully and voluntarily extended for seven, nine, 
and ten minutes, respectively. The first of these was a 
stout elderly lady, who still had the remains of an old 
synovitis when she began this treatment, under which 
she fully recovered. The second was a gentleman of 
sixty-three years, who had developed a rheumatoid 
arthritis of his left knee in consequence of an injury, 
and though the peri-articular thickening disappeared, 
and the quadriceps extensor muscles improved so that he 
could hold the leg extended for nine minutes, yet grating 
of the articular surfaces remained, and locomotion was 
much impaired. The third was a long-levered, awkward 
woman, -who had for many years suffered from relaxa- 
tion of the quadriceps extensor to such an extent that it 
allowed the patella to slip externally without the power 
of voluntary ot involuntary replacement, causing her 
many bad falls. When she had gained strength suf- 
ficient to hold the leg extended for ten minutes, she had 
correspondingly good use of the limb, but for security I 
still made her wear a few turns of roller bandage to keep 
(SUPPLEMENT.) 
the patella in situ. Let any of our readers take his 
watch and try to hold his leg and thigh fully extended 
without support for one or two minutes, and he will ap- 
preciate what was accomplished in these cases. 
Massage in Sprains and Fractures.-It is an en- 
couraging sign that physicians and surgeons are begin- 
ning to use massage themselves in sprains. The ortho- 
dox treatment of absolute immobility alone in these cases 
has little else to support it than the dogmatism of cen- 
turies, from which it has been almost impossible for a 
surgeon to free himself unless he has been the unfortu- 
nate victim of a sprain and had it treated with massage. 
Supposing that anyone wanted to make a well joint stiff, 
to what more effectual means could he resort than first 
to give it a wrench or sprain, and then do it up in a fixed 
dressing, so that the resulting inflammation would have 
an opportunity to produce adhesion of the tissues ? Pre- 
cisely the same course of treatment is employed for the 
purpose of closing up a hole, namely, that of exciting 
adhesive inflammation, and unfortunately it sometimes 
closes the cavity of a joint also. In my " Treatise on 
Massage " will be found the method of applying massage 
in sprains, and its results in seven hundred cases, show- 
ing that they got well in one-third of the time that they 
do without it, and with less tendency to subsequent pain, 
weakness, and stiffness than when massage had not been 
employed. The earlier after a sprain massage is em- 
ployed, the more speedily does recovery take place. But 
sprains are sometimes complicated with fractures near 
and into joints, and of late years massage and move- 
ments have been used in these cases with advantage over 
the ordinary methods. In intra- and para-articular fract- 
ures the French surgeons, MM. Championniere, Tripier, 
and Rafin, have found that immobilization is accompanied 
with danger, whereas massage acts well from the first and 
can be used with other means. Their experience has been 
confirmed by Professor Lauderer, Dr. Kendal Franks, 
and others. The dangers of immobilization are stiffness 
of the joints and atrophy of the muscles ; and the anaemia 
of the muscles (ischaemia) caused by fixed dressings may 
be mistaken for neuritis. It has been demonstrated by 
Kraske that the application of a rubber bandage to the 
leg of a rabbit for six hours has produced vitreous 
(hyaline) degeneration of the muscles, from which they 
cannot recover, The advantages of massage are that it 
promotes absorption of effused products, prevents stiff- 
ness of the joints and atrophy of the muscles, and favors 
repair. It should be done once or twice daily in these 
cases. 
M. Championniere found that massage relieved pain, 
as most observers do who know how to apply it, but M. 
Rafin states that its application was painful. The man- 
ner of employing it would probably account for the dif- 
ference. This is not stated. I have elsewhere given full 
directions how painful, swollen, and tender tissues can 
be gradually approached without hurting by working 
first on the adjacent healthy parts. Good recoveries 
were obtained by both MM. Championniere and Rafin, 
in from one-half to two-thirds of the usual time. Those 
cases in which there was no displacement did well under 
massage, and passive motion without immobilization. 
Those in which there was displacement of the fracture 
had massage at first to hasten absorption, then a reten- 
tive dressing for the shortest time possible to make sure 
that the displacement would not return, and after this 
massage and passive motion for the restoration of mobil- 
ity. As soon as consolidation had taken place it was 
found that motion was free and easy. 
In an article in L' Union Medicale of February, 1889, 
on fracture of the fibula treated by massage and mobili- 
zation, M. Marevery summarizes his experience by say- 
ing that almost all of his patients treated in this way re- 
covered the use of their limbs in less than nineteen days 
after the injury. This treatment he finds can be used 
only for certain fractures, such as those of the inferior ex- 
tremity of the radius, and of the lower end of the fibula. 
He also made use of cold applications and the rubber 
bandage as well as massage from the first, and passive 
motion was given to the joints early. 
596 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Massage. 
Massage. 
Professor Lauderer applies a fixed dressing for four 
or five days at first. After this he removes it for a 
short time daily in order to give massage, and at the end 
of ten or twelve days consolidation is sufficiently ad- 
vanced to lay aside the splint altogether. This plan of 
treatment he finds preferable to all others for transverse 
fracture of the patella, as it is safe and simple and gives 
good results, the patients going about freely in four or 
five weeks. He has employed it in ninety cases of sim- 
ple fractures of various bones, including fracture of the 
olecranon, of the anatomical neck of the humerus of the 
thigh, etc.3 Dr. Kendal Franks considers that certain 
fractures are well suited for massage, such as fractures 
of one of the bones of the leg or forearm when the other 
bone acts as a natural splint and prevents displace- 
ment ; and transverse fractures of the humerus and fore- 
arm or leg. The temporary removal of the splints in 
these cases for massage is not attended with any risk.4 
In transverse fracture of the patella, even where good 
union has been obtained either by immobilization or by 
suturing of the fragments, or by fixation of them with 
Malgaigne's hooks, the resulting stiffness of the knee- 
joint, atrophy of the quadriceps extensor muscles, and 
impaired motion may cast a shadow of gloom over the 
most careful treatment or the most skilful operation. 
But the lesson taught by the cases in which the frag- 
ments have remained widely separated, and yet accom- 
panied by good motion, has not passed unheeded. Pro- 
fessor Tilanus, of Amsterdam, treats cases of fracture 
of the patella without immobilization, using instead 
compression, massage, and early movements of the joint, 
leaving consolidation to take care of itself, for union is 
by no means certain under the best of care. In this 
manner the effusion is quickly dispelled, atrophy and 
stiffness prevented. His patients were encouraged to 
walk after the first week. Of six cases that Professor 
Tilanus treated in this way, the patients could walk very 
well in fourteen days (according to his own statement); 
-Rafin treated one case in this manner and the patient 
could walk perfectly in forty-two days, experiencing 
only slight difficulty in descending stairs. The seat of 
the fracture could then be felt with difficulty, being 
marked only by a slight depression of the skin, and the leg 
could be flexed within two fingers' breadth of the thigh. 
Dr. Wagner, a regimental surgeon of the Austrian 
army, states that he has obtained astonishingly good re- 
sults in five cases of fracture of the patella which he 
treated with massage, passive and active movements, but 
without even the application of a bandage. His method 
is somewhat as follows: The patient is put to bed and 
the affected limb stretched on a simple inclined plane, or 
on an adjustable wooden splint, so that the heel is ele- 
vated. In the first three or four days an ice-bag is 
placed upon the swollen and painful knee. As early as 
the fourth day massage may be begun, not only over the 
entire extent of the quadriceps extensor muscles, but also 
over a large portion of the knee-joint. This is done daily 
and soon followed by passive movements. As soon as 
possible the patient himself begins to move the joint, and 
after fourteen or twenty days may attempt to walk on 
crutches, and in six weeks is usually able to walk with- 
out support. Should the fragments be widely separated, 
Wagner advises subcutaneous suture, but even here mas- 
sage and exercise "cannot be begun too early." In 
fine, by means of massage and movements, the indica- 
tions in every case are largely met. These are, the re- 
moval of the effusion so as to allow the fragments to 
come closer together, the favoring of repair and the 
formation of callus, the prevention of atrophy of the 
quadriceps extensor and the shrivelling of the capsule, 
and the early restoration of motion. It is needless to 
state that these manipulations should only be undertaken 
by some one having sufficient anatomical and surgical 
knowledge. 
It is worthy of notice that the principal muscles of the 
quadriceps extensor that effect extension of the leg, are 
the vastus internus and vastus externus. The insertion 
of these on the lateral aspects of the patella extends much 
lower than is generally supposed, and affords leverage to 
extend the leg when a fragment of the patella is de- 
tached above their insertion. Rupture of the rectus 
femoris alone has little or no influence in hindering 
walking (after the immediate effect of the injury is re- 
covered from). Dr. Kummer, of Geneva, and Dr. Kauf- 
mann, of Zurich, and Mr. Page, of Newcastle-on-Tyne, 
have each performed total extirpation of the patella for 
disease of that bone without impairing the patient's gait 
or interfering with the movement of the knee-joint, when 
the latter was healthy. Slightly weakened power of ex- 
tension of the leg was the only noticeable feature on close 
examination.6 
After union of any solution of continuity, whether of 
bone, muscle, or nerve, massage and movements are in 
order, and even when repair is going on the mobility of 
the joints may be still better secured by altering the 
position of them at each dressing. 
Contusions of Joints or Muscles are speedily re- 
lieved of pain, swelling, and stiffness when massage is ap- 
plied from the first, and atrophy, which is so apt to follow 
even slight injuries of this kind and of sprains, is pre- 
vented. M. Castex has recently made a very interesting 
series of observations, both clinically and experimentally, 
on this subject {Archives Generales de Medecine, 1891-2). 
For the sake of comparison he purposely bruised corre- 
sponding muscles and joints of the same legs of various 
dogs, and to one limb he gave massage, and to the other 
none. The limb that was masseed quickly recovered, 
while the other remained swollen, sore, and stiff, and 
later there was atrophy of the muscles. His experiments 
were carefully watched by others, who did not know 
which leg was being masseed. Massage gave like good 
results when applied immediately after the reduction of 
dislocations in dogs, and in man also the results were very 
favorable when massage was used after the joint had 
been held in place for a few days. 
M. Castex reaches the following conclusions, which 
are based upon both clinical and experimental observa- 
tions : 
In simple contusions of muscles massage rapidly dis- 
pels the various troubles, but principally the pain. 
In articular contusions massage dispels the reflex mus- 
cular contractures and the pareses, and above all it pre- 
vents the rebellious muscular atrophies which are the 
most serious complication thereof. 
Applied to sprains, it is remarkable by the rapidity of 
its good effects. 
In luxations we ought to have recourse to it as soon as 
the reduction is assured, for it very speedily reduces 
the swelling, the ecchymoses, and the pain. It awakens 
the muscular fibres from that local stupor into which 
they have been plunged by the injury. It prevents 
atrophy and stiffness. 
Applied to juxta-articular fractures, massage rapidly 
terminates pain and swelling. By this means a simple 
fracture of the inferior extremity of the radius without 
deformity is cured in fifteen days, whereas it would take 
forty days, at least, with plaster immobilization. If it 
is applied after the removal of the fixed dressing it ren- 
ders the parts supple and dispels the oedema. 
Massage has proved of little use against acquired mus- 
cular atrophies. It prevents them when applied early. 
Histological Results. - The muscle injured and not 
masseed, under the microscope presented a diffuse sclerosis 
with hypertrophy of the connective tissue in its various 
parts, interstitial hemorrhages, engorgement of the blood- 
vessels, and hypertrophy of their external coat. 
The muscle injured but masseed presented a normal 
histological aspect. 
The blood-vessels are normal in the muscle masseed. 
In the muscle not masseed they show a hyperplasia of 
their external coat. 
The nerve-filaments in the masseed muscle are normal ; 
in the non-masseed muscle they present evidences of 
perineuritic and interstitial neuritis with compression of 
the nerve-tubes. The perineurium is at least three times 
as thick in the non-masseed side as it is in the masseed 
side. The lesion of the nerves is more marked than that 
of the vessels. 
597 Massage. 
Mastoid Anatomy. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
In brief, massage acts by deterging a part from the 
various injurious materials which have been poured into 
it as a result of injury, in bringing this part back to its 
normal condition, and in preventing the process of diffuse 
sclerosis which would result. Such is the positive ex- 
planation of massage, and it can only increase its credit. 
Incontinence oe Urine in Females.-Some of our 
readers may wonder why attention has not been given in 
this article to massage of the uterus and its suburbs. For 
information on this subject we would beg leave to refer 
them to my " Treatise on Massage," which has a chapter 
on " Massage of the Uterus and its Surroundings," which 
the New York Medical Record said was " worse than ig- 
norance," while the Dublin Journal of Medical Science, 
August, 1891, said of the same : " Those who objected so 
strongly a short time ago to the employment of massage 
in these regions, would do w'ell to read this chapter and 
to bear in mind the author's observation, that 'Massage 
of the pelvic organs should be entrusted to those alone 
who have clean hands and a pure heart.'" 
It is both novel and interesting that massage can be 
applied to relieve and cure incontinence of urine in 
females. Dr. W. S. Bagot, of the Rotunda Hospital, 
Dublin, has used it with complete success in a number of 
cases of this kind. His method is that of Brandt 
stripped of all unnecessary details. He introduces the 
index-finger of the left hand into the vagina (the rectum 
in children), slightly flexed and passed obliquely, so as to 
partially encircle the neck of the bladder. The right 
hand grasps the wrist so as to regulate the pressure used, 
and then the finger in the vagina or rectum is made to 
vibrate against the neck of the bladder, compressing it 
with moderate force against the pubes. This is done 
three or four times, and then the opposite side of the 
bladder is treated in the same way with the index-finger 
of the right hand. In this manner one patient, who had 
suffered for a year and a half from incontinence of urine, 
with a patulous urethra and slight prolapses of the an- 
terior wall of the vagina, and abnormal distensibility of 
the perineum, was cured in twenty-nine days, and nine 
months later had no relapse. Another patient, twenty- 
four years of age, who had suffered from nocturnal 
enuresis from childhood, was treated in this way every 
other day for five weeks, and thus got well. Another 
patient, forty years old, whose water had passed from 
her involuntarily for three years ■while walking, got well 
in three weeks under this treatment. Brandt and Boldt 
have also reported numerous successful cases treated in 
this way when other means had failed. A lady who 
had been treated by some of the most eminent German 
specialists by dilatation of the urethra, electricity, etc., 
for incontinence of urine of six years' duration, was 
cured by Brandt in eight days. In two cases of chil- 
dren, aged nine years, Boldt reported success after treat- 
ment of three weeks. 
Dr. Sanger's method is also a sort of massage, and has 
been successfully used for incontinence of urine in fe- 
males. It consists in dilating the vesical sphincter with 
the patient in the dorsal position. The urethra is disin- 
fected and a metallic female catheter is passed into the 
bladder a distance of from five to seven ctm., so that its 
point is on a level with the orifices of the ureters. The tip 
of the right index-finger being kept in the mouth of the 
catheter prevents the urine from flowing off, while the 
index- and middle-finger of the same hand steady the in- 
strument. The index- and middle-fingers of the left hand 
are placed upon the catheter close to the urethral orifice, 
and with these the operator makes a springy and forcible 
pressure, at first downward and then toward both sides, 
alternately, so that the urethra becomes widely open and 
urine flows out by the side of the catheter. Thus the 
sphincter of the bladder and the muscularis of the 
urethra are strongly stretched. Further massage can 
also be done by a finger in the vagina or rectum pressing 
against the catheter. The stretchings are not very pain- 
ful, but in sensitive people the urethra can be previously 
brushed with a ten per cent, solution of cocaine. Ten or 
twelve seances usually suffice. They should be twice 
daily at first, and later every other day. The stretching 
causes an irritation of the sphincter which makes it con- 
tract more strongly, both in a direct and reflex manner, 
and thus a certain degree of hypertrophy from work is 
set up. This method is not applicable when there is an 
abnormal dilatation of the neck of the bladder and of the 
urethra with incontinence.' Douglas Graham. 
1 Practitioner, vol. xxxiv., No. 5. 
5 Archives O6ncrales de Medecine. September, 1891. 
3 Sanunlung klinischer Vortriige, No. 19. 
4 Dublin Journal of Medical Science, November, 1891. 
5 The Provincial Medical Journal, January, 1890. 
6 Dublin Journal of Medical Science, October, 1891. 
MASTOID ANATOMY, FROM THE SURGICAL 
STANDPOINT. From its revival, in the middle of this 
century, the operation of opening the mastoid process to 
evacuate pus, which had undergone an eclipse after its 
introduction by Petit (1750) and Jasser (1776), has been 
growing greatly in frequency and success. To this 
nothing has contributed more than the anatomical stud- 
ies which have thrown increasing light upon the struct- 
ure of the parts involved and pointed the way to avoid- 
ance of the dangers which surround it. Now, the 
well-posted aurist feels that the Held is as safe as any in 
surgery, that the indications for operation are as well 
defined, and that the serious or fatal results of timidity 
or neglect are as likely to be the subject of lay criticism 
as unlucky temerity would have been at an earlier 
epoch. The advances of pathology have cleared up 
many of the mysteries as to the causation of brain- 
abscess, septic thrombosis, and neck-abscess, formerly 
not recognized as aural in origin ; and the progress of 
otological teaching and practice has done much to dis- 
seminate information and lead each medical man to call 
in the aid of a specialist when he feels unwilling to pro- 
ceed unaided. 
The earlier operations were usually either guided by the 
presence of a fistula or softened bone, or were done with 
a blind boldness that could not be often repeated with- 
out disaster; and the procedures described and com- 
mended were sometimes such as could rarely be safe. 
Because Kolpin bored a hole up and back of Von Berg- 
er's ear, where he was certain to enter the cranial cavity 
or the lateral sinus, the operation was discarded for a 
century. In like manner the real dangers of imperfect 
procedures and the magnified risks of those better 
planned have greatly retarded the due acceptance of the 
measure. Yet the wide experience of many men has de- 
monstrated the value of operation for the saving of life, 
of hearing, or of time ; since the fatality among the 
cases not operated upon is many times greater ; the dam- 
age to the organ of hearing, when they survive, gener- 
ally much more serious ; and the treatment, though at 
times many months long after operation, is apt to extend 
over years without it. Only in cases where the indica- 
tions are very doubtful can the over-cautious any longer 
claim that it is less dangerous for the competent surgeon 
to temporize than to explore; and as the knowledge is 
spread of the best rules as to when and how to operate, 
a still more brilliant showing will be made. 
The mastoid process is a conoidal protuberance of the 
lower posterior portion of the temporal bone, forming 
the major part of the insertion of the sterno-mastoid mus- 
cle. It is developed from the outer part of the petro- 
mastoid and the lower posterior part of the squamous, 
and enlarges from an inconspicuous tubercle at birth 
to form the large process usually found in the adult. 
It is a response in part to the needs of the muscle in- 
serted upon it, and shows an external development usu-. 
ally corresponding to the general osseous and muscular 
development of the individual ; being large, rugged, 
and massive in most strongly built males; smaller, 
smoother, and thinner-walled in females and those of 
slight physique. Its posterior border is only partly 
marked by the deep digastric fossa or groove, which in- 
tervenes between its apex and the skull-base ; anteriorly 
its convex external surface slopes inward to become the 
back wall of the meatus. Above, it may be said to 
extend to the curving and often ill-defined temporal 
598 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Massage. 
Mastoid Anatomy. 
ridge ; but is better considered to end at the imaginary 
horizontal line on the level of the upper wall of the ex- 
ternal meatus (Fig. 392). Almost exactly at the junc- 
ture of these anterior and superior limits there may al- 
most always be found a depressed groove or pit, below 
which a ridge or spine projects toward the canal. This 
spina supra meatum, to which 
Bezold especially directed at- 
tention, is present in the great 
majority of cases, and forms 
as fixed and clear a 
guiding-point as can 
be taken, not only for 
its structure. Hence they are hardly in existence 
when the mastoid forms but a tiny tubercle in in- 
fancy ; but they increase in number and size with the 
growth of the process, and exhibit extreme growth by 
the thinning of walls and septa and the coalescence of 
adjacent cells in the rarefied bones of senile individuals. 
Whether pneumatic or diploetic, they are gener- 
ally present throughout the process and extend 
into the adjacent squama and petrous, and may 
even communicate with similar cavities in the 
occipital. Among two hundred and fifty tem- 
poral bones, Zuckerkandl found 36.8 per cent, 
wholly pneumatic, 20.4 per cent, wholly diplo- 
etic, and varying combinations of pneumat- 
ic spaces and diploe in 42.8 per cent. The 
question as to how often an apparently 
sclerosed condition may be met in normal 
bones is still an open one,- although its oc- 
currence is well established. Among 
sixty-five pairs and fifty single macerated 
temporal bones, in the writer's collection, 
examined in this regard, only tw'enty-three, 
or thirteen per cent., showed absence of 
completely pneumatic structure 
throughout, although in sixty-two 
more, or thirty-five per cent., the cortex 
and the intra-cellular walls were thick 
and massive. Fig. 393 shows a metal 
cast of one of these fully pneumatic mastoids, Fig. 394 of 
one which was half diploetic, and Fig. 395 one in which 
pathological sclerosis had rendered it a nearly solid, ebur- 
nated mass. The pneumatic cells are claimed to show in 
general a pear-shape (Figs. 396 and 397) and a radiating 
Fig. 399.-Right Temporal Bone, showing the vertical and horizontal 
lines and the position for opening the mastoid antrum. (After Nuhn.) 
all measurements of the temporal bone, but for the en- 
tire cranium. It was absent or very ill-defined in but 
five temporal bones among one hundred and eighty in 
my collection, examined as to it-every time on the right; 
Kiesselbach found it in eighty-two per cent, of juvenile 
and eighty-seven per cent, of adult bones. 
The median surface of the cranium, at the part which 
may be considered the inner surface of the mastoid, is 
grooved more or less deeply by the sigmoid sulcus to ac- 
commodate the lateral sinus, which is formed by separa- 
tion of the layers of the tentorium in its posterior part, but 
is wholly in the posterior 
cranial fossa as it passes 
down to the jugular fora- 
men. The middle cere- 
bral fossa is partly formed 
by the squama and 
reaches downward to- 
ward the upper wall of 
the canal. The height of 
its floor is subject to great 
individual differences, 
and also at different 
points of the same bone, 
being lowest in front and 
rising backward/ It is, 
however, practically 
never so low as the base 
line of the mastoid, al- 
though not rarely lower 
than the temporal ridge. 
It cannot be said, like the 
lateral sinus, strictly to belong to the anatomy of the 
mastoid ; yet it has too great practical importance to be 
omitted in our consideration of the field of operation. 
The interior of the mastoid is more or less filled by 
cavities, usually pneumatic, and lined by extensions of 
mucous membrane from the tympanum, with which 
they communicate. They may serve some unknown 
physiological purpose in connection with hearing, but 
probably they are only to be regarded as rarefactions of 
Fig. 394.-Metal Cast of the Spaces of a Temporal Bone, in which only 
the portion of the mastoid adjacent to the antrum was occupied by 
pneumatic cells, while the major part of the process was diploetic. 
(Randall.) 
direction, the smaller ends pointing toward the mastoid 
antrum, with which they communicate. This antrum, 
which has been generally described as the most constant 
in size and position of the mastoid cells, is really the up- 
per posterior cavity of the tympanum, being full-formed 
at birth and of about the adult dimensions. Its later 
changes are principally in the fenestration of its walls 
for communication with the adjacent cells. The antrum 
is superficial in infancy, its outer wall and part of the 
Fig. 393.-Metal Cast (freed by cor- 
roding away the structure of the 
bone itself) of the Spaces of an ex- 
ceedingly Pneumatic Mastoid, 
showing the large cells so developed 
that only the thinnest septa re- 
mained to separate them. (Ran- 
dall, Corrosion Anatomy.) 
Fig. 395.-Metal Cast of a Sclerotic Mastoid, in which the extensive 
pneumatic spaces had been almost without exception filled by ebur- 
nated bone tissue, and but a single chain of pneumatic cells extended 
down from the antrum to the tip of the mastoid process. (Randall.) 
599 Mastoid Anatomy. 
Mastoid Anatomy. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
upper being furnished by the thin vertical plate of the 
squama ; but the thickness of the outer plate increases 
with maturity, reaching an average of 12 mm. as the 
squama grows outward to form the bony external 
meatus (Fig. 396). There is no dividing-line above be- 
tween tile antrum and the attic (recessus epitympanicus), 
turn, which deeply grooves the bone at times in its passage 
to the mastoid foramen, where it unites with branches of 
the external jugular system. Rarely this emissary re- 
ceives nearly or quite all of the blood of the lateral sinus, 
and may present quite a bulla where it enters the bone ; 
the jugular foramen then giving exit merely to the in- 
ferior petrosal. Sac-like bullae 
are also found upon the anterior 
part of the lateral sinus, and may 
thin the bony wall toward the 
meatus or the mastoid surface, 
even forming a considerable de- 
hiscence. The bony surface of 
the sulcus is generally entire, 
though often as thin as paper- be- 
tween it and the adjacent cells ; 
Jret dehiscence here is only a little 
ess rare than in the tegmen. 
The relation of the sigmoid 
sulcus to the outer surface of the 
mastoid and to the back wall of 
the canal depends upon a series 
of varying factors. The sinus 
which it accommodates varies 
greatly in size, form, an'd posi- 
tion. The mastoid process pre- 
sents very differing dimensions, 
wholly independent of the blood- 
vessel, and the interposed bone 
may be solid, diploetic, or full of 
pneumatic cells, and thus present 
wholly dissimilar grades of pro- 
tection against injury in the open- 
ing of the mastoid. Indetermi- 
nate as the mastoid process is in size, there is usually 
fair symmetry, so that the form of one mastoid when 
concealed by swelling may generally be determined 
from a study of the other. In a study of forty-eight 
pairs of bones Bezold found an average length of the 
process below the spina of 25.17 mm. on the right, 25 
mm. on the left (19 to 31 on each side), with a max- 
Fig. 396.-Vertical Section of Mastoid Process at Right 
Angles to the Axis of the Auditory Canal, showing 
highly developed pneumatic cells and their radiating 
relation to the antrum. (After Eysell.) 
Fig. 397. - More Compact Temporal 
Bone, cut vertically at right-angles to 
the auditory canal and showing 
thicker septa of bone and medium- 
sized cells. (After Eysell.) 
the thin tegmen rooting in both cavities (Fig. 400, upper 
half) ; but the facial and external semicircular canals 
form a lower median prominence, which serves to nar- 
row the communication and constitute the aditus ad 
antrum (Fig. 400, lower half). Measured from the middle 
of this threshold the antrum is 10 to 12 mm. in length, 
while about 6 mm. in breadth and height. Leidy de- 
scribes backward and outward exten- 
sions of the antrum as occurring at 
times. Its long axis is about the same 
as that of the tympanum and tube, and 
at an angle of some fifty degrees to the 
axis of the external meatus (Fig. 401); 
but one case was found by Bezold where, 
on each side, the antrum lay above, and 
not at all behind the meatus. Its inner- 
most end is, therefore, close above the 
upper posterior extremity of the audi- 
tory canal, but it diverges from it as it 
passes back and out, and the intervening 
wall of bone is wedge-shaped, as it in- 
creases to 4 or 5 mm. in thickness. This 
septum is rarely solid, but so occupied 
by small cells that the actual bony separa- 
tion is quite readily broken down by 
antrum disease and a fistulous opening 
formed into the upper back part of the 
meatus. 
The groove upon the inner posterior 
surface of the mastoid for the lateral 
sinus (sulcus sigmoideus) is one of the 
most varying features of the temporal 
bone. Generally distinct, but shallow, 
and presenting gentle curves, it may be 
almost too faint for recognition (Fig. 
398); or again of double the usual size 
and with strongly pronounced curves 
and margins greatly overhanging (Fig. 
399). Receiving the superior petrosal at 
about the point where it turns down- 
ward, and the inferior petrosal near its 
entrance into the jugular fossa, it ex- 
periences some change in size and form 
on this account. It gives off generally a 
good-sized emissary vein near the lower 
Figs. 398 and 399.-Horizontal Sections of Right and Left Temporal Bones at the Level of 
the Middle of the Auditory Meatus, showing the position of the sigmoid sulcus of the lateral 
sinus at F, in the left far anterior, and closely approaching the meatus and outer mastoid 
surface: further hack, and separated, in the right, by abundant pneumatic cells from the 
meatus and surface. (After Hartmann.) 
Fig. 398. 
Fig. 399. 
600 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Mastoid Anatomy. 
Mastoid Anatomy. 
imum difference of 5 mm. where the right was larger, 
and of 3 mm. where the left was larger. Among fifty 
pairs of temporals in the writer's collection, studied in 
like manner, the average length was 28.3 mm. (35 to 21) 
right, 29 mm. (38 to 22) left, with a maximum difference 
(SUPPLEMENT.) 
only thirteen right and nine left among his forty-eight 
pairs), is given as forty per cent, by Schulzke (24:5 
among 60), was tifty-six per cent. (28 + 5?: 12) among 
my fifty pairs, and among two hundred and forty skulls 
was forty-four per cent. (106+29? : 59+24 ?). With this 
larger size, which may be due to 
the fact that' the superior longi- 
tudinal sinus generally goes to one 
side instead of dividing its blood 
stream at the torcular, and that 
the right jugular furnishes a 
shorter and readier path to the 
heart, there is often a more power- 
ful flow of blood, which may be 
the reason for a more curved and 
deeply hollowed sigmoid sulcus. 
Hartmann and Bezold noted that 
the sinus extended in about equal 
proportion outward and forward 
(Figs. 405 and 406); and Koer- 
ner confirmed this so decidedly 
that he measured only its exten- 
sion outward to approach the outer 
surface of the mastoid. Koerner 
also studied the relation of this 
curved superficial position to the 
general form of the cranium (Figs. 
402 and 403), and confirmed 
Bezold's showing that it is more 
usual in brachycephalies (skulls 
short for their breadth). These 
views are combatted by Schulzke, 
who found little relation between 
the anterior and the external loca- 
tion of the sinus, and that the more 
dangerous position was commoner 
among the dolichocephalic (long 
and narrow) skulls. This contro- 
versy deserves careful statement 
and analysis, as it furnishes some of our most important 
data as to the anatomy of the mastoid. Koerner made 
x ig. 4UU.-Horizontal Section of Left Temporal Bone, showing an extreme anterior and superficial 
position of the sigmoid sulcus, bringing the lateral sinus almost into contact with the meatus wall 
and the mastoid surface in the region of the spina, and rendering wholly impossible the ordinary 
operation for opening the antrum. (Randall, Photographic Illustrations.) 
of 5 mm. with larger left, and 3 mm. with larger right. 
Hartmann measured from the linea temporalis and found 
an average length of 32.4 mm. (23 to 42) and breadth 26.7 
mm. (18 to 35). The less determinate breadth averaged in 
the writer's series 22.9 mm. (17 to 27) right, 22.5 mm. (16 
to 28) left, with a difference only once as much as 3 mm. 
No such symmetry exists as to the sigmoid sulcus ; on 
the contrary, one, more often the right, is almost always 
larger. This larger size of the right sinus, which Bezold, 
with Riidinger, estimated at seventy per cent, (although 
Foss.sigm. 
-Meat.and 
Squama. 
Sigmoid sulcus. 
Temporal 
ridge. 
Mastoid cells. 
Fig. 402.-Horizontal Section of a Dangerous Temporal Bone, showing 
the anterior position of the lateral sinus, which closely approaches the 
auditory meatus and the mastoid surface, and lies in the operation 
path to the antrum, A.m. (After Koerner.) 
Spina. . 
Internal 
auditory 
canal. 
the claim that the broad skull generally showed a lower 
cerebral fossa and a more forward and superficial posi- 
tion of the lateral sinus than 
the skull of lower index ; 
and that this relation was 
more m a r k e d upon the 
right side. Hence the mere 
measurement of the length 
and breadth of a patient's 
head and consideration of 
which side is affected 
would serve to f u r n i s h 
most important prognostic 
data as to the safety or dan- 
ger of operation. This re- 
lation he ascribed to the 
incurved line of the mas- 
toid and the upward direc- 
tion of the pyramid in the 
External au- 
ditory canal. 
'Carotid canal. 
Jugular fossa. 
Tip of mastoid. 
Zygoma 
Fig. 403. - Outline Sketches of 
Casts of the Sigmoid Sulcus 
seen from the side. A, from 
brachycephalic ; B. from do- 
lichocephalic skull, showing 
at x the point of greatest curv- 
ature and most vulnerable posi- 
tion. (After Koerner.) 
Fig. 401.-Posterior Inferior Aspect of Temporal, sectioned nearly front- 
ally to show the mastoid cells between the lateral sinus and the 
exterior, generally thin-walled toward the sigmoid sulcus and the 
digastric fossa within the mastoid tip. 
601 mastoid Anatomy. 
Mastoid Anatomy. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
brachycephalic skull (as shown in Fig. 405). He meas- 
ured in sixty skulls the thinnest point of the mastoid 
over the sinus, and in a later paper gives the data of 
(SUPPLEMENT.) 
tion of the sulcus, so that it remains wholly uncertain 
from his data whether the superficial sinus lay in or 
wholly beyond the field of operation. In Bezold's earlier 
work this point is well studied, and he gives the average 
distance of the sinus from the mastoid surface as 7.6 
mm. (2 to 17), at an average distance of 15.6 mm. (6 to 
24) horizontally back of the spina supra meatum. Koer- 
ner's results are rather specious, therefore, as to the vul- 
nerability of the sinus. A much more important point 
was determined by Hartmann among the fifty pairs of 
bones he operated on and then sectioned. He measured 
the distance between the lateral sinus and the posterior 
wall of the auditory canal at about the level of the spina, 
finding it to vary from 5 to 19 mm. (Figs. 406 and 407), 
with an average of 11.5. In 41 of the 100 bones it was 
10 mm. or less (in 1, 5; in 5, 6 ; in 6, 7 mm.). In like 
manner Schiilzke found in sixty skulls the meatus-sulcus 
distance to vary from 3 to 20 mm. It averaged 11.9 
mm. (3 to 16) on the right and 13.4 mm. (10 to 19' on the 
left in nineteen dolichocephalic skulls, and 12.5 mm. (5 
to 20) right, 13.7 mm. (5 to 20) left in thirty-six brachy- 
cephalic skulls; the general average being 12.4 mm. 
right, 13.6 mm. left. The maximum difference in any 
skull was 7 mm. where the right, and 4 mm. 
where the left, was farther forward. Similar 
figures from twenty-seven skulls measured by 
Koerner gave averages of 12.50 
mm. for dolichocephalic, 12.28 
mm. for brachycephalic, 11.86 
mm. right and 12.91 mm. left, 
with a maximum differ- 
ence of 7.2 mm. in any one 
Fig. 404.-Outline Sketches of Casts of the Sigmoid Sulcus seen from 
above, showing the stronger curves and more outward extension in the 
brachycephalic, A, than in the dolichocephalic, B. (After Koerner.) 
twenty-seven more, while in a third 
paper he sets forth the results obtained 
from horizontal sections of twenty - 
seven of the same pairs. 
Yet Koerner's figures 
show the strange omis- 
sion of any reference 
the position of this 
most superficial por- 
Fig. 405.-Schematic Vertical Section of Skull showin, 
on the right, B, the brachycephalic form with the mid 
die cerebral fossa as low as the linea temporalis, the out 
curving squama and the ascending petrous. The an 
trum, Am, lies above the spina supra meatum, and the dotted operation 
track has to take a strongly upward direction. On the left. A, is shown 
the dolichocephalic skull with vertical squama, high cerebral fossa and low, 
safely accessible antrum. (After Koerner, Arch, of Otology. XVI.) 
602 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
jHaKtoid Anatomy. 
Mastoid Anatomy. 
case. Study of two hundred and forty skulls has fur- 
nished the writer with an average of 11.9 mm. (1 to 
20) right, 12.8 mm. (0.2 to 20) left, with the right 
sinus more anterior (13 mm. max.) in 101 and the left 
(7 mm. max.) in 78. The eighty-five long skulls gave 
(SUPPLEMENT.) 
sinus, as to which Koerner makes his showing, averaged 
7 mm. (0 to 17) right, and 7.5 mm. (0.5 to 22) left, among 
the writer's two hundred and forty skulls, and its posi- 
tion back of the spina 16.5 mm. (1 to 25) right, 15.8 mm. 
(1 to 24) left-figures of small significance except in 
showing, as do the other parts of the study, that mini- 
mum results may be met on either side and in any form 
of skull. 
Another series of measurements made by the writer 
have probably more importance than either of the former. 
The distance was determined between the most vulnera- 
ble point of the sinus and a point 5 mm. behind the spina 
-thus giving the "operation room" presented by each 
specimen. This averaged 10.9 mm. (2 to 19) right and 
11.7 mm. (1 to 20) left, among 85 dolichocephalic skulls ; 
the right sinus being in the more dangerous position in 
43 and the left in 24. For the 120 brachycephalic skulls 
the averages were 11.6 mm. (3 to 18) right, 12 mm. (1 to 
20) left, the more exposed sinus being fifty-two times the 
right and thirty-eight times the left. For the entire 240 
skulls it averaged 11.4 mm. (2 to 19) right, 11.9 mm. (1 
to 20) left, with the right the more dangerous in 112, the 
left in 72, and equality in 56.* In like manner, among 
the writer's fifty pairs of temporals, the right averaged 
9.76 mm. (3 to 16), the left 9.66 mm. (0.5 to 16), the more 
dangerous side being twenty-one times the right and eigh- 
teen times the left. In eight instances the operation room 
was 5 mm. or less-4 on 
each side ; the maximum 
difference was 8 m m. 
with the right, 5 with the 
left, the greater distance. 
It appears, therefore, 
from an analysis of all 
available data that the 
right sinus is usually 
larger, m ore anterior, 
and more vulnerable than 
the left, but in a degree 
too slight to be of practi- 
cal moment ; while the 
position of extreme dan- 
ger may be met on either 
side and in any form of 
skull. Bezold's observa- 
tion that an unsymmetri- 
cal skull has the more 
dangerous sinus on the 
larger side is as good a 
guiding indication as we 
can find. 
The other limitation of 
the operative field in opening the mastoid is the position 
of the floor of the middle cerebral fossa. This cavity ex- 
tends in rare instances down to the field of the operation, 
and uncovering or wounding of the dura mater is readily 
possible in an ill-placed opening (Fig. 407). So long as 
the tinea temporalis was accepted as an index of the 
height of the fossa, blunders were easy, since its variable 
position furnished no true criterion. The upper wall of 
the auditory meatus or its adjacent spina are now the 
usual guiding points, and by keeping below these safety 
is assured. In this matter of the height of the fossa Koer- 
ner has thought that a relation to the skull-form can be 
found, and that the brachycephalic skull and the right 
side (Fig. 409) are the more dangerous (Fig. 410), and 
that dehiscence of the tegmen tympani is therefore 
more common on the right (Fig. 407) and in brachy- 
cephalies, with consequent more frequent right-sided 
cranial involvements. His measurements of 87 skulls 
showed the height of the fossa above the upper meatus 
wall to average 11.5 mm. (7 to 17) among the very 
long, 8.7 mm. (4 to 14) among the less dolichocephalic 
Fig. 406.-Vertical Section of Pneumatic Left temporal Bone at right 
angles to the Auditory Canal, showing abundant cellular interspace be- 
tween the sigmoid sulcus and the meatus. (After Hartmann.) (Same 
lettering as in Fig. 407.) 
exactly the same figures as the whole series, while the one 
hundred and twenty short skulls gave averages of 11.4 
mm. (1 to 19 right), 12.5 mm. (1 to 20) left, with the more 
anterior sinus forty times on the right and forty-four 
times on the left. 
Such figures wholly fail to support Koerner's view, 
Fig. 408. - Dehiscent Areas in the 
Roof of the Tympanic Attic and 
Antrum of a Right Temporal Bone, 
with a low middle cerebral fossa. 
The internal auditory meatus is 
seen to the left, part of the sig- 
moid sulcus to the right. 
Fig. 407.-Vertical Section at Right Angles to the Canal, M, of a diploetic 
right temporal bone, showing a forward and superficial position of the 
sigmoid fossa, F, and a low middle cerebral fossa, C. (After Hart- 
mann.) 
and the choice of the twenty extreme examples at each 
end of the scale gave averages of 11.5 mm. right (0 to 17) 
and 13.1 mm. left (9 to 16) for dolichocephalic, as com- 
pared to 12.8 mm. (7 to 17) right and 13 mm. (10 to 16) 
left for brachycephalic. His findings must, therefore, 
be regarded as accidental. The thinnest point over the 
* Measurement of these dimensions with one branch of the calipers 
passed through the foramen magnum in the intact skull probably slightly 
exaggerates, since an error, fairly uniform throughout the series, and 
less than a millimetre in amount, was probably introduced from slight 
obliquity of the placing of the instrument. 
603 Mastoid Anatomy. 
Mastoid Anatomy. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
skulls, as against 5.2 mm. (2 to 9) in the brachycephalic. 
Schiilzke, on the other hand, found a low fossa (10 mm. 
or less) in fourteen long, ten medium, and fourteen short 
specimens, although 36 of his 60 skulls were brachy- 
cephalic ; and 20 times it was on the left side, and 18 
on the right. The average was 11.2 mm. (8 to 17) right, 
(SUPPLEMENT.) 
temporal ridge and its convexity in the horizontal plane 
passing gently into the auditory canal, is probably safe ; 
but there is no possibility of predicting the real condition, 
and nothing can relieve the surgeon of the duty of oper- 
ating as though the case were known to be very dan- 
gerous. 
The cells of the pneumatic mastoid are generally larg- 
est and thinnest-walled at its apex and especially upon 
its median aspect toward the digastric groove. Hence 
suppuration may rather readily break through in this 
region, especially when the outer mastoid cortex is thick. 
Dehiscence is not rare in this region, and may be met 
upon the outer aspect; but emphysema from such a con- 
dition almost never occurs. 
The third structure to be avoided in opening the mas- 
toid is the prominent inner wall of the antrum, where 
lie the facial and the horizontal semicircular canals. 
Generally these lie deeper than the part of the antrum 
reached by the operator ; yet in a sclerotic mastoid there 
may be danger of striking them when the antrum is not 
found. These structures are never farther outward than 
the upper posterior tympanic margin, and this point may 
usually be found with the probe on the patient and its 
depth used as a guide. It is easily measured on the 
macerated bone, and its distance from the spina is given 
as 12 to 17 mm. by Allen. In my fifty pairs of temporals 
it averages 17 mm. (14 to 20) from the spina, and 
19 mm. ( 16 to 21) from the operation point, 5 mm. 
back of the spina. A penetration of 15 mm., therefore, 
could hardly in any case wound these structures. Yet 
in many cases uncovering or necrosis of the bone may 
render uncertain the limits of the antrum, while calling 
for curretting of the surface. Cautious efforts should, 
therefore, be made to determine the location of these 
very important canals, since penetration of the semicircu- 
lar canal may be the death-blow to the auditory appara- 
tus, and through it or the facial, pus may readily pene- 
trate to the cerebral base with fatal effect. 
A point formerly more considered, and still practically 
Fig. 409.-Diagram of Right Temporal Bone Sectioned Horizontally and 
Showing the Inclination of the Tubo-tympanic Axis, C, D, to the 
sagittal plane of B; the length, m n, of the upper back wall of the mea- 
tus, and the depth, o, p, of the antrum from the operation point. (Af- 
ter Allen.) 
and 11.1 mm. (8 to 16) left, among the long ; 12.5 mm. 
(8 to 19) right, and 12.2 mm. (8 to 18) left, among the 
short ; with general averages 12.1 mm. right and 11.9 
mm. left. The height was equal in 12, differed but 1 
mm. in 41, and its maximum difference reached 4 mm. 
in only one case. In the writer's fifty pairs of temporals 
the right averaged 4.82 mm. (1 to 10), the left 5.41 mm. 
(2 to 11), with a maximum difference of 4 mm. among 
the 23 where the right fossa, and 12 where the left, 
was lower. In his study of this point in 240 skulls, the 
writer determined the vertical height of the fossa above 
the spina and the lateral displacement in the frontal plane 
within or beyond the spina. The averages were 6.5 mm. 
(1 to 14) right, and 6 mm. (0 to 14) left, with the left 
fossa lower in 138 and the right in 53. It was a shade 
lower in the brachycephalic-6 mm. (1 to 14) right and 
5.8 mm. (0 to 14) left-than in the dolichocephalic-6.6 
mm. (1 to 14) right and 6 mm. (1 to 12) left. The lowest 
point thus determined generally lay within the spina, 
sometimes 5 mm. internal, at times 5 mm. external, to it; 
while in some cases where it was but 1 mm. above, it 
was exactly over the spina. In no instance was it below 
the spina ; although at times lower than the upper mar- 
gin of the auditory meatus. In these measurements the 
extreme length and breadth of the skulls were taken to 
obtain the index, as was done was by Schiilzke, in accord 
with most craniologists ; although Koerner had used the 
breadth between the parietal protuberances. The dis- 
tance was also measured from spina to spina, and from 
sulcus to sulcus within, at the widest point. It was thus 
shown that the sinus, like the middle cranial fossa, not 
rarely lay farther outward than the spina or the more 
prominent operation point, yet was far enough back to 
be well out of reach and covered by 5 to 7 mm. of bone. 
It was therefore evident that the form and convexity of 
the mastoid process itself play an important part; and 
that irrespective of the size and position of the sigmoid 
sulcus there may interpose a thick wall of compact or 
cellular bone to protect the sinus, even when its large 
size and sweeping curves make the danger of its position 
seem inevitable. This question, therefore, of the exterior 
configuration of the mastoid process, as revealed to pal- 
pation of one or both bones, may be really our very best 
indication as to the probable safety or danger of opera- 
tion on the bone before us, as was pointed out by Bezold. 
A large mastoid, with not too deep a concavity below the 
Fig. 410.-Horizontal Section (upper half) of the Left Ear, with the Soft 
Parts in Place, showing the location back of the meatus, Jf, and the 
spina, Sp, of the posterior insertion of the auricle, I. The glenoid 
cavity, G, the tympanum, T, and the jugular, J, are also shown ; and 
the sigmoid sinus, /J, which in this case is safely distant from the field 
of operation, is seen to be most superficial opposite the insertion of the 
auricle. 
well worthy of mention, is the relation of the soft parts 
to the more important bony structures beneath. The 
incision preliminary to opening the mastoid has generally 
been made 5 to 10 mm. back of the insertion line of the 
auricle and not carried down very far toward the mastoid 
tip in order to avoid the branches of the posterior auric- 
604 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Mastoid Anatomy. 
Mastoid Anatomy* 
ular. Only to the aural specialist long unaccustomed 
to general surgery has the spirting of these little arteries 
any importance. Even in the swollen and infiltrated 
tissues they can generally be readily seized with haemos- 
tats and afterward twisted, should they tend to bleed at 
all when released. It is more important, perhaps, to cut 
slightly behind the insertion of the auricle, in order that 
there may be the least projection of the pinna subse- 
quently. The old rule that this insertion marked the 
point for entering the bone, has been wholly superseded ; 
and it may be better said to mark the usual location of 
the most superficial part of the sinus (Fig. 411). Ac- 
cording to Bezold it averages 15 mm. behind the spina, 
but Hartmann's finding of 10 to 12 mm. is probably 
more accurate. The older operators usually selected the 
area thus posterior to the auricle for entrance ; modern 
operators usually work in the area covered by its inser- 
tion. A third location has been advocated as the best 
site for all cases-as it certainly is for some-the mastoid 
surface anterior to the spina, which constitutes the pos- 
terior wall of the auditory canal. For a case like that 
shown in Fig. 410, no other entrance would be possible at 
the usual level. Here we may be sure of thin bony plates 
to be opened, and a shorter, safer path to the antrum. Yet 
a little swelling of the soft tissues of the canal will serve 
to impede greatly free access to such an opening or the 
free exit of discharge ; and whether made from the canal 
or from the incision back of the auricle, it is probably 
rarely so satisfactory as the more usual perforation. 
The thin walls of the cells upon the median surface of 
the mastoid tip have been referred to. They are some- 
times dehiscent, as Bezold found four times among 200 
skulls, and often so thin as to be broken in the specimens; 
in 22 they could be readily pierced with a needle. Hence 
it is easy for pus to break through into the digastric 
fossa, thence to burrow beneath the fascia of the neck to 
form post-pharyngeal, deep cervical, or even mediastinal 
abscesses. Generally in the cases of this sort clinically 
met, there is a distinctly excessive thickness (whether 
natural or pathological, of the outer lamella of the mas- 
toid, which probably as greatly influences the result as 
does the thinness in the digastric fossa. Such pus col- 
lections are apt to be concealed from ready detection by 
the interposition of the bony process and the tendon and 
muscle of the sterno-mastoid, which may, as a whole, 
be pressed outward. Surgical common-sense seems to 
demand that these cases should be attacked at the pos- 
terior margin of the digastric groove, where the neck ab- 
scess and the mastoid empyema are both within reach, 
the pus fully evacuated, and then such counter-openings 
made as the case may demand. A sinus can generally be 
found upon the digastric surface of the bone, and through 
it the interior can be emptied of pus and granulations, 
so that irrigation can pass freely in to the tympanum ; 
yet a more typical opening of the outer surface of the 
bone at or below the usual point is also called for to give 
free access to the antrum. Bezold, indeed, now does this 
alone, neglecting the lower opening unless compelled to 
interfere here also ; yet this seems to ill accord with the 
anatomical conditions presented. 
The anatomy of the juvenile mastoid presents great 
variations according to the age, as has been previously 
suggested. A mere tubercle upon the surface of the in- 
fant temporal, some distance from the lowest part of the 
bone, the mastoid process changes in every respect as it 
grows. Small as are the general dimensions of the 
bone, some parts are full-sized even thus early. The 
tympanum undergoes little change in after-years, except 
in being separated from its fellow by the growth of the 
skull base between, and more deeply buried by the out- 
ward growth of the auditory canal. The size of the an- 
trum, as of the other portions of the tympanum, increases 
little after birth ; but while the bony wall separating it 
from the exterior grows from almost nothing to a thick- 
ness of 10 to 15 mm., the separation from the lateral 
sinus steadily decreases (Fig. 411). Hartmann found this 
wall never less than 3 mm., generally 4 mm., in 21 
temporals of new-born infants ; while in 12 bones of 
children from one to five years it averaged 2 mm., but 
was hardly 1 mm. in 5. This is due to the pressing for- 
ward of the lateral sinus as it grows, grooving more 
deeply the inner aspect of the petro-mastoid. It thus 
tends to approach the auditory meatus, for while in 40 
infant bones measured by Hartmann the meatus-sulcus 
Fig. 411.-Portion of Skull showing Trephining Opening at T, with a 
dark line above to indicate the usual height of the middle cerebral 
fossa, the curved lines posteriorly to show the usual limits of the lat- 
eral sinus and the horizontal line at A, part of Reid's base line, pass- 
ing through the lower edge of the orbit and the occipital protuber- 
ance. (After Birmingham.) 
distance averaged 12 mm., and was never less than 10 mm. 
in the 12 bones of children from one to five years, it was 
sometimes but 8 mm., with an average of 10 mm. In 16 
bones of individuals from five to twenty years it averaged 
still less. Similarly the writer found among 10 tempo- 
rals of new-born infants in his collection a distance 
averaging 6 mm. (4 to 7 mm.) between the sulcus and 
the antrum, and 13 mm. (11 to 14 mm.) between the sig- 
Fig. 412.-Left Temporal Bone Chiselled to Open the Mastoid Cells and 
Antrum. The opening, although not so extensive as sometimes figured 
and advocated, could be safely thus made in only a fraction of cases. 
(After Politzer.) 
moid sulcus and the meatus. This latter dimension had 
an average of 11 mm. (8 to 14 mm.) among 15 temporals 
of children from one to five years of age, the smaller 
distance being in the more developed bones-figures a 
little greater than the average in the adult, and presenting 
no such minimal measurements as are there often found. 
The antrum is, therefore, readily reached at little depth 
605 Mastoid Anatomy. 
Meninges, 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
in tbe child, and the lateral sinus is generally well back 
of probable injury. The middle cerebral fossa is gener- 
ally low (1 to 5 nun.), averaging 3 mm. ; and in not a 
few instances a large venous sinus deeply grooves the 
most vulnerable outer portion of it. The spina is more 
often lacking and tbe outer margin of the meatus is less 
well-defined than in the adult ; so special care should be 
taken to avoid penetration at too high a point. 
Bibliography. 
Zoja, G. : Annales Universales, clxxxviii., p. 241, 1864. 
Zuckerkandl, E. : Monatschrift fiir Ohrenheilkunde, 1873 ; Schwartze's 
Handbuch, 1892. 
Buck, A. H. : Archives of Ophthalmology and Otology, vol. vii, 
Politzer. A. : Handbuch, 1887. 
Schwartze A Eysell: Archiv fiir Ohrenheilkunde, vol. vii., 1873 ; 
Schwartze's Lehrbuch, 1885. 
Bezold, Fr. : Monatschrift fiir Ohrenheilkunde, 1873 ; Archiv fiir Ohren- 
heilkunde, 1881. 
Hartmann. A. : Archiv fiir klinische Chirurgie, vol. xxi., p. 335 ; Text- 
book, 1887. 
Leidy, J. : Science. May and June, 1883 ; Elementary Anatomy, 1889. 
Koerner, O. ; Archives of Otology, vol. xvi., p. 281 ; vol. xviii, p. 310 ; 
vol. xxi., p. 431. 
Schuelzke, O. : Archiv fiir Ohrenheilkunde, vol. xxix., p. 201. 
Birmingham, A. : Transactions Academy of Medicine, Dublin, January, 
1891; Jones and Stewart's Text-book, 1892. 
Allen, S. E. : The Mastoid Operation. Cincinnati, 1892. 
Randall, B. A. : Preliminary Notes on Craniometric Studies in Relation 
to Aural Anatomy, Transactions of American Otological Society. 1892 ; 
The Corrosion Method in the Study of the Anatomy of the Ear, Trans- 
actions Philadelphia College of Physicians, 1890; Photographic Illus- 
trations of the Anatomy of the Ear, second series. 
B. Alexander Randall. 
MATLOCK. A favorably known spa and summer re- 
sort in Derbyshire, England. 
Location.-Matlock is situated on the banks of the 
river Derwent, between the sheltering tors of Matlock 
Dale. The place is noted for its agreeable summer cli- 
mate just as much as for its indifferent thermal springs. 
Bradshaw describes the place as follows : 
"Matlock Bath is built partly in a valley, through 
which flows the river Derwent, and partly upon terraces 
of tufa, deposited from its warm springs. It is sheltered 
from the north and east by the heights of Masson and the 
High Tor. To the south and across the Derwent are the 
grounds of Willersley Castle. There is a large pavilion 
in which a band plays and concerts are given during the 
summer, and a promenade by the side of the Derwent. 
The neighborhood is very beautiful and picturesque." 
Access.-Matlock Bath is reached by the Midland 
Railway in a four hours' trip from London. 
Analysis.-The temperature of the springs is 68° F. 
Their chief mineral ingredients are magnesium sulphate, 
carbonate of lime, and sodium chloride. But the solids 
amount to only about thirty grains per gallon of the 
water. Matlock water is palatable, owing to a fair pro- 
portion of free carbonic acid gas. 
Indications.-Matlock is resorted to in cases of gout, 
rheumatism, bladder affections, skin diseases, and mild 
neuroses. Scrofula is also said to be treated with good 
results there. 
Accommodation.-The bathing establishments, ho- 
tels, and lodging-houses are only moderately comfort- 
able. Edmund C. Wendt. 
MENINGES (THE ENVELOPES OR MEMBRANES 
OF THE BRAIN AND SPINAL CORD). § 1. Introduc- 
tory Note.-During the preparation of the present arti- 
cle points supposed to be clear have proved to need 
further elucidation, and problems altogether unexpected 
have arisen, demanding for their solution time, mate- 
rial, and apparatus at present unattainable.* Indeed, 
so impressed has the writer become with the vague- 
(SUPPLEMENT.) 
ness, inadequacy, and inconsistency of current accounts, 
and with the necessity for a re-examination of the 
meninges in all their relations, that only a sense of obli- 
gation to the patient and considerate editor who has en- 
trusted him with the subject stands in the way of re- 
treat at the eleventh hour. Necessarily transmitted to 
the printers at a certain time, the article is neither so 
clear, consistent, correct, concise, nor complete as the 
writer would wish it to be. The least unsatisfactory 
position relates to the question of the existence of a nat- 
ural communication between the true cavities of the 
brain and the spaces ectad of it. 
Of the eleven figures four (418. 420, 421, 422) are origi- 
nal. One (423) is from Henle, and one (417) from Sappey. 
The diagram, Fig. 416, from Dr. Langdon's paper, 1891, 
is kindly loaned by the author. The remaining four 
(413, 414, 415, 419) are copies of the reductions of figures 
by Key and Retzius in Quain's "Anatomy." * 
In quoting from these and other works the terms pre- 
ferred by the present writer are commonly employed. 
Seethe article, "Anatomical Terminology." in Vol. VIII. 
Fig. 413.-Transection of the Myel and its Meninges in the " Upper " 
Thoracic Region. Enlarged somewhat from Key and Retzius (Taf. i., 
Fig. 7), after Quain (iii., Fig. 132). a. Dura (not the spinal perios- 
teum, but representing the ental layer of cranial dura) ; b, arach- 
noid ; c, septum posticum ; d, e, f, trabeculae in the subarachnoid 
space, those at / supporting the dorsal (posterior) nerve-roots ; g, 
ligamentum denticulatum ; A, ventral (anterior) nerve-roots, cut 
off; A, I, subarachnoid spaces. The pia is not designated, but may 
be recognized as the double outline of the myel dipping into the dorsal 
fissure as a narrow septum and into the ventral as a fold. 
Note.-The foregoing is substantially the description in Quain. But 
some of the writer's observations lead him to suggest that the spinal, 
like the cranial, arachnoid comprises two layers, a dural and a pial, 
connected by the reflected layers of the septum posticum. This view, 
however, would homologize the space k, I, with the intrarachnoid space 
of the cranium, and hence their free communication with the postcis- 
terna would be difficult to explain. 
S 2. Points illustrated by Fig. 413. + A. The subcyl- 
indrical form of the myel, and the relations of the areas 
of alba and cinerea at this level ; for these and most of 
the other features shown in this figure see the account 
by Spitzka, Vol. VIII., pp. 476-477. 
B. The existence of a dural sheath (theca) of the myel, 
independent of the periosteum, the two being united in 
the cranium. 
C. The somewhat loose adhesion of the arachnoid to 
the dura, leaving slight and scattered subdural spaces. 
D. The presence of the septum posticum at this level; 
it is said (Quain, iii., 188) to be most perfect in the cer- 
vical region, and more or less incomplete farther cau- 
dad4 
E. The size of the subarachnoid space traversed by the 
* The conditions of investigation of the meninges are peculiar. The 
pia and arachnoid are relatively delicate : they are easily torn and their at- 
tachments ruptured. But they are surrounded by an unusually tough 
membrane, the dura, and the whole is enclosed within a case of bone 
which must be sawn or otherwise forcibly opened by measures which 
are almost su'e to rupture the pia and arachnoid. It is much to be 
desired that the whole subject be reviewed by some anatomist having 
the use of a mechanical bone-cutting apparatus, e.g., the electro-osteo- 
tome of Dr. M. J. Roberts. 
* Besides those here included, the new figure, 182, of the tenth edition, 
vol. ii., is worth consulting, although not altogether satisfactory. 
+ See note under the description of Fig. 413. 
J (Septum posticum is an undesirable term, but septum dorsale might 
be confounded with the prolongation of the pia into the dorsal fissure of 
the mye). 
606 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Mastoid Anatomy. 
Meninges. 
spinal nerve-roots, the trabecuke, and the ligamentum den- 
ticulatum. 
F. The location of the ligamentum denticulatum at 
either side of the myel. As shown in Vol. VIII., Fig. 
5047, 9,9, 9, and described on p. 477, this is a fibrous band 
connected with the pia, and reaching the dura by a tri- 
angular extension in the intervals between the nerve- 
The term pachymeninx (tough envelope) is sometimes 
used for the dura, irrespective of the recognition of a pa- 
rietal layer of arachnoid. In like manner leptomeninx 
(tender envelope) is sometimes used for the pia and the 
commonly admitted visceral layer of arachnoid. The 
pathological terms, pachymeningitis and leptomeningitis, 
are derived from these words. 
§ 5. Points illustrated by Fig. 414. A. The formation 
of a nerve-root from the union of several funiculi or 
rootlets. 
B. The extension of the myelic dura upon the root at 
its exit from the spinal canal, to be lost in the sheath of 
the nerve. 
§ 6. The Pia.-This was formerly more often called 
pia mater,* sometimes also meninx tasculosa (Ger., dunne 
Hirnhaut, weiche Hirnhaut; Fr., pie-mere). It is deli- 
cate, fibrous, highly vascular, and intimately connected 
with the neuraxis, into the substance of which it sends 
numerous nutrient small vessels. When stripped off, 
these vessels commonly break at a short distance from 
the pia, and their number and minuteness impart to the 
ental surface of the membrane a flocculent or woolly 
aspect, the tomentum; Vol. VIII., p. Ill, § 11, F. 
§ 7. Myelic Pia.]-This is thicker and firmer than the 
encephalic, less vascular, and more closely adherent to 
the nervous substance. It has sometimes been called the 
" neurilemma of the cord." Two layers are recognized : 
the ental, sometimes called intima pia, sends a fold into 
the ventral ("anterior") fissure, and into the dorsal a 
lamina not recognizable as a fold. Along the ventri- 
meson the pia presents a conspicuous fibrous band, the 
linea splendens, not represented in Fig. 413. 
§ 8. Points Illustrated by Fig. 415.-A. The relative 
positions of the meninges; compare Fig. 416 and Vol. 
VIII., Fig. 4687. 
B. The formation of the longitudinal sinus within the 
substance of the dura. 
Fig. 414.-Section, Lengthwise, of a Ventral Nerve-root at its Place of 
Exit from the Spinal Canal. Enlarged. From Key and Retzius (Taf. 
i., Fig. 10) after Quain (iii., Fig. 128). a, Four funiculi uniting to 
constitute the root ; b. dura reflected upon the root at its emergence 
through the intervertebral foramen (the periosteum is not shown) ; c, 
arachnoid ; d, reticular lamella of the arachnoid reflected upon the 
root (compare Fig. 413,/) ; s, subdural space; s', subarachnoid space. 
roots ; but opposite the roots (as in this figure) it is nar- 
rower, and does not reach the dura. 
§ 3. Definitions.-Meninges is the plural of meninx, 
from the Greek finviyl, signifying any membrane or coat- 
ing, as of the eyeball, and even the scum upon milk or 
•wine ; but, as stated by Hyrtl (" Onomatologia," p. 324), 
the word was restricted by Aristotle ("Hist. Anim.," 
lib. i., cap. 16) to the coverings of the brain (and myel ?), 
and the limitation has been 
since maintained. The syn- 
onyms of meninx are: Fr., 
meninge ; It. and Sp., me- 
ninge ; Ger., Himhaut. 
§ 4. The Three Meninges.- 
Nearly all anatomists rec- 
ognize three chief membra- 
nous envelopes between the 
substance of the neuraxis 
(brain and spinal cord) and 
the cranio-spinal canal, viz. : 
An ental, the pia; an ectal, 
the dura; an intermediate, 
the arachnoid. Their rela- 
tive positions when the cra- 
nium is opened are indicated 
in Vol. VIII., Fig. 4687. 
Properly speaking the pia 
pertains to the neuraxis, and 
the dura to the cranio-spinal 
canal, while the arachnoid 
has more or less varied rela- 
tions to both the other me- 
ninges. All three present dif- 
ferences according to their 
location within the cranium 
or the spine, and there are 
transition conditions in the 
cephalic portion of the latter 
which are not yet fully made 
out. 
♦ The reduction of the polyonyms, pia mater and dura mater, to the 
mononyms, pia and dura, was urged by the writer in 1880 in a paper be- 
fore the American Association for the Advancement of Science. Since 
that time the uae of pia and dura, and of the natural adjectives, pial and 
dural, has become quite general. The simplification has been recom- 
mended by the Association of American Anatomists (December 27, 1889) 
and by the American Association for the Advancement of Science, 1890 
M . .... . . . , . n 
obscure it. 
--dura. 
i pia. 
■-cortex. 
-mcdul'a. 
Fio. 415.-Transection of the Dorsal. Mesal Region of the Cerebrum, to show the.Meninges and Arachnoidal 
Villi. Slightly enlarged. From Key and Retzius (Taf. xxix., Fig. 4) after Quain (iii.. Fig. 134). 
Preparation.-The spinal subarachnoid space (Fig. 413, k, I) was injected with a fine blue mass, which 
filled (and distended ?) the corresponding space upon the cerebrum and entered the arachnoid villi. The 
original figure is appropriately colored and on a larger scale. Judging from the relation between the width 
of the falx, and the interval between it and the callosum, the plane of section was not far cephalad of the 
splenium ; see Fig. 418. c.c.. callosum ; f, falx : x. falcial sinus ; s.a. (at the left), subarachnoid space. 
Defects.-The pia is not as distinct ns the writer would make it. The relation of the arachnoid to the 
ventral margin of the falx is not quite clear. There is no extension of the cortical cinerea upon the 
dorsum of the callosum as an indusium ; see p. 104, § 47. There is no indication of the existence of the two 
layers of the dura, e.<j„ periosteal and encephalic, described by Spitzka (Vol. VIII., 47) and Langdon (Fig. 
416). The falcial (inferior longitudinal) sinus may have been absent in this case, as it is said to be in many 
(Browning, Vol. VIII., 241). The lacuna1 lalerales are somewhat indistinct, probably inconsequence of 
the reduction from the original figure, where they are much more clearly shown. 
607 meninges. 
Meninges. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
C. The projection of the arachnoid villi into the sinus 
and the parasinual spaces; see Browning, Vol. VIII., p. 
242. 
D. The accumulation of the villi at one point, on the 
right, to such an extent as to cause the protrusion of the 
dura, and presumably a depression of the ental surface 
of the cranium. 
E. The separability of the arachnoid from the pia, 
leaving a distinct subarachnoid space increased along the 
fissure lines. 
F. The conterminousness of the arachnoid and the falx, 
and their separation by a distinct interval. 
§ 9. The Encephalic Pia.-According to Quain (iii., 
186), only the ental of the two myelic layers of the pia 
is represented on the brain, but where and how the other 
layer' disappears is not stated. The pia follows all the 
undulations of the encephalic surfaces, dipping into the 
fissures and rimulas as folds or rugas of corresponding 
depth ; see Fig. 300 and Vol. VIII., Fig. 4687. At the 
bottom of the intercerebral fissure, the rnesal cleft be- 
tween the dorsal portions of the two hemicerebrums, the 
pia enters the callosal fissure at either side, is then reflect- 
ed, and crosses the callosum. 
Since the pia is practically the ectal surface of the brain, 
its cut edge is not commonly represented excepting when 
the figure is on a very large scale ; but on diagrams its 
§11. 1 he Plexuses.-At several localities in the brain 
the pia forms vascular quasi-intrusions (choroid plexuses) 
into the cavities, carrying before it, however, the endyma 
lining those cavities, so as to be, strictly speaking, ex- 
cluded therefrom ; see Figs. 60, 61, 62, and 418 ; also Vol. 
VIII., Figs. 4708, 4709,4710, 4740, 4745,4749, and 4751.* 
§ 12. Points Illustrated by Fig. 416.-A. The existence 
of two layers of dura in the cranium, the one correspond- 
ing with the periosteum of the spinal canal, the other 
with the dural sheath of the myel, Fig. 413, a. 
B. The existence of two layers of arachnoid-an ental 
or pial, and an ectal or dural. 
C. The propriety of regarding the so-called subdural 
space as an intrarachnoid space, analogous with the se- 
rous sacs in other parts of the body ; see § 24. 
§ 13. The Dura.-This mononym is rapidly replacing 
dura mater and the German hartc Hirnhaut; see § 6, 
note. As shown in Figs. 414 and 415, and in Vol. VIII., 
Fig. 4687, the cranial dura is apparently a single sheet, 
dense, strong, fibrous, and unyielding, fining the bones 
and constituting their ental periosteum. But a closer 
examination detects two layers, an ectal and an ental, 
which gradually separate in the cephalic part of the cer- 
vical region, and in the spine maintain diverse relations, 
the one with the canal, the other with the myel. 
§ 14. The Theca.-The ental or myelic portion of the 
spinal dura constitutes a fibrous 
tube, the theca. It is consider- 
ably longer and larger than the 
myel itself, and separated from 
the periosteum, constituting the 
wall of the canal by venous plex- 
uses and much areolar tissue. 
The cavity between the pia and 
the dura is occupied by cerebro- 
spinal fluid (ccelio-lymph), and is 
divided by the curtain-like arach- 
noid into the spaces subdural and 
subarachnoid. Within the latter 
the myel, closely covered by pia, 
is suspended, being kept in posi- 
tion by a ligament on each side, 
ligamentum denticulatum (Fig. 
413), which fixes it at frequent in- 
tervals to its sheath, and by the 
roots of the spinal nerves (Fig. 
413, f), which cross the space 
from the surface of the myel to 
the intervertebral foramina. 
§ 15. The Epidural Space.- 
In the spine, since there are 
two layers of dura, an ectal 
(periosteal) and an ental (myelic), the interval be- 
tween them constitutes an epidural space. In the 
figures this is nowhere clearly shown, but it may be 
represented in Fig. 413 by drawing around the pres- 
ent ectal outline, the myelic dura, a second at a little 
distance therefrom ; the interval would be the epidural 
space. 
§ 16. Two questions naturally arise in connection with 
the epidural space. 
1. Does it communicate with the subdural space ? If 
so, where ? 
2. If not, what is the source of the liquid occupying 
the space, and what is its nature ? 
§ 17. Points Illustrated by Fig. 417.-A. The relation 
of the dura to the cranium as a complete lining of con- 
siderable thickness. 
B. The relation of the falx and falcula, as mesal ex- 
tensions of the dura, to the tentorium as a transverse ex- 
tension. 
C. The tent-like form of the tentorium, the lateral 
margins coinciding approximately with the long axis of 
-Periosteum. 
-Calva. 
-Dura 
-Ectal arachnoid. 
-Intrarachnoid space. 
-Ental arachnoid. 
-Subarachnoid space. 
-Pia. 
ectal. 
ental. 
Fig. 416.-Schematic Transection of the Parietal Region of the Newborn, to show the Relations of 
the Meninges to the . Cerebrum and Cranium. From F. W. Langdon. 1891. C, C. cerebrum ; F, 
falx; S, longitudinal sinus; xxx, subserous connective tissue between the dura and the ectal arach- 
noid. 
Defects.*-The mesal dark area dorsad of S (the longitudinal sinus) represents the ligamentous 
connection of the two parietal bones; it should be continuous with the periosteum and ectal dura. 
The "subserous dura," between the dura and the arachnoid, represented by the series of crosses, is 
made too wide in nrouortion. 
vascular character may be instructively'indicated by a 
red line.f Sometimes, as in Fig. 59, §43, 6, the pia forms 
the only boundary of an area. 
§ 10. The Telas.-As has been described in Vol. VIII., 
p. 118, § 44, Fig. 4707, the ccelian parietes, i.e., walls of 
the true encephalic cavities, typically comprise three con- 
centric layers, viz., an ental endyma, an ectal pia, and an 
intervening brain-substance. The endyma and the pia 
are nearly uniform in thickness and constitution ; the ner- 
vous layer varies considerably in cellular structure and 
even more in thickness, from thin and apparently func- 
tionless areas, terma, valvula, etc., to the enormously 
thickened roof of the paraccele (lateral ventricle). In 
most animals at two places, and in man and apes at three, 
the proper nervous wall disappears (or in some cases, per- 
haps, is never formed), leaving the endyma and the pia 
in contact. The membranous area so constituted is a tela. 
The roof of the metacoele is the metatela (tela choroidea 
inferior) -, Fig. 59 and Vol. VIII., Figs. 4684, 4710, and 
4711 ; that of the diacoele is the diatela (Fig. 59 and Vol. 
VIII., Figs. 4711 and 4751. In man and apes a zone of 
the paracoelian floor is a membranous paratela. Fig. 61 
and Vol. VIII., Figs. 4750 and 4751. 
* On the mode of formation of the rima (sometimes called choroid fis- 
sure) independently of the blood-vessels, see His, " Die Formentwickel- 
ung des menschlichen Vorderhirns," etc., Leipzig, 1889, pp. 694 and 712, 
as quoted by Cunningham, ''Surface Anatomy of the Primate Cere- 
brum," 1892, p. 3. 
♦ Dr. Langdon informs the writer that the cut does not represent the 
original drawing quite fairly in some respects. 
+ On such diagrams the endyma ("ependyma" or lining of the cavi- 
ties) may be represented by yellow or green. 
608 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Meninges, 
Meninges. 
the cranium, the intermediate portion rising toward the 
meson at an angle rapidly increasing from the occiput 
cephalad. 
I). The inversion of the falcula as compared with the 
falx. 
E. The general arrangement of the more prominent 
fibres of the falx ; there is a marked divergence or radia- 
tion from about the place of intersection of the free mar- 
gins of the falx and the tentorium. 
F. The locations of the principal sinuses along the lines 
of attachment of the dural folds to one another or to the 
cranium. 
G. The direction of the current in the principal sinuses: 
(SUPPLEMENT.) 
(cerebelli). Its topographical relations with several of 
the sinuses are described by Browning, Vol. VIIL, pp. 
241-242, and indicated in Figs. 417 and 418. 
The tentorium exists in most, if not all, mammals, 
but not, so far as the writer is aware, in other vertebrates; 
in the Carnivora it is ossified. 
§ 19. The Falx.-From the cerebral side of the ten- 
torium extends cephalad a mesal duplicature of the dura, 
the falx, well named from its sickle-shape ; Figs. 417 
and 419. The narrower cephalic end is attached to the 
crista gaUi. The distance between the free margin of the 
falx and the callosum increases cephalad. The relations 
of the falx to the longitudinal and falcial sinuses are 
shown in Figs. 417 and 418. 
§ 20. The Falcula.-This name (wrongly 
printed falcicula) was proposed by the 
writer as, a mononym for falx cerebelli, 
designating the mesal fold of dura which 
extends ventrad from the tentorium to the 
foramen magnum, where it bifurcates. It 
is vaguely shown) in Fig. 418, 5, more 
clearly in Fig. 417, 13. 
§ 21. The Fontanels (Fr. fontanelles}.- 
These are the intervals between the cor- 
ners of the infantile parietal bones before 
these corners have formed sutural union 
with the adjacent bones. There are six 
fontanels, two mesal and two pairs of 
lateral. The lateral, at the cephalic and 
caudal angles of the ventral border of the 
parietal bone, are small, irregular, and of 
comparatively little interest. The two 
mesal fontanels are at the ends of the sagit- 
tal suture ; their more common designa- 
tions, anterior and posterior, may appropri- 
ately give place to prefontanel and post- 
fontanel. 
§ 22. Analogy of the, Fontanels with the 
Telas.-The structure of a tela was de- 
scribed in § 10. But since, in mammals at 
least, the telas are alw'ays more or less 
closely adherent to adjacent parts, and 
their margins are easily detached, their 
relations are sometimes not clearly appre- 
ciated. But if an infant or foetal cranium 
be divided across the prefontanel diagon- 
ally, so as to include either parietal bone 
and the opposite frontal, the cut edge will 
present three layers, viz., an ental, the 
dura, representing the endyma ; an ectal, 
the pericranium, representing the pia ; an 
intermediate, the bone, representing the 
nervous parietes. At the fontanel this 
third element is absent, and the conjoined 
dura and pericranium contribute a mem- 
branous area quite comparable with a tela 
and available for illustration thereof. 
A defect in the analogy is this : The 
cranial bone is of nearly uniform thick- 
ness, and thins out at the margin of the 
fontanel. But in the brain, although the 
immediate margins of the telas may be 
thin, the general parietes are commonly 
very massive, and there is usually a par- 
allel zone specially differentiated, e.g., the 
habena. * 
§ 23. Points illustrated by Fig. 418 as to 
Meninges and Vessels ; other points are indicated in Vol. 
VIIL, pp. 121-123. 
A. The degree of retention of the dura in this speci- 
men is greater than wdth any brain ever seen or heard of 
by the writer. The brain was most skilfully removed, 
according to the writer's directions, by Professor W. C. 
Krauss, a former student; see p. 117, § 33. 
Fig. 417.-Mesal Aspect of Right Half of Medisected Skull retaining the Dura. X .5. 
From Sappey (iii., Fig. 462); after Quain (iii., Fig. 129). Compare Fig. 759 in 
Vol. II. of this work. 
Def'ctt.-As usual, there is no indication of the change that occurs at or near the 
foramen magnum, by which the apparently single dura of the cranium divides into a 
true dura related to the myel (Fig. 413) and a spinal periosteum; see, however, 
Quain, iii., Fig. 182. The region of the postoccipital sinus (12) is so heavily shaded 
as to give the impression of its considerable width ; as shown in the original of Sap- 
pey, this sinus is no larger than the subpetrosal; according to Browning (Hand- 
book, VIII., p. 242), this is merely a constituent of the irregular basilar plexus of 
venous channels. The vein of Galen (25) here joins the tentorial sinus at an angle 
of about 45° ; really, as shown in Fig. 418, it curves about the rounded splemum and 
joins nt nearly a right angle. 
1, falx; 2, longitudinal sinus; 3, concave ventral margin of falx; 4, falcial (in- 
ferior longitudinal) sinus; 5, base of the falx where it joins the tentorium ; 6, ten- 
torial (straight) sinus or s. rectus; 7, cephalic, narrow end of falx, a little dorsad of 
the crista galli to which it is attached ; ventrad of the line is a frontal (air) sinus, 
seen also in Fig. 4684 ; 8, right side of tentorium, sloping latero-ventrad from the at- 
tachment to the falx to the side of the cranium along the lateral sinus (9); X, the tor- 
cular, the place of confluence of the two lateral sinuses, the longitudinal and the 
falcial; 10, the superpetrous (superior petrosal) sinus ; 11, the subpetrous (inferior 
petrosal) sinus; 12, postoccipital (posterior occipital) sinus ; the arrows indicate the 
direction of the blood in the larger sinuses; the lateral sinus is continuous with the 
ento-jngular vein; 13, fdcula (falx cerebelli); 14, optic nerve; 15, oculo-motor 
nerve; 16, trochlearis nerve; 17, trigeminus (trifacial) nerve; 18. abducens nerve; 
19, facial and auditory nerves; 20, glosso-pharyngeal, vagus, and accessory nerves; 
21, hypoglossal nerve ; 22, 23, first anil second cervical nerves ; 24. cephalic end of the 
ligamentuni denticula'.um (see Fig. 413); 25. union of the velar veins to constitute 
the vein of Galen opening into the tentorial sinus (see Fig. 418). 
in the longitudinal (2) and tentorial (6) (with the falcial, 
(4)) toward the torcular ; in the lateral (9), toward the exit 
in the base of the skull at the jugular vein (4), in the 
superpetrosal and subpetrosal (10, 11) to the lateral. 
H. The entrance of the supercerebral veins into the 
longitudinal sinus at the points indicated by the black 
spots in the course of the latter and at others not indi- 
cated ; see Vol. VIII., p. 237. 
§ 18. The, Tentorium.-The cerebral region of the 
cranium is partitioned off from the region containing 
the cerebellum by a fold of the ectal layer of the dura, 
which, from its arched shape, is called the tentorium 
♦ It is proper to add that, although this analogy between the telas and 
the fontanels had already occurred to the writer, he was reimpressed 
with it on listening to an admirable lecture upon the anatomy of the 
brain by Professor D. K. Shute, at the Columbian Medical College, Wash- 
ington, D. C., December 16, 1889. 
609 Meninges. 
Meninges. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
B. The existence, in the caudal three-fifths of the 
cerebrum, of a distinct and considerable mesal depres- 
sion, containing the longitudinal sinus, so that here the 
retreating surface of the dura is seen beyond its dorsal 
cut margin ; presumably this corresponded with a mesal 
thickening of the cranium. 
C. The distinctly sickle-shape of the mesal extension 
of the dura between the two hemicerebrums, whence its 
name, falx. 
D. The non-correspondence of the width of the falx 
with the area dorsad and cephalad of the larger part of 
the callosum. 
E. The location, form, and extent of the medicisterna 
{cisterna ambiens), the irregular space between the cere- 
bellum, the splenium, and the geminums, roofed by the 
arachnoid and tentorium. 
(SUPPLEMENT.) 
F. The location, form, and extent of the ventricisterna 
(cisterna intercruralis), between the crura, the pons, and 
the tuber* (tuber cinereum), infundibulum and hypophysis. 
It forms a very deep indentation of the ventral outline 
of the brain, corresponding with the cranial or mesen- 
cephalic flexure ; Vol. VIII., p. 112, § 16. It is bridged 
by the arachnoid, following substantially the line of the 
dura, and thus includes the arteries of this region. 
G. The location, extent, and form of the postcisterna 
(cisterna magna cerebello-medullaris), the interval between 
the dorsum of the oblongata, the cerebellum, and the 
adjacent portion of the cranium, or strictly the ectal 
layer of arachnoid in that region, represented by the 
black line marked 10 ; see Figs. 420, 421. 
H. The location of the metapore (Foramen of Magen- 
die), the orifice in the metatela (tela choroidea inferior), 
constituting the roof of the metacoele 
or me ten cephalic portion of the 
" fourth ventricle." The metapore is 
thus a direct orifice of communication 
between the metacoele, one of the 
encephalic cavities, and the post- 
cisterna, a part of the subarachnoid 
space ; see Figs. 422, 423, and § 28, 
note. In this specimen its relations are 
complicated by the postcerebellar ar- 
tery, a loop of which lies just dorsad 
of it; see under. Defects. 
I. The location of the postcerebellar 
artery. This is not named on the fig- 
ure and is imperfectly shown. The 
central portion, from its origin at the 
vertebral, is invisible here, but shows 
in Figs. 420 and 423. Just at the side 
of the metapore it turns sharply upon 
itself, forming a loop, somewhat as in 
Fig. 420, but in the present figure the 
peripheral portion of the artery alone 
is seen, and looks as if it began in the 
metapore. The two principal divisions 
are as here represented. There is ap- 
parently considerable variation in the 
course and subdivision of this vessel. 
J. The length of the longitudinal 
sinus, equalling nearly the greater 
curvature of the cerebrum; its ce- 
phalic end was probably not quite 
reached. 
K. The presence of the falcial sinus 
(2) along the ventral, free margin of 
the falx. This is said to be often 
wanting; see Vol. VIII., p. 129, § 59, 
and p. 241. The writer suggests that 
the alleged absence of this sinus in 
the foetus may be due to its nondetec- 
tion. 
L. The straight course of the ten- 
torial sinus in line with the falcial, 
along the ventral margin of the caudal 
fifth of the falx, w'here the latter is 
continuous with the tentorium (Fig. 
417, 8). The tentorial sinus is not 
named or otherwise designated on this 
figure, but in Fig. 417 it is numbered 
6 ; it is also called straight sinus or 
sinus rectus. 
M. The junction of the mesal longi- 
tudinal and tentorial sinuses at the 
torcular (Herophili). The course of 
the lateral sinuses thence is indicated 
in Fig. 417. 
N. The location of the right velar 
porta 
pseudocoele | 
rostrum ; 
genu, ! ! ! 
tomlconiniHisure 
; । inedicomnussure 
12 velum 
; ; J ! fornix 
. aulix. 
habena 
/ supracommissure 
conanum 
spleniuni 
termatic 
pregeminum.; 
■-aqueduct $ 
^postconunissure 
Kv postgeimnum 
iw\ _ .valvula 
■M&C , h ngula^ 
pre cerebral 
ccpuJa/ / 
aula/ / 
precorrrmissure' 
terma 
■ i । o ■ 
optic n. । { [ 
chiasmal < I 
hypophysis! I 
albicans' 
postcribrum 
' torcular 
5 
crus! ■ \ 
myel 
myeiocoele 
\ \ x nodulus 
10 ' metatela 
meta pore 
Fio. 418.-Mesal Aspect of the Right Hemiencephal of an Adult White Man. 376 X-65. 1, 
auliplexus; 2, falcial sinus ; 3, right velar vein ; 4, orifice of Galen's vein into the tentorial 
sinus; 5. falcula or '•cerebellar falx;" 6, tentorial sinus; 7, uvula, a mesal division of the 
cerebellum; 8, tuber ("tuber cinereum"); the line seems to stop at the artery, but should 
reach the thin floor of the diacoele just caudad of the hypophysis; 9, ventral end of the falx ; 
10, cut edge of the ectal layer of the arachnoid ; the line is too heavy and should be white in- 
stead of black ; at a point between the lines from 6 and 7 it becomes attached to the cerebellar 
piarachnoid ; 11, longitudinal sinus. 
Preparation.-This figure is reduced from the writer's Fig. 4711 in Vol. VIII. In addition 
to what is there recorded it should be said that the figure represents a combination of the more 
perfect portions of the two mesal aspects, and the left more than the right. The dura has 
since been removed, excepting its ventral margin. The left half has been transected through 
the mesencephal; the dorsal portion of the right hemicerebrum has been sliced off to the level 
of the paracoele, but secured in place with long pins. 
Defects.-Although one of the purposes of the preparation of the figure was to indicate the 
relations of the dura to the brain, the word is omitted altogether. Falx designates its mesal 
extension between the halves of the cerebrum, as shown in Figs. 415 and 417. Along the longi- 
tudinal sinus (11) should be indicated the points of entrance of the supercerebral veins (see 
Vol. VIII., Fig. 4684). The sinus, dorso-caudad of the cerebellum, between the torcular and 
the point marked 4, should be named tentorial sinus. On the precerebral artery, dorsc- 
cephalad of the chiasma, are two orifices. The more caudal, at the root of the termatic artery, 
is caused by the removal of the left precerebral (see § 23. P). The more cephalic, between the 
lines from copula and aula, should be omitted, together with the intervening depressed area ; 
they represent an accidental excavation of the artery. The arteries in the ventricisterna, the 
interval between the pons, the crura, and the tuber, are vaguely and inaccurately shown (see 
§ 23, F). The postcerebellar artery (undesignated but lying between the lines from metapore 
and metatela) looks as if it begins in the metapore (see, however, § 23, H). The pia is nowhere 
distinctly represented. The black line marked 10 is the ectal layer of the arachnoid (see Fig. 
421); the ental layer, in contact with the cerebellum, may be recognized : they unite just 
dorsad of the line from 7. The curved white line about midway between the callosum and 
the fornicommissure is due to an error; the surface of the hemiseptum forming the lateral 
wall of the pseudoccele should be uniformly shaded. 
* In previous articles in the Handbook the 
tuber cinereuni was called torus ; but the writer's 
attention has been called to the use of torus, 
either alone or in combination with semicircu- 
laris, to designate mesencephalic elevations in 
fishes; hence it will be better to retain the sub- 
stantive element of the original name. 
610 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Meninges. 
Meninges. 
vein (3) between the splenium of the callosum and the 
•conarium, and its junction with its opposite at the point 
indicated by the circular spot at the edge of the splenium, 
just in line with the dotted line from that word. The 
two velar veins form the short vein of Galen. 
O. The brief course of the vein of Galen about the 
splenium, and its entrance at 4 into the tentorial sinus, at 
the place of continuity of the latter with the falcial when 
this is present. 
P. The location of the right precerebral artery (ante- 
rior cerebral). Branches of this are seen dorsad and 
cephalad of the callosum. The main trunk extends dor- 
so-cephalad from the chiasma. The dark spot between 
the dotted lines leading from the words terma and pre- 
commissure represents the junction of the two precere- 
bral arteries at the meson; in some cases they are sep- 
arated by a considerable interval and communicate by a 
Blender precommunicant artery. Here, however, they 
unite by their full width and again diverge. 
Q. The origin of the termatic artery from the place of 
junction of the two precerebrals ; its course, parallel 
with the terma and copula, then around the genu at least 
to the dorsum ; its short branches to the terma and ad- 
joining parts of the hemicerebral meson. 
R. The location of the postcerebral artery. The be- 
ginning of this, severed from the basilar, is represented 
by the circular spot between the hypophysis and the 
convexity of the pons. From it are seen small arteries 
entering the crura as described by Browning, Vol. VIII., 
p. 235. For the two large vessels represented in the 
ventricisterna, see under Defects. 
8. The location of the aulix, the S-shaped furrow on 
the inesal surface of the thalamus ventrad of the medi- 
•commissure. This, originally called sulcus Monroi by 
Reichert (" Der Bau desmenschlichen Gehirns," Taf. ix., 
i.) is held by Minot ("Human Embryology," pp. 611, 
680) to represent the fundamental division between the 
" dorsal and ventral zones of His." 
§ 24. The Arachnoid.-The word arachnoid is derived 
from the Greek apdxvV (signifying either a spider or a 
spider's web), and elSos (form or likeness).* Our know- 
ledge of the arachnoid is even less complete and satis- 
factory than that of the dura and pia, and there are direct 
•contradictions in the accounts by different anatomists 
which the writer has as yet been unable to reconcile. 
As stated by Langdon (1891), Bichat described (1802, 
1813) the arachnoid as a serous, shut sac, conforming in 
all essential particulars with the serosa of the other cavi- 
ties. But most recent writers follow Kolliker (1860) in 
denying the existence of a parietal layer in contact with 
the dura, and Tuke regards (1882) even the visceral layer 
as merely an element of the pia. 
§ 25. On February 17, 1888, the writer made and re- 
corded the following observation upon a child, still-born, 
at term, No. 2258 : In removing the parietal dura, a del- 
icate membrane separated from it more or less easily in 
different localities on the two sides ; it was observed also 
by the writer's colleague, Professor S. II. Gage. Al- 
though this distinctly indicated the existence of a parietal 
(ectal) layer of arachnoid, at that time the writer supposed 
the subject, Meninges, would be treated by another, and 
was, moreover, then fully occupied with the articles al- 
ready undertaken ; hence the observation was not made 
public. 
§ 26. On December 29, 1890, Dr. Langdon's paper 
(1891) was presented before the Association of American 
Anatomists. He records observations made upon two 
children, at term, and one adult. His summary is as 
follows : 
" The arachnoid is a true shut sac, similar in structure 
and function to the serosa of the other great cavities. 
Its parietal layer is easily separable from the dura at the 
vertex in the foetus and young infant, but practically 
inseparable in this region in the adult. At the base of 
the skull it is demonstrable as a separate membrane, even 
in the adult. To assert that the parietal layer of arach- 
noid is absent because its subepithelial connective tissue 
has fused at the vertex with the dura (connective tissue),. 
Fig. 419. - Medisection of the Cerebellum and Adjacent Parts. From 
Key and Retzius (Taf. viii., vii., Fig. 1); after Quain (iii., Fig. 131), 
reduced and somewhat modified. Compare Fig. 6, and Vol. VIII., Fig. 
4684. 1, 1', Atlas vertebra; 2, 2', axis vertebra; 3, diacoele (third 
ventricle) ; 4, epicoele, the cephalic or cerebellar portion of the "fourth 
ventricle;" C, cerebellum; C.C., callosum; C', callosal gyrus; M, 
postoblongata; P. V., pons; X, falcula (falx "cerebelli) c, medicom- 
missure ; c.c., just dorsad of (behind) the myelocoele (central canal 
of the cord) ; f. M., meta pore ; p, hypophysis ; t, torcular. 
/'reparation.-A blue mass was injected into the spinal subarach- 
noid space ; the head was then frozen and medisected. The original 
includes the mesal aspect of the entire head, less the integument and 
mandible. The true encephalic cavities and the subarachnoid spaces 
are colored, so only the actual mesal parts appear. 
Defects.-In the original there is no indication of the arachnoid, 
although the circumscription of the subarachnoid space was the very 
feature supposed to be illustrated. Should it be claimed that the 
arachnoid is sufficiently indicated by the ental boundary line of the 
dura, the answer would be that, although in places the two meninges 
may be in contact, they are not in all; furthermore, as distinctly shown 
upon Taf. vi. of the same work, in Fig. 4711 of Vol. VIII., and in 
Figs. 420 and 421 of this volume, there is a point near the crest of the 
cerebellum (nearly opposite I) where the arachnoid (or its ectal layer) 
leaves the cerebellum and passes directly to the dura at the fora- 
men magnum. There is no boundary between the metepiccele (fourth 
ventricle) and the subarachnoid space ; even if, as in other cases, the 
membranous roof of the metacoele (metatela) adheres to the caudo- 
ventral surface of the cerebellum, the plexuses and the endyma consti- 
tuting its ental surface must end somewhere; see p. 119, § 49. 
The copy in Quain (9th and 10th eds.) omits the face and most of 
the cerebrum. Since the cavities are not colored, they appear as 
white areas without perspective, as if the preparation were a thin 
mesal slice. Most unfortunately, probably through some defect in 
execution, there is left a clear line between the conarium and the splen- 
ium, as if there were a passage from the diacoele (third ventricle) to the 
irregular subarachnoid space between the splenium, conarium, pre- 
geminum and cerebellum. This is altogether misleading, for. as shown 
in Fig. .700 and on 4684, 4711, and 4718, and stated on p. 123 of Vol. 
VIII., the diacoele is completely circumscribed at that point by the 
endyma reflected from the velum upon the conarium. In the present 
copy this defect has been remedied so far as it could be by uniting the 
conarium and splenium so as at least to block the passage ; but it 
should be remembered that it is closed not by nervous tissue but mem- 
branes. The editors of Quain have represented the missing metatela 
by the dotted line from near the number 4 to near the abbreviation 
f. M. A continuous line would have been more appropriate, and sep- 
arated farther from the metaccelian floor; that could not be changed 
in the present copy, but the interval representing the meta pore (fora- 
men of Magendie) has been enlarged somewhat. Finally, the falcula 
(falx cerebelli), which was unmarked in Quain, is here designated by a 
cross (x). 
* The open-meshed disks of the common garden-spiders, Epeira, 
Argicpe, etc., are not comparable ; rather the compact glazed sheet con- 
structed by one of the house-spiders (Tegenaria) which will hold water, 
or the still more substantial nest of the water-spider (Argyronetra), which 
is like a stationary diving-bell and retains the air nlaced under it against 
considerable pressure. 
is as incorrect as to describe the great omentum as one 
layer of peritoneum, because its original four layers have 
become matted and adherent." 
§ 27. During the preparation of the present article the 
writer has verified the correctness of the previous obser- 
611 Meninges, 
Meninges. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
vation as to the presence of an ectal or dural layer of 
arachnoid, and lias noted its reflection upon the carotid 
and vertebral arteries to become continuous, presumably, 
with the ental, pial, or visceral layer. But no such re- 
flection occurs at the nerve-roots unless at some depth 
within the foramens of exit, and this point the writer 
has as yet not had time to determine. 
§ 28. Points Illustrated by Fig. 419.-A. The com- 
plete circumscription of the true encephalic cavities, ex- 
cepting at the metapore. 
A. The non-communication of these cavities with the 
pseudocode (fifth ventricle). 
C. The presence of considerable, irregular intervals, 
snbarachnoid spaces, or cisternas, between the pia and 
the arachnoid. 
D. The continuation of the largest of these, postcisterna, 
between the cerebellum, postoblongata and occipital 
part of the craniun, with the spinal subarachnoid 
space. 
E. The relation of the falcula (falx cerebelli) to the 
mesal portion, vermis, of the cerebellum; in Fig. 418 
(SUPPLEMENT.) 
B. The extent of the postcisterna (cisterna magna or c. 
eerebello-meduUaris) upon about one-half the entire cau- 
dal aspect; there is, however, considerable variation in 
this respect. 
C. The definite dorsal and lateral limitation of the post- 
cisterna, although the boundary line is undulating and 
asymmetrical. 
D. The lack of ventral boundary of the cisterna ; the 
ectal layer of the arachnoid is attached to the dura so 
that this cisterna is continuous with the spinal subarach- 
noid space. 
E. The union of the two vertebral arteries to form the 
basilar. 
F. The origin of the postccrebellar arteries from the 
vertebrals near their junction. 
G. The length and course of the postcerebellar ar- 
tery, and the tortuous course of its central portion. 
H. The passage of a branch of the postcerebellar ar- 
tery mesad toward the metapore, apparently supplying 
the metaplexus. 
I. The extension of the metaplexuses dorsad from the 
metapore upon the cerebellum. 
§ 31. The Postcisterna. - Notwith- 
standing the presumption that all the 
cisternas form a continuous series, the 
writer's observations, up to the present 
time, compel him to regard the space 
in the angle between the cerebellum 
and the oblongata as presenting an im- 
portant peculiarity, viz., as lying, not 
between the pia and the visceral arach- 
noid, but between two layers of the lat- 
ter. The facts upon which this view 
is based cannot be detailed here. The 
view is indicated upon Fig. 421. 
The writer is aware of the difficulties- 
involved in its acceptance; without 
question, the postcisterna communi- 
cates on the one hand with the true- 
encephalic cavities through the meta- 
pore, and on the other with the spinal 
subarachnoid space; its free com- 
munication with the other cisternas, 
although commonly accepted, seems to 
the writer not yet clearly demonstrated. 
§ 32. Points Illustrated by Pig. 421.- 
A. The usual relation of the meninges 
in these respects, viz., the indepen- 
dence of the dura ; the adhesion of the 
pia to the brain-substance ; the dip- 
ping of the pia into the narrow depres- 
sion at either side of the vermis as a 
vascular fold; the adhesion of the 
arachnoid to the pia over most of the 
cerebellum, so as to constitute a piarach- 
noid ; Vol. VIII., Fig. 4687. 
B. On the caudal aspect of the cere- 
bellum, the formation of a consider- 
able space, the postcisterna, by the 
separation of an ectal layer of the ental 
or visceral layer of the arachnoid. 
§ 33. The Metapore (Foramen of 
Magendie).*-Historical. On Decem- 
ber 18, 1826, before the Academie des Sciences, Magendie 
read the second part of his second memoir upon the 
liquid contained in the spinal canal and the cavities of 
the brain. It was published in the Journal de Physiologie 
for January, 1827, Tome vii., pp. 1-29. 
On pp. 21 and 22 Magendie declares that the fourth 
ventricle of the brain communicates with the subarach- 
noid space of the spinal canal through an orifice in the 
roof of the ventricle. He adds that, in the human adult, 
this is a constant condition easy to verify, and briefly de- 
scribes the method of exposing the brain for the pur- 
pose. 
Vallicula. 
7 
Postvermis. 
6 
5 
Metaplexus. 
Tonsilla. 
4 
3 
2 
1 
Myel. 
Postcerebellar a. 
Vertebral a. 
Basilar artery. 
Pons. 
Fig. 420.-Caudal (lower) Aspect of the Cerebellum, etc., No. 376 ; X .9. 
Preparation.-Through the kindness and skill of Dr. W. C. Krauss (a former student, now 
Professor of Pathology in the Medical Department of Niagara University in Buffalo, N. Y.), 
the brain was received fresh and in the dura. The cavities were injected with alcohol; the 
arteries first with alcohol and then with the starch mixture (p. 115, § 24). The alcohol passed 
through the metapore into the postcisterna and thoroughly preserved all the parietes ; it hail 
access also about the myel, where the arachnoid was cut in removing the brain. The ectal 
layer of the arachnoid was cut away along the line of its attachment. 
Defect*.-The perspective of the postoblongata is defective. The metapore is vaguely indi- 
cated and few of the vessels are shown. Of the lobes only the tonsillas are outlined. The 
flocculi and nerve-roots are omitted, also the rimuias (interfoliar crevices) on the left side. 
The most serious defect is the non-indication of the dorsal limit of the endyma which presum- 
ably accompanies the metaplexuses. 
1, 3, Branches of the postcerebellar artery, the former passing between the cerebellum and 
the oblongata, the latter apparently supplying the corresponding metaplexus. 
2, 6, Edge of the ectal layer of arachnoid bounding the area whence it had been cut away. 
4, Loop of postcerebellar artery, an example of its tortuous course. 
5, Main trunk of the artery near where it reaches the crest of the cerebellum; its branches are 
omitted. 
7, Mesal ridge formed by the vein which divides into a right and left branch upon the cau- 
dal surface; the arachnoid here forms a somewhat sharp angle. 
this is obscured by the fact that part of the left lateral 
lobe remains. 
§ 29. The Cisternas.- At several regions the ental 
layer of arachnoid is separated from the pia by consider- 
able spaces, called cisternas by Key and Retzius, 1875, p. 
93.* They are enumerated and' briefly described by 
Browning, Vol. VIII., p. 244. 
§ 30. Points Illustrated by Fig. 420.-A. The general 
appearance of this aspect of the cerebellum together with 
the oblongata and pons; in Fig. 4177 these two parts 
were omitted. 
* Admitting that most of the cisternas do He between the arachnoid 
and the pia. as commonly described, the writer's later observations lead 
him to regard the (>osteisterna as between two layers of the ental arach- 
noid itself ; see Figs. 429 and 421. 
* This portion of the article is based upon a paper by the writer, read 
before the Association of American Anatomists, at Princeton, December 
29, 1892. See Amer. Neurol. Trans., 1893. 
612 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Meningem. 
Meninges. 
Magendie designated the orifice as entree des carites 
du cerreau or entree des ventricules cerebranix. In 1855 
Luschka published a description and figure of the ori- 
fice, which he re-named foramen Magendii. In the pres- 
ent article, as in Vol. VIII., p. 123, these and various 
other polyonyms are replaced by the mononym metapore, 
Latin, metaporus, signifying an orifice in the metatela, 
the membranous roof of the metacoele, the cavity of the 
metencephal. 
§ 34. Most later anatomical writers have admitted the 
existence of the metapore, but the descriptions arc com- 
monly brief and the figures unsatisfactory. That by 
Key and Retzius is suspiciously symmetrical, though it 
is copied by Schwalbe ; Henle's (Fig. 423) is more natural; 
the best figures and the fullest description are those of Carl 
Hess, 1885, but no figure has the appearance of having 
been based upon a photograph. 
§ 35. The metapore is regarded as an artificial orifice 
by Kblliker, 1884, p. 248, but apparently on a priori 
embryological grounds and without a personal examina- 
tion of carefully prepared adult brains. An orifice in the 
metatela is shown by Reichert (1859) in a transection, 
Taf. ii., Fig. 14 ; the description, p. 113, merely states 
that the roof is incomplete, but in the Resume, p. 185, he 
distinctly holds that any orifice in this region is arti- 
ficial. 
Gegenbaur (1888) admits the usual presence of the 
metapore (p. 819), but adds that it is sometimes absent, 
as in his Fig. 522. 
§ 36. In 1884 (Cartwright Lectures on " Methods of 
Studying the Brain," New York Medical Journal, April 
26, p. 458), the writer expressed doubts as to the existence 
of the metapore upon the following grounds : 
1. Its absence in the cat and other animals examined. 
2. Its morphological improbability, in view of the as- 
sumed conditions expressed in the phrases endymal con- 
tinuity and coelian circumscription. 
3. The observed readiness with which membranous 
walls and adhesions are ruptured in the customary ma- 
nipulations of the brain. 
The paper of Hess (1885) and the possession of more 
perfect material, led to a re-examination of the subject. 
Several preparations were made and photographed (nega- 
tives 164 and 592). In a paper (1886), while reaffirming 
the unbroken continuity of the metatela in the cat, the 
writer stated that in man there is a mesal aperture ap- 
proximately rhomboidal in outline, and about 5 by 8 
mm. in diameter. 
In 1889, in the article, " Gross Anatomy of the Brain," 
in the Reference Handbook, upon the supposition 
that a special article upon the meninges would be pre- 
pared by another, the writer restricted himself to in- 
dicating the location of the metapore upon a medi- 
sected brain, Fig. 4711 (this volume, Fig. 418), and 
to remarking, page 122, § 60, "that the meta pore un- 
doubtedly exists in man, though not, perhaps, in other 
vertebrates." The qualification was due to the condi- 
tions observed in a chimpanzee brain, but as this had been 
medisected no final conclusion could be derived from it. 
§ 37. Notwithstanding the above declaration upon the 
part of one who at that time had been an anatomist for 
thirty years, in Minot's "Human Embryology" (1892), 
neither of the terms, foramen of Magendie or metapore, 
is used, and the whole subject is apparently disposed of 
in the following passages (p. 676):-" Several writers 
have thought that the membrane was broken through at 
certain points, but it probably is really continuous 
throughout life. The fourth ventricle is to be regarded, 
then, as an expansion of the central canal permanently 
bounded by the original medullary walls." 
The writer infers that Minot follows Kolliker in regard- 
ing the almost unanimous testimony of anatomists as 
inadequate to outweigh the presumption against the for- 
mation of an orifice in a pre-existing membrane ; yet he 
describes (p. 262, Fig. 170), under the name of oral plate, a 
septum between the mouth and the pharynx of the 
human embryo which must disappear before those two 
divisions of the enteron can become parts of a continuous 
canal. 
§ 38. Aside, however, from the desirability of dispell- 
ing embryological scepticism, the question of the pres- 
ence or absence of the metapore involves so many and so 
serious considerations, zoological, physiological, psycho- 
logical, and even philosophical, that the writer has re- 
cently re-examined all the specimens in the Museum of 
Cornell University, and has prepared two with which the 
possibility of artificial disturbance of the natural relations 
had been avoided. 
As the result, the following proposition is submitted : 
In the normal adult human, brain there is a considerable 
orifice in the roof of the meta cade whereby the liquid of the 
encephalic cavities may escape into the postcisterna. The 
only cases of apparent absence are in the brains of two 
insane persons, one of them hydrocephalous ; but as both 
of these brains had been medisected, no final conclusion 
should be based thereon. 
arachnoid - 
POJTCIsrW/M 
pi arachnoid 
.dura 
-preverniis 
[noid. 
• dura and its arach- 
. intrarachnoid space. 
, ectal layer of ental 
arachnoid. 
• postcisterna 
[arachnoid. 
jental layer of ental 
- pia. 
paravermian sulcus. 
postvermis. 
pial fold. 
Fig. 421.-Sections of the Cerebellum and Postcisterna; semidiagram- 
matic. t 
A. Dorsal (cut) surface of the ventral portion of the cerebellum, to- 
gether with the adjacent dura and the large "subarachnoid space," 
postcisterna, commonly called cisterna magna or c. cerebello-medul- 
laris. At the meson appears the postvermis, separated by the para- 
vermian sulci (1) from the large lateral lobes ; 3 is the ental layer of 
the arachnoid. The meninges are here represented by lines only. 
B. Enlargement of the meso-caudal region of A. The meninges 
are here represented by zones conventionally shaded ; 2, the place of 
junction of the two layers of the ental arachnoid at the margin of 
the postcisterna. 
Preparation.-An adult cerebellum (2891) was divided at a plane 
corresponding with the line X-Y in Fig. 8, so as to separate the dor- 
sal two-fifths; on Fig. 4711 (Vol. VIII.) the plane of section would be 
indicated approximately by a line across the unshaded (cut) surface 
connecting the points where the dotted lines from the words nodulus 
and epicoele intersect the margin of that surface ; as seen in Fig. 420 
it passes dorsad of the plexuses. The ectal layer of arachnoid is 
represented as the continuous caudal boundary of the postcisterna, 
while in Fig. 420 it is supposed to have been trimmed closely along the 
line of its depression from the ental layer 3. 
Defects.-For readier comparison with Fig. 421 the figures should have 
been inverted so as to have the postcisterna nearer the reader. In B 
the postcisterna is enlarged two diameters, but the several zones repre- 
senting the meninges are disproportionately widened, and their shad- 
ing is conventional for discrimination only, and not for the indication 
of histological structure. The ectal or dural layer of arachnoid was 
inadvertently omitted, and there is no indication of the two layers of 
the dura itself. The numerous rimulas and interventing foliums that 
were divided in the section are not indicated, and the usual relations 
■of the pia and arachnoid to each other and to narrow encephalic de- 
pressions generally are illustrated only at the paravermian sulci. 
613 Meninges. 
Meninges. 
DEFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
§ 39. Points Illustrated upon Fig. 422.-A. The exist- 
ence of a natural orifice in the membranous roof of the 
" fourth ventricle.'' 
B. The simplicity of the form and relations of the 
metapore in this specimen. It is mesal, symmetrical, and 
oval. 
C. The appearance of the metaplexuses just within the 
cephalic margin of the metapore with no such extension 
upon the cerebellum as is shown in Fig. 420. 
§ 40. There is perhaps no point in gross anatomy 
wherein the result is more dependent upon the method ; 
hence the procedures in the two cases where the orifice 
was last observed shall be described in detail. 
§ 41. Alcoholic Specimen, No. 2655.-In the spring of 
1890 the head of an adult man, with most of the neck 
attached, was received in a fresh condition. The brain 
was hardened in place by the continuous injection of 
alcohol through the arteries ; Vol. VIII., p. 200, and this 
(SUPPLEMENT.) 
volume, p. 114. The calva and contained portion of the 
cerebrum were sawn off, and the face with the frontal 
portion of the brain separated from the neck, cerebellum, 
and occipital region of the cerebrum. This latter mass 
was kept in strong alcohol until December 19, 1892. On 
this date, with a thin saw newly sharpened, the left side 
of the head and neck was removed so as just to clear the 
myel (spinal cord) and leave the region of the metapore 
wholly inclosed between the untouched right lobe of the 
cerebellum and the remnant of the left lobe. With a 
very sharp scalpel, frequently dipped in alcohol, the 
larger part of the cerebellum was cut away ; more of the 
cranium was sawn off, and the vertebral arches removed 
with nippers. During all these operations the thorough 
hardening of the soft parts had prevented any movement 
of the cranium upon the atlas. The remnant of the cere- 
bellum was now peeled cautiously up from its pia, and 
the left half of the oblongata cut out. Upon the region 
where the metapore was supposed to open was now 
dropped a little soapy water ; the point of a blow-pipe 
was directed at-not pushed into-the metacoele from the 
ventral side ; on blowing gently, bubbles formed on the 
dorsal side, showing the passage of air through the meta- 
pore. This was done in the presence of six witnesses, 
most of them trained observers. 
The writer was at first disappointed that the metapore 
was not patent to the eye, but soon remembered that the 
tendency of arterial alinjection is to increase the volume 
of the masses at the expense of the cavities; further, it 
was evident that in this, as in most cases, the convolutions 
of the postcerebellar arteries were intruding upon the 
region. 
Hitherto no instrument, even the comparatively safe 
syringotome (Vol. VIII., Fig. 4880), had approached the 
supposed location of the metapore. But when repeated 
trials had satisfied all interested that there was a natural 
communication, the syringotome was cautiously intro- 
duced, and the limits of the passage ascertained ; then 
with fine scissors the leftwTall was removed. The cephalo- 
caudal diameter of the metapore is more than 5 mm. ; its 
transverse diameter would be about the same in the fresh 
state, but a knuckle of the right postcerebellar artery 
encroaches upon it. 
In view of the ease with which natural membranous 
adhesions yield in poorly preserved brains, it is important 
to add that all the membranes in this preparation were 
firm and maintained their natural attachments so as to 
perceptibly resist separation. When it is added that 
the various operations upon the already hardened brain, 
which are briefly indicated above, consumed at least four 
hours, it may be believed that adequate precautions were 
taken against the production of any artificial conditions. 
Two stages of the dissection are represented in photo- 
graphs 590 and 591. 
§ 42. Fresh Specimen, 2971.-The head of an adult man 
was received fresh through the kindness of a former 
student, December 21, 1892. The neck and occipital 
region were sawn away from the rest of the head ; the 
cephalic slope of the cerebellum remained attached to the 
cerebrum, but the larger part, containing the metapore, 
was undisturbed. 
The specimen was immersed in normal salt solution ; 
the blow-pipe was so placed that the stream of air entered 
the metacoele. As soon as it was used the air collected in 
the postcisterna and gradually distended the arachnoid. 
At this first trial, in the presence of one witness, the 
arachnoid, notwithstanding its extreme delicacy, was ab- 
solutely unbroken, and when the cerebellum was per- 
mitted to tilt slightly cephalad, as in photograph 593, 
the distended sac presented a really beautiful appear- 
ance ; during the subsequent manipulations a small rent 
was made at one margin where the arachnoid becomes 
attached to the cerebellum, so that the distention there- 
after was less complete ; it was observed, however, by 
several, that the air passed from the metacoele freely into 
the postcisterna, and the outline appears in the photo- 
graph, though vaguely. 
It is essential in this connection to call attention to the 
fact that when the cerebellum was permitted to fall 
pyramis. 
uvula. 
tonsilla. 
metatela. 
metaplexus, 
flocculus. 
met a pore. 
pons. 
oliva. 
obex. 
Fig. 422.-The Metapore (Foramen of Magendie) as Exposed by the 
Divarication of the Cerebellum and Oblongata. Specimen 318, Mus. 
Cornell University. X 1. 
Preparation.-The brain of an adult Swedish* carpenter was re- 
moved with great care, according to the writer's method, i.e., by di- 
viding the calva sagittally at the left of the meson (Vol. VIII., p. 199), 
so as to avoid tearing membranous adhesions. The brain was sup- 
ported on a bed of cotton ; the arteries and the arachnoid extending 
from the cerebellum to the oblongata were cut away and the two parts 
held asunder with fingers so as to expose the region of the metapore. 
A photograph was then taken, upon which the drawing is based. 
After hardening, however, most of the cerebellum was cut away and 
another photograph taken of the reduced mass. The specimen and 
both photographs were shown at the meeting of the Association of 
American Anatomists, December 28, 1892. 
Defects.-The right side of the cerebellum was displaced more than 
the left, giving rise to the marked obliquity. The metapore itself 
should be shown on a larger scale. The postcerebellar arteries are 
omitted ; they do not appear distinctly in the first photograph, and no 
record was made of their locations. This is unfortunate, since in all 
the cases where they are preserved their relations to the metapore are 
close. Had more of the caudal aspect of the cerebellum been included, 
there might have been shown the line of attachment of the arachnoid 
at the boundaries of the postcisterna. The wavy lines on the dorsum 
of the oblongata hardly do justice to the vascularity of the pia cover- 
ing that region. 
♦The left hemicerebrum is represented in Vol. VIII., Fig. 4778. 
Since that volume was published, and indeed after the pages of the pres- 
ent volume containing corrections of the article " Brain " therein, the 
writer has learned from a relative of the carpenter that he was not a 
Hungarian, as first stated, but a Swede. 
614 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Meninges. 
Meninges. 
cephalad it was held by the arachnoid, even after re- 
moval from the liquid. Through the transparent mem- 
brane it could be seen that none of the parts included 
within it were upon the stretch. 
Later the cerebellum and oblongata were removed from 
the remnant of cranium, the arachnoid was trimmed 
close to its attachment, and a second photograph (No. 594) 
taken. Then the specimen was hardened in alcohol and 
reduced to a more convenient size by cutting off most of 
the lateral lobes of the cerebellum. 
There is no reason to suppose that any of the mem- 
branous attachments have been torn, but the presence of 
the metapore is unmistakable. 
Even, therefore, if some doubt might be cast upon the 
reliability of the previously prepared specimens, the two 
whose preparation and examination have been here de- 
scribed, prove that Magendie and others have been cor- 
rect in affirming the existence of a mesal orifice in the 
roof of the metacoele. 
§ 43. The writer now feels justified, not only in re- 
iterating the conviction which was expressed in 1886 and 
1889, but in holding that upon the unbelievers now rests 
the burden of disproof. He is ready to demonstrate the 
metapore upon any fresh or well-preserved brain, and 
from the cephalic border of the metapore upon the uvula 
and pyramis of the cerebellum. 
C. The extension of the metaplexuses upon the thus 
everted ental aspect of the metatela, whereas in the spec- 
imen represented in Fig. 420 they barely appeared at the 
margin. 
D. The topographical relation to the metapore of the 
contorted postcerebellar arteries. 
E. The relation of the flocculus to the lateral recess. 
See Vol. VIII.. Fig. 4720. 
§ 45. But while the main fact may be regarded as 
demonstrated, there are many subordinate points upon 
which our information is far from satisfactory. 
§ 46. It is evident that there are two different arrange- 
ments. The simpler is apparently the less common. It 
exists in specimens 318, 376, 706, 2347, and 2870. 
Here, as in Figs. 418 and 422, the metatela is readily 
separable from the overhanging cerebellum, excepting, 
of course, at the cephalic margin, where its two constit- 
uents, the pia and the endyma, are continuous with the 
same membranes on the ectal and ental surfaces, respec- 
tively. 
In this kind the plexuses on the ental surface of the 
metatela appear, if at all, only just 'within the cephalic 
margin of the metapore. 
In the second kind the metatela adheres closely to the 
cerebellum, the two apposed layers of pia not being sep- 
arable ; thus the cephalic wall of the metapore appears 
to be the cerebellum itself; but the extension dorsad of the 
metaplexuses shows that it is truly the metatela. As 
yet the writer has been unable to determine the precise 
limit of the metatela. See Figs. 420 and 423. 
§ 47. Since the metatela consists of two different mem- 
branes, the ental endyma and the ectal pia, we should 
know their exact condition at the margins of the meta- 
pore. An analogous case is the orifice of the oviduct, 
where mucosa and serosa become continuous. 
§ 48. At ■what period of development does the meta- 
pore appear ? From the extreme softness of new-born 
and foetal brains, it is evident that artificial rupt- 
ure of the delicate metatela may easily be produced. 
Probably the best results may be anticipated from the 
examination of specimens prepared by transecting the 
brain at the mesencephal (gemina and crura), and in- 
jecting the preservative gently but continuously caudad 
through the mesoccele or aqueduct, so as to fill the cav- 
ities and fix the membranous attachments. 
§ 49. How is the metapore produced ? Is there an 
absorption of material over a given area ? or is a rupture 
accomplished by spontaneous mechanical agencies, the 
margins of the rent becoming rounded off later ? 
§ 50. What is the significance of the close topograph- 
ical relations of the postcerebellar arteries ? The length 
and tortuousness of these vessels can hardly fail to im- 
press anyone who carefully studies the region in ques- 
tion. 
§ 51. Does the coeliolymph (cerebro-spinal liquid) pass 
in both directions with equal facility ? 
§ 52. Is the non-formation or obliteration of the meta- 
pore a cause or merely a concomitant of idiocy, insan- 
ity, or hydrocephalus ? Horsley has recorded (Brain, 
July, 1885, p. 238) a case of encephalocele where the 
metatela was a "strong, fibrous sheet," and there have 
been already referred to two insane brains, one of them 
also hydrocephalic, where there is at least room for 
doubting the presence of the metapore. 
§ 53. Does the metapore exist in any other animals, 
especially in the anthropoid apes ? If not, then its pres- 
ence would constitute one of the rather small number of 
absolute distinctions of humanity. Although the chim- 
panzee brain in the Museum of Cornell University prob- 
ably is the most perfectly preserved in the world, its 
medisection prevents us from relying implicitly upon it. 
So far as may be inferred, there was a metapore, the 
plexuses extending upon the caudal surface of the cere- 
bellum as in the second kind already mentioned. On 
January 11, 1893, through the kindness of Superintend- 
ent A. E. Brown, of the Philadelphia Zoological Gardens, 
the writer received the body of a baboon in excellent 
vallicula. 
arachnoid. 
pyramis. 
tonsilla. 
metaplexus. 
metapore. 
obex. 
postcerebel- 
lar a. 
vertebral ar- 
tery. 
Fig. 423.-The Metapore (Foramen of Magendie) and Adjacent Tarts 
nearly as represented by Henle. (Anatomie, iii., Fig. 232.) 
Preparation.-In the absence of statement by the author, it may be 
said that the brain was probably removed in the usual way, and the 
cerebellum tilted cephalad so as to expose its caudal aspect and the 
dorsum of the oblongata. The left tonsilla was then cut out, exposing 
on that side the parts marked I, IX, and a continuation of the post- 
cerebellar artery. 
I, metatela (welwm niedullare posterius), its lateral portion ; II, 
lateral recess of the metepictule (fourth ventricle) opened by the re- 
moval of part of the metatela ; III, flocculus ; IV, epiplexus (plea-.us 
choroideus lateralis); see Vol. VIII., Fig. 4702; VII, VIII, IX, cranial 
nerve-roots. 
Change/t.-The boundary line of the tonsilla has been made more 
distinct than in the original. In the upper part has been introduced 
a line to represent approximately the line of attachment of the arach- 
noid, constituting the dorsal boundary of the postcisterna. (See Fig. 
420.) 
Defects.-The margins of the metapore are too sharply defined ; this 
is, perhaps, unavoidable when the parts are upon so small a scale; it 
cannot be said to bear either way upon the question of the naturalness 
of the orifice, for the effect of tearing a tough membrane like the me- 
tatela would be to leave ragged edges. The relations of the plexuses 
and accompanying strip of metatela are inadequately indicated, and 
the writer regrets his present inability to elucidate them. The post- 
cerebellar arteries are represented as if distributed only between the 
oblongata and cerebellum, and between the lobes of the latter. (Com- 
pare Fig. 420.) 
will maintain its normal existence in the human adult 
until there are produced several otherwise normal brains 
presenting a continuous metaccelian roof. 
§ 44. Points Illustrated bg Fig. 423.-A. The admis- 
sion of the normal existence of the metapore in the adult 
by so expert an anatomist as Henle. 
B. The attachment of an extension of the metatela 
615 Meninges. 
Meningitis. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
condition.* The cerebrum was removed without disturb- 
ing the cerebellum. Air was blown gently at the aque- 
,duct ; the stream was immediately felt escaping at the 
foramen magnum. A blue liquid allowed to run into the 
aqueduct from a small glass syringe, with a minimum 
of pressure, also escaped at the foramen. On removing 
the tentorium there was recognized a small but distinct 
postcisterna (cisterna magna), full of the liquid. On 
carefully lifting the cerebellum there was found to be a 
metapore of the first kind. This observation has been 
confirmed upon two other Old World monkeys, f 
§54. What is the Use of the Metapore ?-Those who 
admit its existence have generally supposed that, during 
the vascular congestion attendant upon cerebration, the 
undue compression of the brain within its unyielding 
case is prevented by the transfer of the coeliolymph, first 
into the postcisterna, and then into the spinal subarach- 
noid spaces. 
But while the non-osseous portions of the spinal canal 
might yield to an ental pressure, is there any evidence 
of the distensibility of the myelic theca ? And would 
not any pressure adequate either to distend it or to com- 
press the liquid, injure the myel itself or the brain, or 
rupture the arachnoid bounding the postcisterna ? 
§ 55. Are there other Natural Communications between 
the Encephalic Cavities and the Arachnoid Space?-Ac- 
cording to Quain (iii., 126, 188), Merkel and Mierze- 
jewski have described an actual cleft in the pia along the 
medicornu. But the writer is not able to learn that 
these observations have been confirmed by others, or that 
any photographs or figures have been published. For 
the present, therefore, in view of the negative testimony 
of other anatomists, and the results of his own repeated 
dissections and experiments, he is compelled to regard 
such clefts, when found, as artifacts, comparable with 
the orifices near the porta in an alinjected brain (Vol. 
VIII., Fig. 4742). 
§ 56. More generally admitted is the existence of nat- 
ural orifices at the tips of the lateral recesses of the 
fourth ventricle. These recesses, parepicoeles, are shown 
more or less imperfectly in Vol. VIII., Figs. 4702, 4703, 
4704, 4714, 4720, 2, and in this volume Figs. 58 and 
423. From Fig. 4702 it will be seen that, in the embryo, 
the extremities of these recesses are closed. The pre- 
sumption is, therefore, that they remain closed in the 
adult. It is true that they are usually-perhaps always 
-found open in brains removed and examined in the or- 
dinary ways ; furthermore, Hess has given (1885) a rep- 
resentation (Taf. xxix., Fig. 10), apparently faithful, of 
what seems to be the natural condition of the parts. 
Nevertheless, so great is the probability of artificial rupt- 
ure of the pia by reason of its adhesion to the nerve- 
roots (a probability far greater than with the compara- 
tively protected metatela), that the writer feels compelled 
to withhold his recognition of the orifices until the pub- 
lication of more dtetailed descriptions and of figures based 
upon photographs. 
§ 57. Is there Direct Communication of the Subarach- 
noid Spaces with the Intrarachnoid (or Subdural) Space ? 
-Whatever view they adopt regarding the constitution 
of the arachnoid as a whole, most writers agree that the 
arachnoid covering the brain and myel is continuous, ex- 
cepting for the capillary spaces about the nerve-roots re- 
ferred to in § 27. Hence, while the coeliolymph may 
pass to and fro between the true encephalic cavities and 
the postcisterna through the metapore, and may thus en- 
ter the other cisternas (§ 31) and the spinal subarachnoid 
space, it is nevertheless confined thereto. 
But Dr. Langdon (1891) holds that " at the base of the 
cranium there are two points where the visceral [ental] 
arachnoid is deficient, one on cither side, in the ' bridge ' 
of arachnoid which stretches across from the cerebellar 
lobes to the under [ventral] surface of the oblongata. 
These foramina measure about half an inch (12 mm.) in 
longitudinal diameter by one-fourth inch (6 mm.) trans- 
versely, and are crossed by three or four fibrous bands, 
the attachment of which to the edges of the openings 
produces a multiple crescentic appearance of their mar- 
gins, which suggests the name, ' lunulate foramina.' " 
It will be noted that the location of these alleged lunu- 
late foramina in the arachnoid corresponds with that of 
the ventral ends of the lateral recesses. Hence, on the 
one hand, if both are natural, the transfer of the coelio- 
lymph from the true encephalic cavities to the arachnoid 
space is provided for ; on the other, the relation of the 
nerve-roots to both the pia and the arachnoid renders 
both liable to rupture during extraction or manipulation 
of the brain. Hess (op. cit., Fig. 10, ar.) implies that 
the arachnoid was cut and reflected at this point. 
Bibliography. 
Bichat, X. (1802) : A Treatise on Membranes in General, etc. (1SG2). 
Translated by J. G. Coffin. Boston, 1813. 
Browning, W. (1889) : Articles, Vessels of the Brain; Pacchionian 
Bodies, Reference Handbook of the Medical Sciences, VIII., 
231-244, 194-195. 
Gage, S. H. (1889) : Article, Lymphatic System, Reference Hand- 
book of the Medical Sciences, VIII., 387-419. 
Gegenbaur, C. (1888) : Lehrbuch der Anatomie des Menschen. Third 
edition. O., pp. 1057, 619 fig. Leipzig, 1888. 
Henle, F. G. J. (1873) : Handbuch der Anatomie des Menschen. O., 3 
vols. 1873. 
Hess, C. (1885) : Das Foramen Magendii und die Oeffnungen an den Re- 
cessus laterales des iv. Ventrikels, Morphol. Jahrbuch, x., 578-500, 
1 plate; 1884-5. 
Key u. Retzius (1875) : Studien in der Anatomie des Nervensystems. 
F., 2 vols., pp. 44S, 75 plates. Stockholm, 1875, 1876. 
KOlliker, A. (1885): Grundriss der Entwickelungsgeschichte. 0.1885. 
Langdon, F. W. (1891) : The Arachnoid of the Brain (read before the 
Association of American Anatomists, Decemlier 29, 1890), New York 
Medical Record. August 15, 1891, 177-178, 2 figs. 
Luschka, H. (1885) : Die Adergeflechte des menschlichen Gehirnes. Q., 
pp. 174, 4 plates. Berlin, 1855. 
Magendie, Francois (1827): Memoire sur un liquide qui se trouve dans 
le crine et le canal vertebral de 1'homme et des anlmaux mammiferes, 
Journal de la Physiologic Experimentale, 1827, pp. 1, 17. 66. 
Minot, C. S. (1892) : Human Embryology. Roy. o., pp. 815, 463 fig- 
ures. New York, 1892. 
Paulet, V. (1873): Liquide oephalo-rachidien. Diet. EncycL des Sciences 
Medicales. Paris. 1873, xiv., pp. 46-65. 
Quain, J. (Schafer, E. A.. & Thane, G. D., Editors) (1893): Elements 
of Anatomy. Tenth ed., in three volumes. O. London, 1890-1893. 
Reichert, C. B. (1861) : Der Bau des menschlichen Gehirns. O. 1861. 
Sappey, M.P. C. (1879): Traite d'Anatomie Descriptive. O., 4 vols. 1879. 
Schwalbe. G. (1881) : Lehrbuch der Neurologie : zugleich des zweiten 
Bandes, zweite Abtheilung, von Hoffmann's "Lehrbuch der Anato- 
mie." O. 1881. 
See, Marc (1878) : Snr la Communication des cavites ventriculaires de 
1'Encephale avec les espaces sous-arachnoidiens, Recur mensuelle de 
Merit cin et Chirurgie, Paris, 1878, ii., p. 424 et seq. ; 1879, iii., p. 295 
et seq. 
Spitzka, E. C. (1889) : Article. Spinal Cord, Reference Handbook 
of the Medical Sciences, VIII., 474-484. 
Swedenborg, Emanuel (1887): The Brain, Considered Anatomically, 
Physiologically, and Philosophically. Edited, translated (from the 
Latin), and annotated by R. L. Tafel. O., two vols., pp. xxxviii. and 
794, xvi. and 645. London, 1882, 1887. [This is one of Swedenborg's 
scientific treatises, written between 1741 and 1744, before his theologi- 
cal writings were begun. There are numerous quotations, and the 
editor has added a very complete modern bibliography of the menin- 
ges and cerebro-spinal liquid.] 
Tuke, J. B. (1882): On the Anatomy of the Pia, Edinburgh Medical 
Journal, xxvii., 1,068, et seq., June, 1882. 
Walker, C. H. (1890) : The Metapore or Foramen of Magendie. A thesis 
[unpublished] on Anatomy for the degree of Ph.B. in Cornell Univer- 
sity, June, 1890. 
Westbrook, B. F. (1880) : Some Points in the Anatomy of the Ence- 
phalon, Annals of the Anatomical and Surgical Society, ii., 337, 
354, September. 1880. 
Wilder, B. G. (1S86): Notes on the Foramina of Magendie in Man and 
the Cat, Journal of Nervous and Mental Disease, xiii., April and 
May, 1886, 2 pages. 
Burt G. Wilder. 
* This is No. 2977 of the University Museum ; the chimpanzee above 
mentioned is No. 265; it also was sent by Superintendent Brown; the 
preparation of the brain by continuous arterial alinjection is briefly de- 
scribed in the Proceedings of the Amer. Assoc. Ado. Science, 1885, p. 527. 
+ Through the courtesy of Dr. W. A. Conklin, formerly Superintend- 
ent of the Central Park Menagerie, the writer has been enabled to exam- 
ine the brain of an adult Orang, No. 3082 of the Museum of Cornell Uni- 
versity. All precautions against artificial rupture were taken. Air 
passed readily from the mesoccele into a large and distinct postcisterna 
through several orifices in the metatela: these orifices and the postcis- 
terna were photographed May 24, 1893 ; Nos. 657-660. 
MENINGITIS. Etiology and Pathology. - The 
cause of cerebro-spinal meningitis is nearly absolutely es- 
tablished. Bonome, of Padua, declares that the diplococcus 
of pneumonia may now be regarded as the typical cause 
of epidemic cerebro-spinal meningitis, but as the cause of 
exceptional cases there are found (a) another diplococcus, 
(b) the streptococcus pyogenes, (c) a short, thick bacil- 
lus like the typhoid bacillus (Neumann and Schafer), 
616 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Meninges. 
Meningitis. 
and (d) an encapsulated bacterium like the pneumo- 
bacillus of Friedlander (Netter). 
Bonome discovered a sixth micro-organism in an epi- 
demic near Padua. The disease developed itself inde- 
pendently of any pneumonia and with quite peculiar 
symptoms: rapid, almost simultaneous attack of many 
and especially of robust individuals with chill, pains in 
the joints and along the spinal column, uncontrollable 
vomiting, fever up to 43° C., violent trismus, opisthotonus, 
fixation of the pupils, etc. Death, w'hich was the result 
in seven of sixteen cases, often occurred within ten hours. 
Section showed abundant exudation, and in one case 
pus in the vicinity of the cerebellum ; cloudy fluid, with 
pus and flakes of fibrine in the lateral ventricles ; numer- 
ous ecchymoses of the pia, and haemorrhage into the ven- 
tricles twice ; haemorrhages under the peri- and endocar- 
dium. The lungs and pleura were always free from 
fibrinous inflammation ; but there was haemorrhagic ex- 
udation in the parenchyma of the lungs, and in a few 
cases in this exudation, as well as in that of the menin- 
ges, Bonome found constantly large round or oval im- 
mobile micrococci isolated or united in chains. 
Huguenin makes the following divisions in explaining 
the origin of meningitis in general : 
1. Hematogenous Meningitis.-The micro-organisms' 
reach the pia through the arterial blood-supply. These 
are the cases of meningitis which occur after or in the 
course of ulcerative endocarditis, typhoid fever, cholera, 
pneumonia, typhus, recurrent fever, variola, scarlatina, 
measles ; traumatic and puerperal sepsis; finally, cerebro- 
spinal meningitis. In most of these diseases it is a case 
of infection of the brain with streptococci. The strep- 
tococcus meningitis certainly occurs after ulcerative en- 
docarditis, typhoid fever, variola, scarlatina (in both the 
last cases usually from the ear), measles, traumatic and 
puerperal sepsis. Of obscure origin are the cases which 
develop in the course of acute articular rheumatism. In 
this connection it must be remembered that hyperpyre- 
sis is often mistaken for meningitis. In the pneumonia 
meningitis the pneumococcus of Fraenkel has been un- 
mistakably demonstrated. The bacteria of epidemic 
cerebro-spinal meningitis have not yet been isolated with 
certainty. Fraenkel's pneumococcus has often been 
found. Weichselbaum has described also a bacillus in- 
tra-cellularis meningitidis. 
2. Meningitis from the Lymph-Vessels.-These cases 
are mostly infections by streptococci in connection with 
peripheric suppuration about the skull ; caries of the 
temporal bone, of the ethmoid, bone tuberculosis, bone 
syphilis, traumatic osteitis of the skull. 
Huguenin says the subdural space is a protection ; but 
a direct bridge through this space is formed by the 
pia-sheaths of the nerves of exit, the pia-sheaths of the 
vessels passing downward, especially of the jugular and 
carotis and the Pacchionian bodies. The pia may be 
affected only directly. Suppurations which reach the 
brain in other ways are confined to the dura. 
3. Meningitis from the Veins.-The cause is here mostly 
a sinus thrombosis from penetration of the pia by micro- 
organisms through the Pacchionian granulations, as from 
caries of bones and diseases of the external skin, and of 
the subcutaneous connective tissue, erysipelas, furuncu- 
losis, and the like. It is not yet definitely settled that 
syphilis and tuberculosis of the bone may excite a men- 
ingitis through the veins, but the virus of an erysipela- 
tous meningitis certainly finds its way through the orbits 
and the sinus cavernosus. 
4. Meningitis from Brain Tumor.-Bare cases may thus 
arise from a central necrotic tumor undergoing softening. 
5. Meningitis from the Spinal Column.-Huguenin re- 
ports a case of streptococcus meningitis from a gangre- 
nous bed-sore, which had broken inward in the course 
of transverse myelitis. Cases of gonorrhoeal meningitis 
have been reported by Hayem and Parmentier. Gull 
reported two autopsies, one showing softening of the 
cord, the other meningitis. 
Adenot distinguishes three varieties of parasitic men- 
ingitis as produced respectively by micrococci, bacilli, 
and mixed forms. The first may be divided into the 
forms produced by the micrococci of pneumonia, or 
the micrococci of Weichselbaum, and the streptococcus. 
By the term pneumococcus is understood the diplococcus 
of Fraenkel. What role the pneumococcus of Friedlander 
plays in meningitis is questionable. Concerning the ba- 
cillar meningitis, forms have been described by Neu- 
mann, Schafer, Adenot, and others, resembling the ty- 
phoid bacillus of Eberth, but not identical with it. Con- 
cerning the mixed forms, Monti produced meningitis in 
one case by injecting the coccus of Fraenkel into the 
dura, and afterward the streptococcus into the blood. 
The cause of epidemic cerebro-spinal meningitis can- 
not be satisfactorily fixed as yet. 
Boulay and Courtois-Suffit report the case of an habitual 
drinker, aged forty-four, whodied after three days' illness, 
and upon post-mortem there were found suppurative men- 
ingitis and peritonitis, while the other organs showed no 
change. The authors found in the suppurative exudations 
capsule cocci, and besides these, in the exudation of the 
peritoneum, other bacteria. A mouse inoculated with 
the pus of the brain membranes died in twenty-four 
hours. The spleen w'as markedly swollen, and " charac- 
teristic pneumococci " were found in the blood. There 
was, therefore, in this case, a remarkable extra-pulmo- 
nary localization of the pneumococcus, produced per- 
haps by the chronic alcoholism. The exudation was 
green, thick, and plastic, characteristics which enabled 
the author to predict the presence of the diplococcus 
pneumoniae. 
In the ensuing, discussion, Sevestre declared that he 
had encountered a case of peritonitis in a young girl re- 
cently where the exudation was accumulated in the left 
iliac fossa. In pus removed by puncture Netter demon- 
strated the pneumococcus. Netter also reported a case 
of meningitis and peritonitis in a small child where he 
found pneumococci in the blood, and supported the dec- 
laration of Debove that he was able to declare the exist- 
ence of the diplococcus pneumoniae in extra-pulmonary 
localizations from the macroscopic condition of the 
exudation, a declaration which had been advocated in 
former statements by Netter. But the diagnosis must 
not rest upon these conditions. It may be determined 
only by bacteriological examination. 
Gabbi and Puritz declare that the occurrence of a men- 
ingitis or endocarditis, either or both, in the course 
of a croupous pneumonia, or during the period of con- 
valescence, is, if not a frequent, at least an established 
sequence, and either may properly be regarded as a com- 
plication of this disease. 
Weichselbaum, as early as 1884, declared that the 
micro-organisms of croupous pneumonia might be the 
cause of meningitis, and Foa and Bordoni-Uffreduzzi 
produced meningitis by the inoculation of animals with 
the pneumonic diplococcus. The same results were ob- 
tained by Fraenkel and later by Netter. 
Lancereaux and Besan^on were able to demonstrate 
Fraenkel's capsule microbe in many cases of endo- 
carditis. 
A review of the later works of Weichselbaum, Vinet, 
and others, shows with certainty that the above-men- 
tioned micro-organisms may produce an acute inflam- 
mation of the meninges or of the endocardium. 
Foa finds an organism that partakes partly of the char- 
acter of the meningococcus and partly of that of the pneu- 
mococcus. If the latter is cultivated anaerobically it 
takes on the properties of the meningococcus in twrenty- 
four hours. The meningococcus can be temporarily 
transformed into the pneumococcus, if it is inoculated at 
the same time with the staphylococcus pyogenes aureus. 
Klippel reports a case of infection by micro-organisms 
in the course of mental disease. The patient, a fifty-year- 
old gardener, had suffered for ten years with dementia 
and slight paresis of the left side of the body. He was 
seized with sudden fever, extensive muscular rigidity 
and convulsions, and died comatose in three days. The 
most careful investigation failed to disclose any lacera- 
tion or break of the surface, which could have furnished 
an avenue for outside infection. The post-mortem re- 
vealed an extensive purulent meningitis, extending from 
617 meningitis. 
Mercury, 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
a centre of softening, which had been regarded as the 
cause of the dementia. Microscopic examination of the 
pus showed the pneumococcus. Such secondary infec- 
tions in the course of insanity occur frequently. Klippel 
claims that the pathogenic micro-organisms circulating 
in the blood find in the diseased centre a locus minoris 
resistentia?. 
The differential diagnosis between simple and tuber- 
cular meningitis may be established by the use of tuber- 
culin, though the procedure is not wholly without danger 
in the tuberculous form. 
In pseudo-meningitis (Boulay), aside from partial pa- 
ralysis, all the symptoms of meningitis may be present, 
and the case may look very doubtful until unmistakable 
hysterical symptoms develop ; or recovery occurs sud- 
denly, sometimes after a convulsion. 
Treatment.-Dauchez in the case of a child, aged four, 
was able to relieve excruciating headache at night only 
by narcotic doses of morphine and chloral, but succeeded 
during the day with antipyrin, in small doses-.02, .04, 
every hour for four doses. The distressing outcry 
ceased, though the child gave vent to sighs from time to 
time. 
Essex-Wynter was able to give some relief in four 
cases of tubercular meningitis by puncture of the verte- 
bral canal, and discharge of cerebro-spinal fluid. The 
breathing improved ; sometimes coma was relieved. Ir- 
responsive pupils regained the reflex, but all improve- 
ment was only temporary. 
Opium remains the anchor in the treatment of menin- 
gitis. Dennison cured a chronic case with tuberculin. 
Pachymeningitis, External and Internal.-As 
illustrative of the rarity of the disease, Northrup declares 
that he encountered internal haemorrhagic pachymeningi- 
tis only four times in one thousand five hundred autop- 
sies. In three cases, severe and prolonged convulsions 
finally terminated in death. In the fourth case there was 
no symptom except restlessness and slight rigidity. The 
patient died of acute enteritis. There was no paralysis 
in any case. 
Bailey reported a case in a man, aged seventy-two, a 
subject of senile melancholia; death from convulsions. 
Autopsy disclosed encapsulated haematoma under the 
dura of the right parietal bone. The haematoma was 
composed of coagula of different ages, and there was a 
recent rupture in the arachnoid cavity. 
Ruhemann found in percussing the skull in a great num- 
ber of patients, that sensitive surfaces could be detected 
only in chronic pachymeningitis, and then with great 
regularity. In genuine epilepsy the remarkable observa- 
tion was made that in twenty of twenty-nine cases a cir- 
cumscribed portion of the temporal bone was sensitive. 
Adamkiewicz emphasizes the fact that in spinal pa- 
chymeningitis it is the extension of the inflammation 
rather than the pressure of the connective tissue which 
damages the nerves and cord. 
Hoffmann remarks that, notwithstanding the fact that 
the intra-cranial diseases as sequels of affections of 
the ear have long since received full consideration, 
purulent pachymeningitis externa, the most frequent 
form of intra-cranial inflammation in consequence of ear 
disease, still receives very little study. Most of the text- 
books do noteven consider an isolated inflammation of the 
dura. Hoffmann collected from literature one hundred 
and two cases in which the autopsy, with certainty, con- 
firmed participation of the dura. From his own and other 
studies, the author recognizes (1), a form in which pus oc- 
curs as a deposit on the outside of' the dura, and (2), a 
form in which it shows itself as an extra-dural abscess. 
The following are the conclusions : Purulent external 
pachymeningitis is the most frequent of the intra-cranial 
diseases after inflammations in the middle ear, but on ac- 
count of its uncertain symptomatology it is recognized 
in life in only a few cases. 
It is the most frequent cause of fatal intra-cranial 
diseases-meningitis, sinus phlebitis, and brain abscess. 
These consequences are favored by the long duration of 
pachymeningitis and retention of its pus. 
So soon as the bones become diseased in consequence of 
(SUPPLEMENT.) 
affection of the middle ear, suspicion should be excited 
of a complication with pachymeningitis. 
Treatment must be operative. It consists in trephin- 
ing the mastoid process and exposure of the inflamed, 
dura. James T. Whittaker. 
MENTHOL. The decided antiseptic qualities, and the 
safety with which it maybe administered, have led to the 
internal use of menthol in a number of diseases and con- 
ditions in which an antiseptic is indicated. In pulmo- 
nary and laryngeal phthisis it has been recommended to 
combine its internal use with inhalations and local appli- 
cation to the diseased parts when within reach. It is 
thought to give rise to a general amelioration of the 
symptoms, promoting expectoration and reducing the 
amount of the sputa, and lessening the night-sweats and 
fever. It does not irritate the stomach or kidneys, does 
not cause haemoptysis, or produce any bad effects. 
For internal use from fifteen to twenty grains are given 
two or three times, and increased to five or six times, a 
day. It has also been used in the form of hypodermic 
injections, when mixed with vaseline in the proportion 
of ten parts to one hundred. For laryngeal phthisis it is 
advised to begin with a ten per cent, solution and grad- 
ually increase the strength until a fifty per cent, solution 
can be applied ; if too strong a solution be used at first it 
produces irritation of the parts. Its use is followed by a 
relief from pain and a reduction of the local inflamma- 
tion and infiltration : a healing of the superficial ulcera- 
tion follows, but it does not seem able to heal the 
deeper ulcers. The intra-tracheal use of menthol has 
been adopted by Dr. Brookhouse (British Medical As- 
soc., 1892)-one drachm of a twelve per cent, solution in 
pure olive oil is introduced into the trachea twice daily. 
This must be effected with the aid of the laryngoscope 
and syringe, the curved tube of the latter being intro- 
duced about half an inch below the rima glottidis. This 
method does not cause any pain or distress if carefully 
applied. The inhalation of the drug may be easily ob- 
tained by placing the menthol in a bottle with two glass 
tubes. As it volatilizes at 113° F., by placing the bottle 
in a dish of hot water, a copious supply of fumes is 
produced. The patient may take five or six inspirations 
several times a day, beginning slowly, as too great 
quantities might provoke irritation and choking. Men- 
thol has also been employed in asthma and chronic 
bronchitis and laryngitis. In diphtheria it is advised as 
a local application in the form of a powder, one part be- 
ing well mixed with ten or twenty of sugar. The pow- 
der is applied with a camel-hair brush, the membrane 
being removed as fully as possible. The application 
should be repeated twice or three times a day. It acts 
as a constant disinfectant, destroying the specific poison, 
and on the second or third day the membrane disappears, 
leaving a clean and easily healing ulcer. 
Menthol has been found to have an anti-emetic action, 
and has proved of great service in all forms of vomiting, 
particularly when pregnancy is the.cause of this dis- 
tressing symptom. This effect is supposed to arise from 
a purely local stimulant action of the drug. For this 
purpose it is best administered at the commencement of 
nausea, before the vomiting occurs; a suitable wTay of 
giving it in this trouble is to prepare a solution in oil of 
twenty per cent, and place ten drops on sugar, and form 
it into a mass which is readily taken and swallowed by 
the aid of a mouthful of water. Another preparation is 
to mix menthol, one part; spirits of wine, twenty parts ; 
simple syrup, thirty parts. One teaspoonful every hour 
until nausea is relieved. 
The following combination also forms a permanent 
mixture : Menthol, two drachms ; alcohol, one ounce ; 
glycerine, one ounce ; syrup, one ounce. It may also be 
given in the form of pills : Menthol, one drachm ; pow- 
dered acacia and sugar, of each half a drachm ; to be 
made into forty pills. 
Menthol continues to be of service as a local application 
in neuralgia, sciatica, pruritus, and other painful affec- 
tions, and in various parasitic diseases. Its local use has 
been facilitated since it was discovered that when mixed 
618 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Meningitis.. 
Mercury, 
with certain other analgesics it assumes a fluid form. When 
triturated in the following proportions, colorless, trans- 
parent oily fluids are produced, which may be used for 
the purpose of inhaling or as local anaesthetics : Menthol 
in equal parts with thymol, absolute phenol or chloral ; 
menthol three parts, camphor two parts ; menthol two 
parts, butyl-chloral-hydrate one part; and menthol two 
parts, with one each of carbolic acid and butyl-chloral- 
hydrate. Beaumont Small. 
MERCURY (Hydrargyrum, U. S. Ph.). Introduc- 
tion.-In taking up the study of mercury after a lapse of 
six or seven years it must be borne in mind that material 
changes have taken place within that period, although it 
is doubtful if salts and preparations of the metal are any 
more highly prized by physicians and surgeons now than 
at any time during the past decade. That mercurials 
possess a wide range of application cannot be denied, but 
aftei» a careful and comprehensive survey of the kaleido- 
scopic changes that have occurred in the minds of intelli- 
gent practitioners within a quarter of a century, there is 
no doubt but that their medicinal properties have been 
greatly overrated, and at the same time the deleterious 
action upon the economy largely underestimated. Judg- 
ing by the character of reports appearing from time to 
time in current medical literature, it is evident that mer- 
curials are now employed with a nicer discrimination, 
with more intelligence looking to the definite effects which 
are likely to follow, and more with a view to their con- 
servative influences than ever before. However, this 
happy condition of affairs has not been reached through 
careful and deliberate investigation of the clinical prop- 
erties of the drug, but, on the contrary, by a series of most 
reckless and flagrant abuses-a sad commentary when 
considered in connection with the coincident advance- 
ment in other sciences. 
Through a strange concatenation of circumstances in 
teaching and practice-due largely to the fact that mer- 
cury was supposed to possess a so-called alterative effect 
upon the organism-physicians appeared to have lost 
sight of the oft-repeated caution that it was a substance 
foreign to the human economy, and an acrid, irritant 
poison. Its properties have been, in many instances, esti- 
mated from the clinical point of view, by considering the 
temporary or immediate benefits from its use rather than 
from the scientific standpoint, which would bring into 
prominence the ultimate disorders following its injudi- 
cious or long continued employment. In studying these 
properties, therefore, in the light afforded by modern in- 
vestigation, it will be necessary to take into account these 
facts, viz.: That mercury is a substance foreign to the 
organism, and an irritant poison producing both imme- 
diate and remote changes in structure, whether used in- 
ternally, locally, or hypodermatically. And in view of 
the additional fact that the so-called "alterative" action 
has come to be regarded as without scientific meaning, 
and lacking in definiteness, the present seems an oppor- 
tune moment for advancing certain evidences that prom- 
ise to offer an explanation of its action, an explanation 
that shall be more in keeping with the demands of modern 
science, while at the same time strictly within the range 
of practical medicine. Scientific facts, supported by 
clinical facts, will go very far with intelligent practi- 
tioners in elucidating the mysteries which have so long 
surrounded and obscured the therapeutics of.this impor- 
tant remedial agent. 
In order to accomplish this laudable purpose it will be 
necessary to consider the nature of its cumulative action, 
and the causes at work which, apparently, prevent or 
modify this action in children. It will also be desirable 
in this connection to study immediate and remote effects, 
the primary and secondary actions of both soluble and 
insoluble salts and preparations, all of which can best be 
accomplished by a critical examination of its pharma- 
cology, which naturally includes its toxicology, physio- 
logical actions in medicinal doses, and mode of elimi- 
nation. This study should include, in short, a complete 
analysis of its general and specific influence upon meta- 
bolism, meaning by that its constitutional as well as 
specific action upon different organs and tissues, includ- 
ing in this category the entire nervous system. And, 
finally, having thoroughly digested and sifted all avail- 
able information upon these various topics, the conclud- 
ing section will be devoted to its therapeutic applications, 
the different diseases being grouped to facilitate study 
and reconcile the conflicting views hitherto held. 
As a preliminary to the present paper, it will be profit- 
able to consider briefly some of the more recent mercurial 
preparations, and to pass in review the antagonists and in- 
compatibles. In the original article by Professor Curtis 
(Reference Handbook of the Medical Sciences, 
Vol. IV., 1887, p. 737), the Pharmacopoeial preparations 
were so fully studied that it does not appear necessary at 
this time to attempt a remodelling of that section, al- 
though their properties will be referred to incidentally in 
connection with toxicology. For more detailed informa- 
tion covering the toxicology the reader is referred to the 
contribution of Professor Hills (loc. cit., p. 744), which is 
exceptionally full and complete. 
Mercury Compounds.-The following list includes 
the principal mercurial compounds * aside from the Phar- 
macopoeial products which have recently been brought 
to the attention of the profession. While some of them 
undoubtedly possess distinct therapeutic properties, the 
greater number are lacking sufficient clinical investi- 
gation to warrant their general use. 
Mercuric Benzoate, (C6H6COO)2Hg,H2O, occurs in 
the form of small colorless crystals, tasteless and free 
from odor ; readily soluble in alcohol and hot water, but 
sparingly soluble in cold water. This preparation has 
been used hypodermatically suspended in liquid paraffin 
(Stukowenko) for the treatment of syphilis, and also in 
combination with sodium chloride in watery solution 
(Cochery) for the same disease. Bose, one syringeful 
daily of a solution containing the following proportions 
of the different ingredients-3 to 1 to 400. 
Mercuric Carbolate or Phenylate, (C6H6O)2Hg, occurs 
in the form of colorless needles, soluble in hot alcohol 
(1 to 20), ether, or a mixture of alcohol and ether, and in 
glacial acetic acid ; insoluble in cold water or cold alcohol. 
Mercuric carbolate has been employed to a limited extent. 
(Schadeck) in the treatment of syphilis. Bose, for an 
adult, gr. f to 4, two or three times a day, and for chil- 
dren in proportion. 
Mercuric Formidate occurs as a solution, produced by 
the action of formamide upon mercuric oxide. It has 
the advantage of not coagulating albumin, is rapidly ab- 
sorbed, excretion taking place through the kidneys. 
Mercuric Bnido-succinate, [C2H4(CO)2N]2Hg, occurs 
in the form of a white, lustrous, crystalline powder ; 
soluble in twenty-five parts of water or three hundred 
parts of alcohol. The substance was first described in 
1852 (Dessaignes), and in 1888 was recommended as an. 
antisyphilitic (von Mering, Vollert). Bose, subcutane- 
ously, gr. | in watery solution, with or without the addi- 
tion of cocaine. 
Mercury I'Alananate is a white, crystalline powder de- 
rived from lactic acid and proplieglycole ; soluble in three 
parts of cold water. It is prepared by dissolving the 
alananine in five times its weight of distilled ■water, and 
while boiling, small quantities of mercury binoxide are 
added so long as it dissolves. Bose, subcutaneously (de 
Luca) gr. to gr. J daily. It is said this treatment in 
syphilitic cases, continued for a period of forty-five days, 
has frequently proved sufficient. 
Mercury Naphthalate occurs in the form of a lemon- 
yellow, odorless powder, containing 30.8 per cent, of 
mercury, insoluble in water. It was first employed in 
the treatment of syphilis (Jaddasohn, Zeissing), but 
proved unsuitable owing to the violent pain produced. 
Bose, internally, one grain. 
Mercury Oleate, Hg(Ci6H33O2)2, a true chemical pro- 
duct containing 28.3 per cent, of mercuric oxide ; it is 
in the form of a brownish-yellow or yellowish-gray unc- 
* The author desires to acknowledge his indebtedness for much of the 
information on this topic to Helbing's Modern Materia Medico, 3d edi- 
tion, 1892. 
619 Mercury. 
Mercury. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
tuous substance, having the odor of oleic acid ; soluble in 
benzene, but not in alcohol, and at ordinary tempera- 
tures is of the consistency of an ointment. It is best pre- 
pared by the double decomposition of sodium oleate 
tCastile soap) and mercuric nitrate, but the process is 
somewhat complicated. 
Oleate of mercury as now prepared is a stable product, 
and has been favorably received as an acceptable substi- 
tute for mercurial ointments, being a more cleanly appli- 
cation, does not become rancid, and, besides, is more 
rapidly absorbed. It is generally employed as an external 
application in the strength of live to ten per cent. Con- 
stitutional effects may be produced to a limited extent by 
the use of mercury oleate, and it may therefore be sub- 
stituted for internal medication when the condition of 
the stomach forbids the internal use of the mercurials, 
but its principal field has hitherto been confined to the 
treatment of diseases of the skin, specific and non-specific, 
including also parasitic affections. It appears to be es- 
pecially adapted to diseases of the skin which are char- 
acterized by an indolent condition of the structures, 
eczema, tumors, pigmentation, and all forms of indura- 
tion or thickening; it should not be applied to ulcera- 
tions where there is a solution of continuity. 
Mercuric, Oxycyanide, Hg3O(CN)2, has been employed 
to a limited extent (Boer) as an antiseptic, and is said 
to be superior to the sublimate in this respect, being less 
caustic, free from any coagulating action upon albu- 
min, and less harmful to instruments. The following 
points are advanced in its favor : 1, Precipitates albumin 
only slightly ; 2, less irritant than sublimate solutions ; 
3, not so readily absorbed ; 4, antiseptic power in keep- 
ing soup six times stronger than sublimate; 5, more 
efficient as an antiseptic and safer in treating suppurating 
and mucous surfaces, owing to tolerance and feeble ab- 
sorption. 
Mercuric Peptone occurs in the form of a yellowish 
liquid, having a saline, feebly metallic taste, and slightly 
acid reaction. It was originally introduced for hypo- 
dermatic use, and is said to be mild and efficient, causing 
no pain or abscesses. Dose, one c.c., said to be the 
equivalent of gr. £ of the bichloride. (See Glutine-pep- 
tone Sublimate.) 
Glutine-peptone Sublimate occurs in the form of a white, 
lustrous, hygroscopic powder (prepared and on sale in 
the form of a one per cent, solution) containing twenty- 
five per cent, of mercuric chloride. It is prepared by 
the action of hydrochloric acid on gelatin-a double com- 
pound of glutine-peptone hydrochloride - with subli- 
mate. Dose, subcutaneously, one Pravaz syringeful 
(Hiitler), the equivalent of gr. | mercuric chloride. 
Mercuric Salicylate, C6HtOCO2Hg, is in the form of 
a fine, white powder, tasteless and odorless, and acid 
in reaction. It was employed as early as 1887 (Silva- 
Aranjo), and again more recently (Schadeck), as an inter- 
nal and external remedy in syphilis, and is said to be 
mild, yet energetic. It has also been employed by intra- 
muscular injection suspended in mucilage, and locally 
in the treatment of gonorrhoea in weak solution as an 
injection. Dose, gr. to |, in pill form. 
Mercury Sozoiodol, [C6H2I2(I2)(OH)SOs]2Hg, is in the 
form of a lemon-yellow powder ; moderately soluble in 
sodium chloride solution, but scarcely soluble in water 
(1 to 500). In strong solution this product is an irritant 
to the tissues, but its insolubility recommends it for hy- 
podermatic use in the treatment of syphilis. According 
to Schwimmer it is superior to all sozoiodol preparations 
in its curative value and certainty of effects. Dose, one 
grain, deposited in the gluteal region. 
Mercury Stearate, recently brought to the attention of 
the profession, is in the form of a white, unctuous pow- 
der, and is said to contain twenty per cent, of mercuric 
oxide-about the same as blue ointment. It differs from 
the oleate in being entirely free from oleic acid, and may 
be used for insufflation, or as a " dry ointment" in place 
of the usual greasy applications when the local action of 
mercury is desired. 
Mercury Tannate occurs in the form of brownish-green 
scales, tasteless and odorless ; insoluble in water and al- 
(SUPPLEMENT.) 
cohol, although when brought into contact with either 
tannin is given off. The theory of its action (Lustgarten) 
is based upon the assumption that metallic mercury is set 
free when exposed to the alkaline contents of the small 
intestine. Dose, one to two grains, an hour after eating. 
Mercuric Thymolate, (Ci0Hi,O)Hg-HgNOs, in the fresh 
state, is in the form of a colorless powder, tasteless and 
odorless ; after exposure it gives off a faint odor of thy- 
mol, with change of color to a reddish hue. 
Mercuric Thymolacetate, (CIOHIaOJIIg-HgCallsOa, is 
a substance similar to the foregoing, although the latter 
is that principally employed in syphilis (Koliert). It 
has been especially advocated also in the treatment of 
pulmonary tuberculosis (Trangen), both in the early stage 
and in those cases far advanced in the disease, the medi- 
cament being suspended in liquid paraffin. For syphilis 
it is given internally or hypodermatically in the manner 
stated. Dose, internally or subcutaneously, gr. to 
Mercury-zinc Cyanide, [Zn4Hg(CN)i0], occurs in the 
form of a white powder, which is said to consist of mer- 
curic cyanide (not to exceed thirty-six per cent.) whose 
particles are " occluded " from the action of water by the 
insoluble zinc cyanide (Dunstan) ; insoluble in water. 
Mercury-zinc cyanide is obtained by adding a soluble 
zinc salt to a solution of the cyanide of mercury and of 
potash. The substance was originally introduced by Sir 
Joseph Lister as an antiseptic and non-irritant dressing, 
and is now employed by a limited number of surgeons 
with most gratifying success. The strength of the so- 
lutions used for the held of operation is 1 to 2,000, and 
that for compresses is 1 to 500. 
Triturations of Mercury and its Salts have, within the 
past few years, come into very general use for internal 
administration, and their employment has been attended 
with such uniformly satisfactory results that it is but a 
question of time when this practice will be adopted in 
nearly all ordinary cases. The causes which have been 
instrumental in bringing about this change will be dis- 
cussed under the head of Antagonists and Incompatibles, 
q. v. 
Antagonists and Incompatibles.-When a lethal 
dose of corrosive sublimate has been taken into the stom- 
ach, albumin in some form-white of egg-should be 
administered and emesis secured as promptly as possible, 
before the resulting albuminate of mercury is redissolved 
by excess of albumen. Demulcent drinks are usually 
advocated, in the belief that they will protect the mucous 
membrane of the stomach from the irritant action of the 
poison ; but mucilaginous substances do more than this, 
inasmuch as they cling to, and hold in suspension, such 
foreign substances as mercury albuminate, the form in 
which mercury enters the circulation. Mercurial salts 
being proverbially uncertain in some respects-especially 
the bichloride-they should be given preferably in the 
form of triturations, although this does not necessarily 
apply to the insoluble salts like the biniodide when sus- 
pended in mixtures. But even the use of this salt, as in 
the "mixed treatment," is far more satisfactory in the 
form of triturations, since incompatibles are avoided, 
smaller dosage required, and the untoward effects, im- 
mediate and remote, reduced to a minimum. The facil- 
ity with which therapeutic effects may be secured by the 
exhibition of small doses of blue pill and calomel, pre- 
pared in this form, practically excludes the question of 
incompatibility. Both the soluble and insoluble prepa- 
rations in this form, alone or combined with other suita- 
ble medicants synergistic in character, may be exhibited 
in suitable doses under proper dietetic regulations with- 
out regard to the possible dangers arising from their ad- 
ministration in bulk. 
A note should be made to the effect that starchy foods 
delay or cause irregular absorption, while a nitrogenous 
diet with free ingestion of liquids heightens the activity 
of mercurials. Constipation, by interfering with elim- 
ination, may produce salivation, and under such condi- 
tions a dry diet, by lessening the urinary water, is not 
infrequently the exciting cause of occult renal disorders. 
Exposure to cold is also inimical to the therapeutic action 
of mercurials, while diaphoretics tend to promote con- 
620 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Mercury. 
Mercury. 
stitutional effects-favorable when the dose is small, but 
unfavorable when toxic symptoms are imminent. Loose- 
ness of the bowels following the exhibition of mercury 
may be counteracted by the temporary administration of 
opium or some of its preparations (codeine sulphate), al- 
though it is better to avoid distinct physiological mani- 
festations by diminishing the dose, regulating the diet, 
and improving the hygienic environment. 
So-called idiosyncrasy, when mercurials are used in 
appropriate dosage, is generally and principally a merely 
accidental or coincident effect, due to physical (personal) 
conditions, habits as to diet, exposure, hygiene, and the 
like, since there is reason to believe that the condition of 
the physical system exercises a more decided influence 
in favoring this manifestation than does the nervous sys- 
tem. Indeed, it appears as if the effects upon the latter 
were indirect or secondary, although there doubtless are 
reflex effects resulting from molecular changes which 
are not altogether independent of the nervous system. 
The effect of mercury upon the system may be compared 
to the effect of adding coal to a furnace when combustion 
is actively going on ; the added fuel may cause a tempo- 
rary lull in the heat dissipation, but this is followed by 
increased combustion and augmented heat. In the case 
of the furnace it is the coal which is destroyed, while 
in the case of the human organism it is the tissues that 
are consumed, each dose of mercury beyond that requisite 
being attended with increased tissue-metamorphosis. 
Pharmacology.-In studying the Toxicology of mer- 
curials as a whole or specifically it is not necessary or 
advisable to recapitulate from text-books, nor sift from 
current literature the details concerning their peculiar 
actions in causing death or contributing toward the pro- 
duction of pathological changes in the organism. It will 
be sufficient for our purpose to pass in review the various 
Pharmacopoeial products, with the addition of some brief 
notes relative to their special properties and activities. 
The preparations of mercury proper include mercury 
with chalk, blue mass, blue ointment, mercurial plaster, 
and mercurial plaster with ammoniacum. None of these 
preparations possesses any marked poisonous properties, 
and they may be used with benefit in properly selected 
cases, provided the dose be small and the drug not too long 
continued. Moderate dosage, for therapeutic effects, may 
be stated as follows : Mercury, with chalk and blue pill, 
grain -Ar at hourly intervals until six to twelve doses 
are taken, or two to four doses of one grain at longer in- 
tervals. Synergists, such as podophyllin resin, aloin, 
ipecac, ox-gall, salines, etc., will heighten the effect of 
small doses and lessen the dangers of toxic symptoms. 
Liberal draughts of hot water may also be of service in 
promoting diffusion and elimination, and there may be a 
demand for the exhibition of minimum doses of opium, 
pilocarpine, atropine, strychnine, etc., to meet special 
indications, and, as a rule, adjuvants are most serviceable 
when given separately, although administered at the same 
time. 
Preparations of the chlorides include corrosive sublimate 
(bichloride), calomel (sub-chloride), ammoniated mer- 
cury (not used internally), and ointment of ammoniated 
mercury. 
Of the two preparations belonging to this class which 
are used internally the bichloride is by far the most 
actively toxic, frequent reports having appeared showing 
unmistakably that it produces both immediate and remote 
pathological changes sufficiently characteristic of its poi- 
sonous action to be recognized both macroscopically and 
microscopically. Calomel, on the contrary, owing to its 
insolubility, is comparatively mild as a poison, so far as 
its immediate effects can be observed, although its re- 
mote action, when long continued or frequently repeated 
in substantial dosage, is antagonistic to a healthy state of 
nutrition, as will be shown presently. 
The dose of these two preparations, as usually recom- 
mended, is entirely too large-if we desire to avoid the 
bad effects. Both are popular remedies in the treatment 
of diseases of children, who seem to be less susceptible 
than adults to the toxic action of the drug ; and there are 
grounds for suspicion that the practice referred to is an 
important factor in prolonging convalescence, if not a 
fruitful source of factitious disease. In ordinary acute 
cases, where indicated, grain of corrosive sub- 
limate, or grain of calomel, given at hourly inter- 
vals, will fulfil every therapeutic indication, while the 
dangers incident to the use of large or toxic doses are 
avoided. The advice given in the preceding section con- 
cerning synergists and adjuvants applies with equal force 
to the administration of the chlorides. The antiseptic 
applications of corrosive sublimate will be considered 
under the head of Surgical Practice, q. v. 
Preparations of the oxide include yellow oxide (oxidum 
flavum), used principally in the preparation of yellow 
ointment and mercury oleate, red oxide, and ointment of 
the same. The preparations belonging to this class are 
decidely irritating, and are seldom used internally. The 
oleate (q. v.) is the only one which has attained any con- 
siderable degree of popularity. 
Preparations of the iodide include the red iodide (bin- 
iodide), Donovan's solution (solution of iodide of arsenic 
and mercury), and the green iodide (protoiodide). Both 
the biniodide and green iodide have shown distinct ther- 
apeutic properties in the treatment of subacute and 
chronic diseases, specific and non-specific, their virtues 
being due largely to their practical insolubility and the 
fact that doses sufficient to produce physiological or 
toxic effects are extremely irritating to the gastro-intes- 
tinal tract. The incorporation of iodine with the mer- 
cury likewise exercises an important function, since the 
remedies, being but slowly diffused throughout the dif- 
ferent structures, produce a more or less constant action 
upon the protoplasmic cells, by which metabolic changes 
are stimulated. 
The usual dose of the biniodide, prepared by thorough 
trituration, for adults in the case of gastro-intestinal, 
hepatic, and syphilitic affections, need not exceed grain 
T()t three or four times a day. The dose of the pro- 
toiodide should be about double this amount, grain fg. 
In the treatment of acute diseases of children, pecu- 
liar to the summer season, with evidences of hepatic in- 
volvement, vomiting, diarrhoea, dysentery, pain, tenes- 
mus, etc., the biniodide, in doses of grain tott hourly, 
is a superior remedy. It is quite as prompt in its action 
as the bichloride, and the benefits appear to be of a 
more permanent character, probably because of its insol- 
ubility as previously stated. It is also of service in the 
treatment of all throat affections, owing to its local anti- 
septic properties and its antiseptic and stimulating action 
upon the stomach and liver respectively. 
Of the acid combinations it is only necessary to say that 
they are actively poisonous. The nitrate is employed as 
a caustic and in the preparation of citrine ointment, the 
subsulphate (yellow) as an emetic. Mercuric sulphide is 
employed for fumigation, now rarely used, and the 
cyanide is actively poisonous. The latter in combination 
with zinc has recently come into use as an efficient anti- 
septic. 
The foregoing summary is put in evidence to show 
that mercurials, in whatever form presented, are all 
either immediate or remote poisons to the organism, 
although this declaration must have slight effect since all 
practitioners readily admit the fact. It becomes necessary, 
hdwever, to reconcile its therapeutic value, long estab- 
lished, with its well-known properties as a protoplasmic 
poison, inimical to all animal and vegetable life. And 
this brings us to the consideration of questions that have 
long vexed the minds of physiologists and clinicians 
alike, questions of weighty significance, pregnant with 
important but unsolved truths that have swayed the 
practice of the healing art generation after generation 
from the dawn of history down to the present time. 
Turning to the text books of the day we find mercury 
classed as a tonic, purgative, alterative, antiphlogistic, 
antiseptic, and sorbefacient, and, to a limited extent, 
cholagogue ; but to the scientific mind this information 
conveys nothing definite, exact, or positive, as it has 
never been demonstrated either definitely, exactly, or pos- 
itively how these manifestations were brought about. 
Of course we know that a peculiar fetor of the breath and 
621 JTIerciiry. 
JIercury. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
metallic taste in the mouth are early indications that " the 
■drug is affecting the system," but evidently this is a loose 
way of calculating. It must be apparent that these early 
indications are, in fact, secondary or remote effects, and 
that the immediate or direct effects have been overlooked. 
For example, we know that corrosive sublimate taken in 
lethal dose causes vomiting, purging, and tenesmus, per- 
haps suppression of urine, and that its effects are espe- 
cially marked upon the lower bowel, manifested at times 
by bloody stools, but apparently there is a long distance 
between this morbid complexus and salivation. Twenty, 
forty, or sixty grains of calomel will produce decided re- 
flex nervous symptoms, but, on the other hand, medicinal 
doses, long continued, are almost certain to be followed 
by stomatitis. That stomatitis is a secondary effect is 
shown by the associated elevation of temperature. 
Experimental workers speak of the physiological action 
and effect, and clinicians talk about therapeutic action and 
just as though the two words, action and effect, 
were interchangeable or mutually convertible terms, 
when in fact there is a wide difference between them. 
What intelligent medical practitioners want to know is : 
How do mercurials act in order to produce the effects ob- 
served ? The latter-the effects-the merest tyro in 
therapeutics can comprehend, but it remains to give a sat- 
isfactory working explanation of the modus operandi by 
which these effects are produced. In short, is there any 
other possible translation of the metamorphoses produced 
by mercurials than that they possess " alterative '' prop- 
erties 'I 
In attempting to reply to these questions let us start by 
accepting as true the belief that the conservative pro- 
cesses of Nature tend toward the elimination of poisons 
and foreign substances. Now we know that certain 
channels are available for this purpose, viz., the liver, 
salivary glands, alimentary tract, skin, kidneys, and the 
pulmonary and bronchial mucous membrane. Mercury 
entering the blood-vascular system, either as an albu- 
minate or oxy-albuminate, is not carried direct to the 
organs or structures named, but indirectly through the 
lymph-vascular system. It is therefore brought into 
contact with the protoplasmic cells, upon whose integrity 
the vitality of the various organs and tissues depends, 
elimination being finally effected from the intercellular 
fluid through the epithelial cells. If we proceed, now, 
to consider the normal condition and functions of proto- 
plasm, recalling the well-known facts relative to its 
capacity for taking up and storing oxygen for its own 
proper work, its ability to produce ozone and thus stim- 
ulate katabolic processes, it will be apparent that when 
an organic substance foreign to the economy-a poison- 
is brought into contact with it, functional activity will be 
increased. Heightened functional activity usually means 
in such cases an increased discharge of carbonic acid and 
katabolic products, together with renewed activity in the 
tip-building process. This is substantially what has long 
been recognized as cellular activity, and working prin- 
cipally in the direction of retrograde metamorphoses, 
studying degenerative effects, it formed the basis of Vir- 
chow's celebrated treatise, " Cellular Pathology." When 
we turn our attention in the direction of reconstructive 
metamorphosis with the object of learning the peculiar 
influences- at work in connection with the exhibition of 
remedial agents, our line of investigation is practically in 
the opposite direction. In other words, our studies lie in 
the direction of cellular therapy rather than toward cellu- 
lar pathology. But the two currents of thought are so 
intimately blended and mutually interdependent-like 
the warp and woof-that it is almost impossible to make 
satisfactory progress unless we take both into account in 
our reckoning. Simply to know or understand what is 
covered by the term "alterative," however, is not suffi- 
cient ; we must have some definite, exact, and positive 
knowledge concerning the difficulties to be met and over- 
come in treating disease, and therefore, as a preliminary 
to the practical adaptation of cellular therapy, the stu- 
dent must be well-grounded in the principles underlying 
normal physiology and cellular pathology. 
And there are good and sufficient reasons for insisting 
upon this course, since the ultimate object of medical 
study is to restore impaired or suspended function, which 
can only be successfully accomplished by the re-estab- 
lishment of cellular activity. Thus the therapy best 
adapted to restore the functions of disordered cells is 
that which will prove most successful in removing dis- 
ease and its symptoms ; but care must be exercised in 
the exhibition of remedies in order to avoid what might 
be called " cumulative " effects, or the depression conse- 
quent upon over-stimulation. For instance, the early in- 
dications that mercurials are affecting the system are, in 
fact, evidences of toxic activity, evidence that there has 
been sufficient "action" upon the protoplasmic cells, 
their nutritive pabulum contained in the intercellular 
fluid, or their nerve-supply, to produce the effects ob- 
served, namely, fetor of the breath and metallic taste in 
the mouth. The proof is therefore conclusive that, while 
mercurials are protoplasmic poisons, it is to this property 
that they owe their therapeutic virtues as tonics, purga- 
tives, alteratives, antiphlogistics, antiseptics, sorbefa- 
cients, and, as will be shown presently, their value as 
cholagogues, and the term cellular therapy, therefore, 
appears to be well chosen. 
In the case of mercurials, for example, the therapeutic 
effect is a resultant, the two forces being the disease and 
the medicine, the conservative processes of cell-life being 
temporarily impaired or suspended. The depressing 
tendencies produced by disease, ptomaines, leucomaines, 
etc., are counteracted or overcome by the irritating, or, as 
it is usually called, stimulant action of the minute quan- 
tity of poison to which the protoplasmic cells are ex- 
posed. These effete products are discharged or burnt up by 
the oxygen or ozone of the protoplasmic cells, so that these 
latter are changed or " altered " in such manner that bet- 
ter prepares them for the performance of their normal 
functions, and to this circumstance may be due the word 
" alterative." Clothed in this new dress the term has a 
greater significance to the clinician, because it rests upon 
a foundation that is both scientific and practical. 
The usual study of physiological actions includes also 
the effect upon the blood. According to the experimental 
studies of Harley, mercuric chloride added to blood les- 
sens the evolution of carbonic acid, and, at the same 
time, increases the absorption of oxygen, evidence that 
it stimulates oxidation ; but, on the other hand, albu- 
minate of mercury added to blood in like manner grad- 
ually destroys the red blood-corpuscles, facts pointing to 
the necessity for exercising the greatest care in its ad- 
ministration. In comparing these results with the clin- 
ical evidence advanced by Keyes (American Journal of 
the Medical Sciences, January, 1876), showing that small 
doses of mercury (gr. | of the protoiodide t.i.d.) increase 
the number of red corpuscles in the absence of disease, 
it is easy to understand the causes which combine to pro- 
duce the apparently conflicting results. In truth, they 
do not conflict at all, but merely express scientific facts 
entirely independent of each other. 
An observation should be made here to the effect that 
the therapeutic results following the exhibition of mer- 
cury are not all direct, since the increased oxidation 
which it causes in the system means more active metab- 
olism, augmentation of the red blood-corpuscles, and im- 
proved primary assimilation. These are what might be 
termed consequential benefits; and in the light of these 
facts, and our knowledge that the inorganic substance is 
eliminated from the organism unchanged, it is not 
deemed necessary to combat the assumption that mer- 
cury must, in some occult manner, become an integral 
part either of the blood or tissues in order to effect re- 
constructive metamorphosis. 
Upon the muscular system mercury produces a some- 
what anomalous effect. For example, we might suppose 
that increased oxidation would be attended by augmented 
capacity for work ; but such is not the case, although 
mercury has no material influence upon muscular irrita- 
bility. And this explains in a measure why patients who 
have taken medicinal doses of the drug for a consider- 
able time finally begin to show evidences of cardiac 
weakness and require tonics. The respiratory muscles 
622 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Mercury. 
Mercury. 
likewise show impairment of their capacity for work, so 
that in calculating the gains from stimulation of the in- 
ternal respiratory function, we must not overlook the fact 
that increased dosage or continued administration may 
produce symptoms which are but transitory, evanescent, 
or misleading. 
In addition to its action as a protoplasmic poison at the 
points of elimination by the renal structures, large doses 
have the effect of producing chronic interstitial nephritis 
by calcareous deposits in Henle's loops, which block up 
the tubules, and this in turn is followed by subacute in- 
flammation of the glomeruli and tubules with atrophy 
and cirrhosis (Brunton), being similar to the effects pro- 
duced by both lead and potassium chlorate. 
That mercury profoundly affects the nervous system is 
•confirmed by the remarkable manner in which persons 
in health are affected when exposed to its vapors. The 
irritability, melancholia, and in some instances furious 
mania, with other evidences of mercurialization that 
have been observed, afford abundant proof that either 
directly or indirectly it effects extraordinary changes in 
the centres of organic life that seriously interfere with 
the normal functions. In the case of leeches, for exam- 
ple, it acts chiefly upon the nervous system, and later 
upon the muscles. Although no evidence is forthcom- 
ing, there are strong probabilities that it affects in no 
small degree the molecular changes in serous membranes, 
and thus is added a new factor to its rapidly increasing 
list of physiological manifestations. 
The well-known eliminative functions of the glandular 
system naturally point to it as one of the principal chan- 
nels for the elimination of mercury, and this is confirmed 
by clinical observation ; but it possesses no property 
aside from its influence upon cellular activity that would 
entitle it to be classed as a specific glandular stimulant. 
It is therefore somewhat misleading to call mercury a spe- 
cific sialagogue, since we can trace the tissue-change to 
the effects of the remedy as a protoplasmic poison upon 
the cells concerned in elimination, and, fortunately for 
the scientific basis of therapeutics, the necessity for 
which this study is intended to develop, the foregoing 
admitted facts practically wreck the so-called "altera- 
tive" theory, viz., that " alteratives are remedies which 
improve the nutrition of the body without exerting any 
perceptible action on individual organs." 
In compliance with the request of the writer a discrim- 
inating study, scientific and practical, covering the physi- 
ological action of mercurials upon the liver and its func- 
tions, has been placed at his disposal for the present 
article by Dr. William II. Porter, of New York, as fol- 
lows : 
"The action of mercurials upon the hepatic function 
is exercised in three successive characteristically dis- 
tinctive stages, namely, as stimulants, as cholagogues, and 
as depressants. 
" As the mild chloride or calomel possesses all these 
qualities to a marked degree, it is perhaps the best exam- 
ple by which to elucidate the complete action of mercury 
upon the hepatic and digestive functions. The blue 
mass and the gray powder act in the same manner, but, 
if anything, are a little less active. The bichloride has 
a similar action, but its more irritating properties make 
it less valuable, or even useless, as a cathartic principle. 
Still, it can be used as a powerful hepatic stimulant, and 
as an adjunct to the cholagogue action of calomel. 
" The exact modus operandi by which mercury in any 
form produces the wonderful results upon the system 
that have been attributed to it for ages, has always been 
more or less in doubt, for the lack of a logical explana- 
tion ; yet the most sceptical, after watching the effects 
of a few doses of this drug upon the human system, can- 
not deny the power and utility of mercury. Taking the 
stand that the inorganic compounds are not destroyed 
within the animal organism, no time need be wasted in 
speculation regarding the decomposition of any of the 
mercurials into other compounds. How, then, shall the 
action of mercury and its compounds be explained ? 
Calomel, for instance, is almost insoluble ; consequently 
it in itself is comparatively non-irritating to the intestinal 
(SUPPLEMENT.) 
tract. At the same time it is known to be one of the 
most active cathartic compounds of mercury-two almost 
contradictory propositions. The cholagogue action of 
calomel cannot be explained by any direct irritating ac- 
tion which it can produce upon the alimentary tract, 
through the increased peristalsis, by reflex irritation 
causing an increased flow of bile. 
" The non-irritating character of calomel is just what 
gives it its chief power. Passing along down the ali- 
mentary tract without producing irritation, it is steadily 
absorbed into the entero-hepatic circulation and carried 
up to the liver. At this point of the animal economy the 
mercurial appears to act like a foreign body, and the he- 
patic cells, by their selective action, pick up the little 
particles of calomel from the blood, and eject them into 
the capillary bile-ducts. In accomplishing this task the 
hepatic cells are called upon to perform more work, and 
if the amount of calomel passed through the liver is 
small, its action is simply to stimulate the organ to a lit- 
tle greater activity. For a time the hepatic cells secrete 
a little larger quantity of bile, and such as has a little 
better quality. Up to this point the calomel has only 
been stimulating and physiological in its action. If now 
the calomel be administered in larger quantities-either 
by frequently repeated small doses or in one large dose- 
the eliminating action of the hepatic gland is greatly aug- 
mented. At the same time the protoplasmic elements 
which constitute the hepatic cells are stimulated, by the 
passage of this foreign body through their substance, to 
a more active production and elimination of the bile- 
acids. 
" When sufficient calomel has reached the liver to pro- 
duce this copious flow of bile-acids, the acids are dis- 
charged into the capillary bile-ducts more rapidly than 
they can react upon the alkaline phosphates or carbo- 
nates, and form the normal and neutral bile-salts. When 
this hypersecretion of the bile-acids is established, a cho- 
lagogue action is developed. This action, however, can 
only be temporary in character, because the protoplasmic 
vitality of the hepatic cells will, in a comparatively 
short time, be exhausted. After this excessive produc- 
tion of the bile-acids and their discharge together with 
the calomel, there is a period of protoplasmic exhaustion 
in which the bile-producing function of the liver is held 
in abeyance. 
" Viewed in this light calomel and its class of mercu- 
rials may be stimulating, cholagogue, and depressing in 
their action upon the functions of the hepatic gland-one 
condition following in quick succession after the other. 
The rapid intestinal peristalsis and frequent discharges 
from the bowel, however, are not the direct result of the 
mercurial action, but a secondary effect which has been 
brought on by the irritating properties of the bile-acids, 
so copiously discharged into the intestinal canal-as just 
shown. This fact is established by the lack of cathartic 
action by calomel in cases of occlusion of the common 
bile-duct; and furthermore, by the counter-test that 
where bile-acids are administered medicinally, a brisk, 
cathartic, and cholagogue-like action is at once estab- 
lished. 
" The hypersecretion of the bile-acids and its conse- 
quent effect upon the intestinal tract is not in any sense 
a physiological action, but is strictly a pathological pro- 
cess. But, by developing this abnormal condition in the 
functional activity of the hepatic gland, the liver-cells are 
stimulated to perform an abnormal amount of work, 
often vicarious in its nature, and by which the cells are 
empowered to expel many abnormal and by-products 
from the system-a task which, in their normal condi- 
tion, they are absolutely unable to perform. In this 
manner Nature rids herself of many foreign and offend- 
ing substances which, if allowed to remain and multiply 
within the system, would, in a short time, destroy the 
animal vitality, a result too often seen in cases imper- 
fectly treated. 
" The period of inaction which is imposed upon the 
hepatic cells as a sequel to this excessive action gives the 
protoplastic elements a chance to rest and to imbibe a 
more serviceable nutritive pabulum - thus augment- 
623 Mercury. 
Mercury. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT 
ing their nutritive activity and enhancing their func- 
tional vitality. When the hepatic cells again resume 
their physiological work, they are in a condition of 
high nutritive tone, and consequently the secretory 
and excretory work of the liver is more perfectly effected. 
The intestinal and hepatic transmutation of the food- 
elements is more perfectly accomplished ; and, as a nat- 
ural sequence, all the nutritive processes of the body are 
intensified ; secretion and excretion in general are more 
perfectly performed, and the animal vitality is raised to a 
higher standard. If the system has been poisoned by 
any form of microbic or ptomainic toxine, or is the seat 
of any inflammatory action, toxic or otherwise, the or- 
ganism is, by the above-described processes, placed in the 
best possible condition to destroy the etiological factors 
and remove the resulting pathological processes, and 
thus restore everything to a normal condition. 
" By a somewhat similar physiological action the well- 
known antiphlogistic power of the mercurials can be ex- 
plained ; and following this method of action for the 
mercurials generally, ptyalism, and all that class of toxic 
symptoms produced by mercury and its compounds, can 
be rationally explained. The same reasoning also shows 
clearly that the size of the single doses has little, if any- 
thing, to do in determining the liability to mercurial sali- 
vation. If, from any cause, the hepatic cells are inactive, 
and thus fail to respond to the presence of the mercurial 
salt, and to eliminate as speedily as it reaches the he- 
patic gland, then the mercurial will pass over into the 
general circulation, where, finally, the salivary glands 
will attempt to perform the work of elimination that 
should have been accomplished by the liver-cells. In 
like manner, when the calomel is given too freely, or 
when opium is given to check the cathartic action, and 
the hepatic cells either become exhausted from over-tax- 
ation, or they are retarded in their action by the opium, 
when the mercurial passes into the general circulation. 
Thus, again, the toxic symptoms with salivation will be 
produced. So long, however, as the hepatic cells retain 
their selective and excretory activity, it is absolutely im- 
possible to develop the toxic symptoms of mercury. 
The use of enormous doses may become the cause of ex- 
hausting the hepatic cells, whereupon poisoning will, of 
course, ensue. 
" From this study of calomel and its allied prepara- 
tions, the belief is entertained that all mercurial prepara- 
tions act in a similar manner, if of any value; that the 
specific effect of the mercurials in syphilis is simply due 
to the augmented hepatic function produced by the 
elimination of the metal. The more irritating prepara- 
tions, in so far as they act at all, act in the same way as 
calomel, but if taken in too large doses, are so locally 
irritating that they become poisonous in themselves. 
Therefore mercury is indicated in all cases where it is 
necessary to increase the functional activity of the liver 
and aid this organ in eliminating not only more bile, but 
also poisons of all kinds, microbic, ptomainic, leuco- 
mainic, katabolic, and vegetable or animal in origin." 
In contrast with the foregoing somewhat optimistic 
views concerning the therapeutic virtues of mercurials 
should be quoted the remarks of Budd (" Diseases of the 
Liver," 1846) : " The frequent use of mercurials in func- 
tional hepatic complaints may lead to much mischief. 
When the liver has become accustomed to the stimulus of 
mercury, no other medicine will sufficiently excite its 
action. The person is then led to the habitual use of the 
medicine, and, after a time, the constitution is under- 
mined by it. It increases the activity of the liver at first, 
but seems to leave it weaker than before, and, if fre- 
quently resorted to, the nutrition of the patient, impaired 
by the original disease, is still further impaired by the 
drug." 
It will not be out of place to insert here the opinion of 
Thomas King Chambers, of London ("The Indiges- 
tions," third American revised edition, Philadelphia, 
1870, p. 377), long and favorably esteemed as an author- 
ity on digestive disorders, as follows: 
" The superstitious use of mercurials is very singular. 
They are supposed to make the alvine excretion normal, 
though the only visible result is its becoming more 
abnormal with each dose. They are supposed to do good 
by ' acting on the liver,' whether the liver is acting too 
little or too much. They are supposed to ' act on the 
liver,' though it has been shown by Dr. Scott's experi- 
ments (' Beale's Archives,' vol. i., p. 209), that the quan- 
tity of bile is not increased, nay, it is rather diminished 
when mercury is taken. All that the metal can be really 
seen to effect on the hepatic function is a poisoning of 
the bile, so as to prevent absorption by the ilia, and to 
cause the secretion to be rejected in excess and in a 
liquid form per anum ; and that is a very doubtful ad- 
vantage to most invalids. 
"The only effect at all desirable following mercurial 
purgation, and which in fact seems to constitute for 
patients the attraction to its use, is the relief of certain 
cerebral symptoms, giddiness, muscse volitantes, dark 
globes in the sight, singing in the ears, etc., which re- 
sult from excess of venous over arterial blood in the 
brain. It acts in this case as a destructive upon the 
venous blood, and adjusts the balance by subtraction. 
Time after time, as the rough experiment is resorted to, 
the strength is lessened by it, and as the necessity for its 
use appears greater, more and more subtraction is re- 
quired. The good and true way of restoring the circula- 
tion to its normal condition is by addition, by increasing 
the supply of new-made blood to the arteries." 
In order to reconcile the differences existing between 
the views held now and those which obtained twenty-five 
or forty years ago, it should be noted that a generation 
ago practitioners had no true conception of the physio- 
logical effects of comparatively small doses, all dosage 
being determined by promptness in effect which, being 
followed by depressant manifestations, was very properly 
condemned. 
While in the preceding remarks but little has been said 
of the antiseptic properties of mercurials-their value in 
this direction being inferred-it will be appropriate to 
consider this principle more fully than can be done in 
the section on Therapeutics. Undoubtedly mercuric 
chloride, owing to its actively poisonous character, stands 
at the head as a general antiseptic. Other drugs are of 
equal value as regards their power to destroy bacteria, but 
none of them seems to possess the same degree of antip- 
athy toward the spores of bacteria ; hence, when these 
spores are removed from contact with ordinary antisep- 
tics and transferred to a suitable soil, they again multi- 
ply as rapidly as before. The favorable results attending 
the employment of less powerful antiseptics than the 
bichloride in surgical practice may be credited to the 
method of using the solutions freely, whereby the spores 
are carried off along with the debris and other foreign sub- 
stances that would act as irritants and thus favor subse- 
quent infection. And to this latter cause (irrigation) may 
be ascribed the beneficial effects of sterilized water. On 
the other hand, oily substances like creolin, lysol, and 
Peruvian balsam, owe their antiseptic virtues in part to 
the fact that they take up and cling to foreign substances, 
thus interfering with the reproduction of spores by pre- 
venting them from being lodged in a proper soil ; the 
latter is an important factor in determining the vitality 
of spores as well as that of the bacteria themselves. 
Again, it has been found that comparatively weak so- 
lutions will prevent the development of bacteria, while 
much stronger solutions are required to kill developed 
bacteria, all of which is graphically shown in the accom- 
panying table, compiled by N. de la Croix, and for the 
most part confirmed by Koch (Brunton : " Pharm. Ther. 
and Mat. Med.," third edition, 1888, p. 91). (See p. 625.) 
The hypodermatic employment of mercurials, popular 
with some, but strongly condemned by many, is advo- 
cated on the ground that curative effects in syphilitic 
lesions are produced more speedily than when the drug 
is given by the mouth or by inunction, and besides, that 
the digestive functions escape serious derangement. 
According to the investigations of Winternitz, when 
mercury is given by interstitial injection, elimination is 
effected principally through the kidneys; and he has 
also demonstrated that the percentage of the drug thus 
624 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Mercury. 
Mercury. 
(SUPPLEMENT.) 
Corrosive sublimate 1 : 25,250 
Chlorine 1 : 30,208 
Chlorinated lime 1 : 11,135 
Sulphurous acid 1 : 5.448 
Bromine 1 : 6.308 
Sulphuric acid 1 : 5,734 
Iodine 1 : 5,020 
Aluminium acetate 1 : 4,268 
Oil of mustard 1 : 3,353 
Benzoic acid 1 : 2,867 
Boro-salicylate of sodium 1 : 2,860 
Picric acid 1 : 2,005 
Thymol 1:1,340 
Salicylic acid 1 : 1,003 
Berman, of potassium 1 : 1,001 
Carbolic acid 1 : 669 
Chloroform 1 : 90 
Borax .... 1 : 62 
Alcohol 1 : 21 
Eucalyptol 1:14 
Chlorate of potassium 
Prevent the devel- 
opment of bac- 
teria taken from 
meat infusion. 
1 : 50,250 
1 : 37,649 
1 : 13,092 
1 : 8,515 
1 : 7,844 
1 : 8,020 
1 : 6,687 
1 : 5,435 
1 : 5,734 
1 : 4,020 
1 : 3,777 
1 : 3.041 
1 : 2,229 
1 : 1,121 
1 : 1,433 
1 : 1,002 
1 : 112 
1 : 77 
1 : 35 
1 : 20 
1 : 30 
Do not. 
1 :10,250 
1 : 4,911 
1 : 488 
1 :135 
1 : 769 
1 : 205 
1 : 59 
1 : 220 
1 : 50 
1 : 303 
1 : 706 
1 : 109 
1 : 343 
1 : 100 
1 : 22 
1 : 44 
Prevent the repro- 
duction of unde- 
veloped bacteria^ 
1 : 12,750 
1 : 6,824 
1 : 578 
1 : 223 
1 : 1,912 
1 : 306 
1 : 2,010 
1 : 80 
1 : 306 
1: 77 
1 : 394 
1 : 841 
1 : 212 
1 : 454 
1 :150 
1 : 42 
1 : 08 
1 :14 
1 :8 
1 : 203 
Do not. 
1 
1 : 5,805 
1 : 22,768 
1 : 3,720 
1 : 2,009 
| 1 : 2,550 
1 : 2,020 
1 :1,548 
I 1 : 427 
1 : 591 
| 1 : 410 
1 : 72 
1 :1,001 
1 : 109 
1 : 60 
1 : 150 
1 : 22 
1 : 112 
1 : 48 
1 : 44 
1 :116 
Kill developed bac- 
teria. 
k-l I 1-L k-L 1-1 1-4 |-L h-l i-t i-L 1-4 »-»•»-* I-* t-L k-l 
o 
co cwcyic oo 
co 
Do not. 
1 : 1,250 
1 : 431 
1 :170 
1 : 190 
1 : 336 
1 : 116 
1 : 410 
1 : 64 
1 : 28 
1 :121 
1 : 30 
1 : 150 
1 : 20 
1 : 150 
j 1: 266 
i 
Prevent the repro- 
duction of devel- 
oped bacteria. 
1 
1 : 5,250 
1 : 460 
1 : 258 
1 : 273 
1 : 550 
1 : 205 
1 : 510 
1 : 92 
1 : 40 
1 : 210 
1 : 50 
1 : 200 
1 : 36 
1 : 35 
1 : 200 
1 : 4 
1 : 08 
1 : 12 
1 :118 
1 : 583 
Do not. 
1 : 10,250 
1 : 28,881 
1 : 3,148 
1 : 8,515 
1 :13,931 
1 : 5,734 
1 :10,020 
1 : 4,268 
1 : 3,353 
1 : 2,877 
1 : 1,343 
1 : 2,005 
1 : 1,340 
1 :3,003 
1 : 2,005 
1 : 402 
1 : 30 
1 : 11 
1 : 20 
Prevent the de- 
velop ment of 
spores in boiled 
meat infusion. 
1 : 12,750 
1 : 34,589 
1 : 4,716 
1 : 12,649 
1 : 20.875 
1 : 8,020 
1 : 20.020 
1 : 4,778 
1 : 5,734 
1 : 4,020 
1 : 1.694 
1 : 3.041 
1 : 2,229 
1 : 6,004 
1 : 3,041 
1 : 502 
1 : 43 
1 : 21 
1 : 29 
Do not. 
1 : 6,500 
1 :1,008 
1 :109 
1 : 325 
1 : 493 
1 : 306 
1 : 510 
1 : 937 
1 : 77 (?) 
1 : 50 
1 : 35 
1 1 : 200 
1 : 109 
1: 603 
1 : 101 
1 : 22 
1:177'" 
Prevent reproduc- 
tion of spores. 
1 :10,250 
1 : 1,027 
1:134 
1 : 422 
1 : 603 
1 : 420 
1 : 724 
1 : 1,244 
1 : 108 (?) 
1 : 77 
1 : 50 
1 : 300 
1 : 212 
1 : 1,003 
1 : 150 
1 : 42 
1 : 14 
1 : 203 
1 : 14 
Do not. 
1 : 7,168 
1 : 15,606 
1 : 286 
1 : 12,649 
1 : 5,597 
1 : 3,353 
1 : 2,010 
1 : 6,310 
1 : 3,353 
1 :1,439 
1 : 2,860 
1 : 2,005 
1 : 1,340 
1 : 1,121 
1 : 300 
1 : 502 
1 :103 
1 :107 
1 : 21 
1 : 205 
Prevent develop- 
ment of spores 
in unboiled meat 
infusion. 
1 : 8,358 
1 : 23,182 
1 : 519 
1 : 16,782 
1 : 8,375 
1 : 5,734 
1 : 2.867 
1 : 7.535 
1 : 5.734 
1 : 2.010 
1 : 3.777 
1 : 3.041 
1 : 2.229 
1 :1.677 
1 : 403 
1 : 669 
1 : 134 
1 :161 
1 : 30 
1 : 308 
1:13 
1 Do not. 
1 : 2,525 
1 : 1,061 
1 : 153 
1:135 
1 : 875 
1 : 72 
5 : 843 
1 : 478 
1 : 40 (?) 
1 : 77 
1 : 35 
1 : 100 
1 : 20 
1 : 343 
1 : 35 
Prevent reproduc- 
tion. 
1 : 3,358 
I : 1,364 
1 : 2>6 
t : 223 
1 : 1,153 
1 : 116 
1 : 919 
1 : 584 
I : 60 (?) 
1:121 
1 : 50 
I : 117 
1 :36 
1: 450 
1:50 
1 :10 
1 : 122 
1 : 87 
1 :142 
1 : 30 
j Do not. 
excreted remains unaffected whether soluble or insolu- 
ble preparations are used, and that potassium iodide, 
even in substantial doses, exercises no influence upon elim- 
ination through the renal structures. The advocates 
of hypodermatic medication have, as yet, advanced no 
plausible explanation of the increased advantages there- 
from, and its acceptance on the part of the profession 
will be referred to in the section on therapeutics. (See 
" Surgical Practice.") 
The popularity of inunctions may be accounted for 
from the fact that mercury thus administered finds its 
way into the circulation in the form of extremely fine 
particles-without running the gauntlet of the liver- 
and its therapeutic effects are thereby enhanced in the 
same manner as when the drug is taken internally after 
thorough trituration. Vaporization also produces more 
distinct effects, probably for the same reason, but both 
methods are open to objection, since the amount actu- 
ally introduced cannot be definitely measured or de- 
termined, and it requires the closest scrutiny to discover 
evidences of toxicity before serious harm results to the 
patient. It is doubtful if any considerable difference 
exists ultimately when mercury reaches the general cir- 
culation, whatever mode of administration is adopted. 
Summary.-Having now, in a general way, completed 
the study of mercurials, beginning with the gross lesions 
which attend acute poisoning, and following up with an 
investigation of their effects upon the brain, heart, liver, 
kidneys, etc. ; and commented relative to their influ- 
ence upon the blood, the tissues, the protoplasmic cells, 
oxidation, secretion, and elimination, when given in- 
ternally, subcutaneously, by inunction, or vaporization, 
it seems as though nothing more could be said which 
would add to our present knowledge concerning the 
wonderful effects of this drug. And yet notwithstand- 
ing the abundant testimony brought forward to account 
for the effects witnessed, and the tentative suggestions 
advanced relative to its influence upon cellular activity, 
there is nothing, absolutely nothing offered which en- 
ables us to determine with any degree of scientific accu- 
racy just how therapeutic results are obtained. There is 
still lacking an important link to complete this chain of 
evidence before the employment of mercury can be said 
to rest upon a strictly scientific foundation. 
Perhaps an inquiry concerning its action as a sorbefa- 
cient will throw some additional light upon this mysteri- 
ous and hitherto unexplained problem. To say that 
the effects of mercury are due to " catalysis," "specific," 
or "selective" action, or to assume that the "hypothesis 
of interference" is sufficient to account for them, is 
merely to substitute one unknown quantity for another. 
For example, with our present knowledge, we can un- 
derstand and explain the causes which conspire to affect 
the pulse, temperature, and respiration ; and we can 
also follow its action upon the functions of the liver, the 
kidneys, the skin, the alimentary tract, the salivary 
glands, and buccal mucous membrane, since these or- 
gans and structures are concerned in eliminating the 
poison ; but how shall we demonstrate its sorbefacient 
properties in removing fibrinous exudations, syphilitic 
deposits, iritis, pericarditis, and inflammatory reactions 
of a benign character, without at the same time admit- 
ting that the drug may have some deleterious or unto- 
ward effect upon the organism as a whole ? The only 
probable explanation of this paradox which suggests it- 
self is based upon the assumption that in moderate dos- 
age, the irritant (stimulant) action of mercury suffices 
to increase metabolism-indirect or constitutional effects 
-and that like all other poisons, it will be eliminated by 
those channels which are best adapted for the purpose- 
direct or local effects. The so-called "specific" action, 
" elective " action, or " catalytic" action on morbid pro- 
ducts and diseased conditions, is nothing more than an 
incidental physiological effect, dependent upon the well- 
known properties of all poisons to manifest a disposition 
to associate themselves with retrograde changes-mer- 
cury not excepted. 
The therapeutic study of mercury is therefore nar- 
rowed down to a consideration of two principal factors, 
Table Showing the Action of Drugs on Bacteria. 
625 Mercury. 
Mercury. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
namely, the indirect or constitutional influences (conse- 
quential benefits), and the direct or local influences ex- 
erted upon functional or pathological disturbances 
(physiological benefits). This discovers the secret of the 
successful employment of all remedies, organic and in- 
organic, which are poisonous in themselves or foreign to 
the organism, and each has its value in certain directions, 
each has its limitations in all directions. When this 
value is overrated, or these limitations exceeded, harm 
invariably attends its administration. Our future tri- 
umphs in therapeutics, therefore, lie in the direction of 
studying, not alone the modifications affected by disease 
upon cell-life and cell-function, but the same strict 
rules must be applied to the reconstructive metamorphosis 
resulting from the employment of remedial agents, as 
has been done in the case of mercury, a remedy which, 
by its action upon cellular activity, removes and dissi- 
pates fibrinous exudations, syphilitic deposits, iritis, and 
pericarditis ; which corrects the derangements of cell- 
function incident to inflammatory reactions, all phenom- 
ena bearing upon its therapeutic value being in perfect 
harmony with pathological study and physiological ob- 
servation. 
Therapeutics.-In preparing the therapeutic sec- 
tion, the writer has aimed to give expression to the trend 
of modern practice in the use of mercurials, and to this 
end has incorporated under various sub-headings per- 
sonal communications from recognized authorities in 
their respective departments. Such reports are, in many 
instances, more representative than a summary by a 
single writer, and in the following arrangement, which 
is intended merely to cover the principal disorders to 
which the drug is adapted, these contributions will be 
the means of guiding the student toward a true concep- 
tion of its proper place in the physician's armamenta- 
rium. 
Gastro-intestinal Affections. - Notwithstanding the 
harm which has attended the use of mercurials in this 
class of disorders, they undoubtedly possess distinct 
therapeutic virtues which entitle them to confidence ; 
but in order to accomplish good, they must be exhibited 
with intelligence and discrimination, the conditions be- 
ing clearly indicated in the following remarks by Pro- 
fessor Andrew H. Smith, of New York : 
" Mercurials may be employed in gastro-intestinal af- 
fections with one of three objects, namely, to simply 
move the bowels, to excite hepatic and glandular secre- 
tion, and as anti-ferments. 
" For the first purpose, calomel is the agent generally 
employed. It acts, probably, by increasing the flow of 
bile-which itself is a cathartic-and by stimulating the 
intestinal glands. This is a fair inference, from the fact 
that the purgative effect of calomel is not increased, but 
rather diminished, by giving large doses. A dose of 
several grains is sufficient to produce a large outflow of 
bile, and if more is taken the excess seems to act me- 
chanically, like bismuth, to stay the cathartic action, 
rather than as a local irritant to the mucous surface. 
Short of producing a cathartic action, mercurials are 
much employed when there is evidence of deficient he- 
patic and glandular activity,such as is afforded by a furred 
tongue, a bad taste in the mouth, headache, anorexia, 
etc. Small doses are sufficient for this purpose, and they 
seem to influence cell-action in the epithelial as well as 
in the glandular structures. It is remarkable what an 
effect a single dose of a fraction of a grain of calomel 
will have in removing the 'patchy' condition of the 
tongue, so often observed in gastro-intestinal disorders. 
"As intestinal antiseptics, mercurials are of great 
value, especially calomel and the bichloride. It is 
probable that the first becomes to some extent changed 
into the second. The efficiency of the bichloride as a 
germicide, in attenuated solution, is universally recog- 
nized. Indeed, it has been suggested that the whole mass 
of the blood might be rendered sterile by non-poisonous 
doses of this agent. Be this as it may, the intestinal 
disturbances attributable to ptomaines, generated in the 
digestive tube, are often relieved with remarkable 
promptness by remedies of this sort." 
From the foregoing, therefore, it is evident that these 
remedies will be serviceable in the treatment of such dis- 
orders as gastric ulcer, gastro-intestinal catarrh, and to a 
certain extent in nearly all cases of diarrhoea and dysen- 
tery. As a purgative, calomel is mostly used when the 
immediate effect is desired, while in cases that do not re- 
quire this effect, and when the object is to reach distant 
organs, one of the more irritant preparations (biniodide, 
protoiodide) may be given. Occasionally, during the 
progress of disease, sometimes in the early stages of 
febrile affections, a single substantial dose of calomel 
may be helpful. It requires a nice discrimination, how- 
ever, to determine the conditions which demand a large 
dose of calomel for its purgative effects. To quote 
Thomas King Chambers : " Some call this clearing the 
decks for action ; in a majority of instances, they may 
be said to throw overboard much of the best tackling on 
the ship and loosen her armor-plates." 
In typhoid fever, calomel in small doses is unquestion- 
ably of benefit, but large doses, or its continuous ad- 
ministration as a routine practice should be condemned, 
since other remedies, safer to the patient, better for the 
disease, are now at our command. In all subacute and 
chronic cases, when the hepatic function is below par, 
the most striking results will attend the judicious em- 
ployment of the biniodide in small doses (gr. two 
or three times a day). 
Hepatic Disorders.-Mercury has long been recognized 
as a useful remedy in that morbid complexus known as 
"biliousness," and when administered in dosage that pre- 
cludes the possibility of after-depression, it appears to be 
quite serviceable, although it is contra-indicated in acute 
congestion of the liver. In passive congestion, on the 
contrary, small doses of mercury-calomel or the bin- 
iodide in solution-will promptly produce beneficial 
effects. It is a mistaken notion that mercurials are of 
value in hepatic abscess, gall-stones, acute yellow atrophy, 
but they are of some temporary service as adjuvants in 
jaundice. It is doubtful if mercurials have any thera- 
peutic value in hepatic cirrhosis, but they may be of 
service in ascites associated with this condition for their 
constitutional effects. Schwass (Berlin, klin. Wochenschr., 
1888, No. 38, p. 762) reports favorable results from the 
employment of calomel when treatment is begun in the 
early stages, although, even when combined with the use 
of digitalis, the disease is not cured. In a total of ten 
cases, only the recent ones (5) were benefited by the treat- 
ment. 
Dujardin-Beaumetz advises a combination of calomel 
and corrosive sublimate as an hepatic stimulant-gr. jss. 
of the former and gr. of the latter-and this, with 
the addition of arsenic, is a favorite formula w'ith Dr. 
William H. Porter (New York). On the whole, however, 
small doses of corrosive sublimate (gr. hourly) with 
suitable adjuvants, will generally accomplish all the good 
that can be gained from these large doses, and thus the 
depressant effects are avoided. In adults suffering from 
passive congestion of the liver, haemorrhoids, and tenes- 
mus, with or without bloody stools, these small doses 
produce magical results. 
Diseases of the Kidneys.-The use of calomel as a diu- 
retic was recommended some years ago, and has attracted 
considerable attention. The objection to its use, how- 
ever, lies in the fact that it must be given in sufficient 
dosage to produce stomatitis, which requires active treat- 
ment in the way of gargles ; and sometimes diarrhoea 
follows, making the use of opium necessary, and for this 
reason the beneficial effects have been questioned. It is 
especially advocated as a diuretic in cedematous conditions 
associated with cardiac disease, and it is said that, when 
continued for a sufficient length of time in the healthy 
subject, it produces in from two to ren days distinct 
diuresis, a condition similar to that which obtains from 
the subcutaneous employment of corrosive sublimate and 
the inunction of blue ointment. It is claimed that the 
subcutaneous injections.act most powerfully as diuretics, 
the inunctions least, while the internal administration 
produces an effect about midway between the two. 
Small doses have no diuretic effect; only medium and 
626 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Mercury. 
Mercury. 
(SUPPLEMENT.) 
large doses increase the amount of urine. The somewhat 
doubtful claim has been put forward also, that calomel 
given under these conditions not only diminishes, but 
cures pathological changes in the kidneys. Biegarski 
(British Medical Journal, June 22, 1889) is of the opinion 
that cardiac dropsies are even more amenable to this 
treatment when corrosive sublimate is given subcutane- 
ously, less to mercurial ointment by inunction, and that 
in dropsy due to kidney disease and obstruction of the 
portal circulation, the mercurials are of very little use ; 
all of which confirms the view advocated by Nothnagel 
a year or so previously. 
Various theories have been advanced to account for the 
diuretic action of mercurials in cardiac disease, when 
this does not obtain in renal disease proper, although in 
health the diuretic action is perceptible. Jendrassik sug- 
gests that calomel causes absorption of the dropsical fluid 
by the blood, while Fiirbringer believes it is due to an 
irritation of the renal epithelium by the mercury ; but 
neither of these theories appears to be satisfactory. There 
is reason to believe that increased oxidation (cellular ac- 
tivity) is an important factor-previously referred to-and 
that the determination of calcareous matter in the kidneys 
may likewise exercise an irritant (stimulant) action upon 
the epithelial cells of the convoluted tubuli, these cells 
being principally concerned in the elimination of solids 
(Heidenhain) ; and the elimination of mercury itself 
would fall within this latter category. 
Phthisis.-In anaemia occurring as a result of phthisical 
dyscrasia, Dochmann (Therap. Monats., September, 1888, 
p. 415) claims that calomel has a rapidly favorable ac- 
tion, even when iron has failed, since it improves the 
appetite, regulates the bowels, and corrects menstrual 
difficulties. The dose recommended is, gr. f, three or 
four times a day, the medicine being discontinued for 
several days at the expiration of five or six days. A 
recrudescence of the fever demands an increase of the 
daily dose for a time. Martell (Prag. med. Wochenschr., 
1888, No. 25) also reports good results from the same 
method. The latter authority advocates the employment 
of calomel topically as well as internally and by inhala- 
tion. Of course, in those cases where the tubercular 
process is of an indolent character, the increased oxida- 
tion resulting from the employment of mercury cannot 
be other than beneficial (consequential and local benefits); 
but it can have no direct influence upon the bacilli. 
Given in small doses and not too long continued, it 
stimulates cellular activity. 
Syphilis.-As an indication of the conservative ten- 
dencies in the employment of mercurials in syphilis, it 
should be noted that Mr. Jonathan Hutchinson, the 
veteran syphilographer, now advocates the employment 
of gray powder (hydrargyrum cum creta), in one-grain 
doses, three to six times daily, one grain of Dover's 
powder to be given twice a day to control the bowels; 
but unfortunately the opium is extremely objectionable, 
since it involves ultimately the treatment of two diseases 
instead of one. There is no doubt of the curative action 
of mercury in syphilis, but in times gone by it has too 
often been accomplished at the expense of the patient's 
health, owing to the unnecessarily large doses adminis- 
tered, facts very fully brought out by the observations of 
Professor Edward L. Keyes, of New York (" Trans. In- 
ternational Medical Congress," September, 1876), whose 
positive conclusions are as follows : 
" 1. Mercury is an antidote to the syphilitic poison, and 
of service in controlling all its symptoms in all (even the 
latest) stages of the disease, its power over gummata being 
least marked and not to be relied upon. 
" 2. Mercury in minute doses is a tonic. 
"3. Iodine cures certain symptoms of syphilis, but 
does not prevent relapse. 
"4. The use of mercury, long-continued, uninter- 
ruptedly, as far as practical, in small doses, from the 
time of the earliest eruption, constitutes the best treat- 
ment of syphilis." 
In connection with the above may be mentioned the 
views of Professor William Osler, of Baltimore (private 
communication) on this important topic, as follows : " Of 
course, we all know the striking influence of the mer- 
curials in relieving the blood-condition of syphilitic 
cachexia, but here, I think, the action is undoubtedly 
similar to quinine in malarial cachexia, not so much a 
direct action upon the blood as a neutralization of the 
poison and natural restitution of the corpuscles." 
Mercurials are also of value in non-specific as well as 
in the specific forms of skin diseasis, the indications for 
their employment being deducible 'from, our previous 
conclusions. 
Ophthalmology.-The following concise report from 
Professor Samuel D. Risley, of Philadelphia, practically 
covers the employment of mercurials in ophthalmology : 
"In ophthalmological practice I esteem mercury of 
great therapeutic value. There are large groups of dis- 
eases in which no other drug is so useful, and this is true 
not only of those forms of eye disease where syphilis is 
the important etiological factor, but also of affections of 
the uveal tract, and in certain forms of corneal inflam- 
mation not traceable to this disease. It is used without 
hesitation in all forms of plastic iritis, in exudative cho- 
roiditis, neuro-retinitis, etc., whether of known specific 
origin or not. My experience would seem to suggest 
that, as a matter of course, this drug should be adminis- 
tered in recognized syphilitic cases, whether occurring 
along with other secondary symptoms or associated with 
the later manifestations. It can be administered either 
in the form of the corrosive sublimate, in small, fre- 
quently repeated doses, by means of inunction, or the 
mercurial bandage. 
" In acute forms of disease, as in plastic iritis, inunc- 
tions pushed to the point just short of ptyalism are to be 
preferred, the patient meanwhile being confined to his 
bed. In chronic forms of inflammation, e.g., interstitial 
keratitis, corrosive sublimate is employed, or, instead, 
the bandage worn around the waist night and day, and 
kept well covered with mercurial ointment. Not infre- 
quently, I employ the well-known formula of potassium 
iodide and corrosive sublimate, but this combination 
seems best adapted to cases of neuro-retinitis than to other 
forms of eye disease." 
Diseases of the Throat and Nose.-As expressing the 
views of practitioners in this special department of 
medicine, the following report from Dr. George B. 
Hope, of New York, will prove interesting and sug- 
gestive : 
"Asa class, hypertrophic derangements of the mucous 
and submucous areolar tissues are so peculiarly resistant 
to the usual range of topical applications as to discourage 
all such measures, and lead to a resort to surgical or de- 
structive agents in order to overcome the effects of struct- 
ural changes. However applicable this may be under 
certain favorable conditions, there are yet cases where 
this course is neither rational nor practicable, and it is in 
these instances that a remedy addressed through con- 
stitutional channels offers the only prospect of relief. 
Iodide of potassium and mercury furnish the most strik- 
ing types of active cellular-therapy agents, and from this 
standpoint-eliminating the former on account of its un- 
favorable action to the mucous membrane-the indica- 
tions for mercurial treatment may be considered to be 
definitely established. As an illustration may be cited 
a case of simple, chronic, hypertrophic laryngitis, in 
which the ventricular bands were so far involved as to 
offer a serious obstruction to respiration, with the sur- 
rounding parts in accord with the prominent pathological 
condition. Under the administration of full doses of the 
protoiodide of mercury, a speedy and satisfactory resolu- 
tion was obtained without the introduction of any aux- 
iliary line of treatment. 
" In a word, if the theory of mercurial action is correct 
in its clinical details-that it encourages the oxidation of 
loosely-formed cell-elements, and stimulates their elimi- 
nation by the lymphatics-it would seem that the legiti- 
mate limits for its administration, aside from syphilitic 
affections, are particularly covered by conditions repre- 
senting the imperfectly organized type of inflammatory 
exudation, as in (chronic) infiltration of the intercellular 
tissues, or the thickening of the epithelial layers, as in 
627 JUerc ury. 
Mercury, 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
moderate pachydermatous laryngitis-features of chronic 
catarrh." 
Nervous Diseases.-From Dr. Wharton Sinkler, of 
Philadelphia, the writer has received the annexed report, 
which fairly comports with views already advanced, and 
in a large measure confirms them from the clinical stand- 
point 
" In regard to the employment of mercurials in nervous 
diseases, will say tbftit in organic diseases of the brain and 
cord, when due to syphilis, of course, mercurials are of 
prime importance. It does not follow, however, that all 
scleroses of the spinal cord are benefited by the adminis- 
tration of mercurials, even in those cases where there is 
a clear and undoubted history of syphilitic infection to- 
gether with secondaries. Locomotor ataxia is an illus- 
tration of the truth of this observation. A large propor- 
tion of the cases of tabes with,which we meet have a 
more or less distinct history of syphilis, some writers 
asserting that as many as seventy or eighty per cent, of 
tabetics have had this disease. Notwithstanding this 
fact, few cases of locomotor ataxia are benefited, even by 
the most vigorous course of mercurials and iodide of 
potassium. On the other hand, some of the other forms 
of syphilitic infection of the nervous system yield 
promptly and completely to mercurials and iodide of 
potassium. Those cases which are spoken of as syphilis 
of the brain and cord seem particularly ready to yield to 
mercurial treatment; and in this class of cases mercury 
seems to be of more value than the ' mixed treatment,' 
or the iodide of potassium alone. 
" For some reason, mercury by inunction gives better re- 
sults in the treatment of syphilis of the nervous system 
than when the remedy is given by the mouth. I have 
had comparatively little experience in the use of mercury 
hypodermatically, but recall one patient suffering from 
spinal sclerosis with a specific history, who made very 
marked improvement under the use of the bichloride of 
mercury administered hypodermatically. 
" In the treatment of nervous syphilis, I have not found 
it necessary to push mercurials to the point of salivation, 
and in one or two cases where I accidentally salivated 
patients, there was no apparent benefit to the nervous 
disorder for which the mercury had been given. As a 
rule, I find it preferable to give mercurials in conjunction 
with iodide of potassium, but frequently I administer it 
alone. In some of the forms of sclerosis of the cord, not 
due to syphilis, small, alterative doses of mercury are of 
great value. Usually, the remedy is to be persisted in 
for a number of months, and it is best to give it in small 
doses. I prefer in these cases to give the bichloride, as 
I think it is less likely to disturb the stomach and intes- 
tinal tract, and it is borne for a longer period of time 
than the other preparations of mercury. As a general 
nerve-tonic in some of the functional nervous disorders, 
mercury is of considerable value, more especially, I think, 
when it is combined with arsenic and iron. 
" There are some forms of headache, especially those 
of specific origin, in which small doses of the bichloride 
of mercury are very useful. In the severe noctur- 
nal headaches of syphilitics, one one-hundredth of a 
grain of this salt, repeated hourly, will sometimes 
afford relief. Cerebral and spinal meningitis are treated 
most effectively by the administration of mercury ; and 
calomel or gray powder seems to answer better in menin- 
geal inflammation than any of the other mercurial salts, 
as it is necessary to get a prompt and speedy impression." 
Obstetrics.-In obstetric practice the use of mercurial 
solutions (bichloride, 1 to 5,000) has largely given place 
to carbolic acid, creolin, and lysol, and other less toxic 
substances for the vaginal douche and intra-uterine ap- 
plications. Indeed, the employment of any antiseptic is 
strongly condemned as both useless and dangerous in un- 
complicated labors. In 1889, Garrigues (American Jour- 
nal of the Medical Sciences, August, page 109) published 
a synopsis of twenty-two cases in which death occurred 
from the use of corrosive sublimate solutions, and at that 
time he favored creolin solutions (two per cent.) as a 
substitute for mercuric chloride. 
Corrosive sublimate injections in ordinary midwifery 
(SUPPLEMENT.) 
cases need not be practised, but the solutions may be 
used for the disinfection of the outer surfaces of the pa- 
tient, for the hands of nurses and physicians, and for all 
materials brought into contact with the patient. When 
intra-uterine medication is demanded, the strength of 
the solution should not exceed 1 to 5,000 to 10,000, and 
the injections should not be given more frequently than 
twice in twenty-four hours, although the vaginal douche 
may be given as often as every three hours; and at 
the time care should be taken that no symptoms of ab- 
sorption arise, and for which the physician must be con- 
stantly on the outlook. Upon the first appearance of 
toxic symptoms, the medicament must be immediately 
discontinued until all danger has passed. As the bi- 
chloride combines with impurities in the water as well as 
with albuminous principles and alkaloidal poisons, and 
is seriously affected by alkaline fluids, it has been sug- 
gested that it might be prepared in concentrated form 
with glycerine and hydrochloric acid dilute, from which 
solutions could readily be prepared. 
By the use of antiseptics and the adoption of measures 
looking to asepsis, the septic death-rate in American ma- 
ternities has been reduced to less than one per cent. In- 
toxication from the intra-uterine douche has been of such 
frequent occurrence that a suggestion is offered to the 
effect that hydrogen dioxide solutions be substituted, on 
account of the latter being harmless to patient, efficient 
as a destroyer of unhealthy tissues and discharges, 
cleanly and perfectly manageable, and, withal, prompt in 
action. Owing to the rapid oxidation which takes place 
when the dioxide is brought into contact with morbid 
products, in using it for the intra-uterine douche care 
must be taken that the outflow is not obstructed, since 
the gas generated might be sufficient to force morbid ma- 
terial into the tubes, and thus defeat the purpose for 
which it was used. 
Concerning the employment of mercurials internally 
against syphilitic infection, the following brief report 
from Dr. Joseph Price, of Philadelphia, will be read 
with increasing interest, since it furnishes a demonstra- 
tion of their almost universal value : 
"I have for years used mercurials freely in syphilitic 
child-hearing and pregnant women, also in syphilis of the 
new-born. The iodides are of but little value, except in 
the management of symptoms, and in the tertiary stage 
in mothers. At present, I have a number of mothers 
under treatment continuing from periods of two to 
nine years; some of them have borne as many as three 
healthy children in that time, no symptoms reappearing 
in either mother or offspring." 
Diseases of Children.-Mercurials find a wide range of 
application in the treatment of diseases peculiar to child- 
hood and infancy, although indications point to the 
probability of their too liberal use in some cases. Al- 
beit their value is not denied, there are many instances 
where other and more efficient medicaments may be 
substituted, so that in them alone does not lie our only 
hope. For example, in croup and diphtheria mercurial- 
ization really accomplishes no good purpose, and be- 
sides, we have other remedies that can be used as ad- 
juvants, which are more effective and entirely free from 
the dangers arising from mercurialization. The routine 
method of treating diphtheria should be remodelled upon 
a scientific basis corresponding with our present knowl- 
edge concerning the life-history of the pathogenic micro- 
organism associated with it. Clinical observation is 
opposed to emetics in both croup and diphtheria, the 
two being so closely connected that it is difficult to say 
positively where the one ends and the other begins. 
By many, calomel is given as a preliminary in diph- 
theria to produce some effect upon the bowels, when 
corrosive sublimate is substituted, but this course must 
be followed with caution, because in the serious cases 
absorption may be interfered with to an extent that will 
prevent or delay the manifestations of mercurialization, 
when constitutional symptoms rapidly supervene. It is 
doubtful if, in such cases, the mercury be of any ser- 
vice ; nay, indeed, clinical experience is against the pro- 
duction of a factitious disease. 
628 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Mercury. 
Mercury. 
The medicinal treatment of diphtheria should be con- 
ducted with two principal objects in view, viz. : (1) To 
arrest the rapid multiplication of germs, and (2) to coun- 
teract the pathological changes effected by their products. 
For the first, an anti-biotic is required, to render the soil 
unsuitable for their growth; and for the second, an 
anti-toxine is demanded, to fortify the system against 
the morbid products. Unfortunately, mercurials cannot 
be used in sufficient dosage, with safety to the patient, 
to accomplish either purpose. Locally, the mercurial 
preparation must not be too readily soluble, and should 
not too easily combine with albumin or other substances 
which destroy its antiseptic value. Internally, diffusi- 
bility is desirable, and with the recent introduction of 
new compounds it is hoped a better and more efficient 
therapeutics will be instituted. In this connection 
should be mentioned an interesting and valuable analyt- 
ical report by Dillon Brown, covering 2,368 patients in 
whom intubation was practised, with 647 recoveries, or 
27.3 per cent., and including from his own personal ex- 
perience 115 cases, all seen in consultation. Of the lat- 
ter number, 50 had not been subjected to the bichloride 
treatment, and the recoveries were 24 per cent. ; in the 
other 65 cases, with bichloride, 36.9 per cent, recovered. 
Stclldcn, a Swedish physician, reports 1,400 cases of 
diphtheria treated by mercury cyanide, with but 69 
deaths (approximately, 5 per cent.), while the usual rate 
of mortality in his district has been 92 per cent. The 
method of using the cyanide consisted in adding to gr. 
| mercury cyanide, half a drachm of tincture of aconite 
and two ounces of honey, and of this mixture the pa- 
tient takes a teaspoonful at intervals of an hour or less. 
In addition to this, a gargle-1 to 10,000 mercuric cyanide 
and peppermint-water-is employed every fifteen min- 
utes. 
The following comprehensive resume by Professor Diary 
Putnam-Jacobi, of New York, very fully embodies the 
practical adaptation of mercurials in this class of cases : 
"The position of mercurial preparations in the nur- 
sery has varied greatly within the present century. At 
one time vaunted under many forms, as specific for many 
ailments or serious diseases; at another, almost com- 
pletely condemned ; they have recently been reinstated 
to a considerable extent in the armamentarium of the 
family practitioner. The list of cases in which mercu- 
rials are to-day employed is not, indeed, long ; but each 
disease on the list is important and of frequent recur- 
rence. 
"Therevival of mercurial medication, perhaps, prin- 
cipally depends upon the modern demonstrations of the 
great antiseptic power of mercury, and especially of its 
most poisonous salts, as the bichloride and the biniodide. 
Coincidently has been demonstrated themicrobic etiology 
of such diseases as diphtheria, and the occurrence of 
fermentations due to microbes in gastro-intestinal disor- 
ders. The utility of mercury in syphilis was well estab- 
lished by clinical experience before syphilis, as an infec- 
tious disease, had been referred, like other infections, to 
microbic inoculation. Although the precise infecting 
agent of syphilis has even yet not been isolated, its ex- 
istence is unhesitatingly assumed ; and with as little hesi- 
tation are the curative powers of mercury attributed to 
the antiseptic virtues of the drug. 
"In the great epidemics of diphtheria which raged in 
France in the first half of this century, Bretonneau used 
calomel extensively and pushed it to the point of saliva- 
tion. The result was disastrous, as was, indeed, every 
other form of treatment used in these terrible times. 
From about 1850-53, calomel was altogether abandoned, 
and tincture of iron and powerful stimulation adopted in 
its place. Quite recently, however, has been introduced, 
in addition to such stimulation, the internal administra- 
tion of minute doses of bichloride of mercury, especially 
when croup is threatened ; the use of sprays of solutions 
of bichloride, 1 to 4,000 to 6,000 of water ; finally, fumi- 
gations of calomel in croup, both before and after tra- 
cheotomy or intubation. One milligramme (gr. ff), per 
hour, may be administered for one or two days to 
even very young children, and in association with tinct- 
ure of iron given throughout the hour. It does not, as 
has been occasionally asserted, cause depression ; and it 
certainly does not cause salivation. Of course, like all 
other remedies in this dreadful disease, it often fails to 
cure. The spray can also be used once an hour. The 
fumigations are made by burning ten grains of calomel 
on a tin plate in the bed where the child is lying, while 
this is surrounded by a blanket to retain the fumes. In 
ordinary non-specific laryngitis, the same small doses of 
corrosive sublimate, or else hourly powders of calomel, 
gr. each, will often arrest an attack in a day or two. 
" What is the precise mode of action of the gray 
powder (hydrarg. cum creta) in acute gastric catarrh, 
is by no means well known; but empirically, its effi- 
ciency cannot be doubted. In fermentative diarrhoea, the 
bichloride, combined with bismuth and the carminative 
oils, is more useful. Even in adults, hourly doses of 
gr. -fa of bichloride are extremely efficacious for this dis- 
order, the poisonous drug seeming to neutralize the poi- 
sons which are forming in the intestinal tract. The same 
dose may also be given to children. 
" The time-honored method of giving a dose of calomel 
for the so-called bilious attacks of children, as of adults, is 
also again revived. In children these attacks generally 
mean gastro-duodenal catarrh with extension to the mu- 
coste of the bile-ducts. Calomel certainly increases the 
flow of bile, even in healthy animals-more probably its 
secretion ; under increased pressure this is able to force 
its way through the ductus choledochus-occluded by 
swelling-and the free passage of the secretion initiates 
the reduction of the swelling. 
" The points to remember in all these gastro-intestinal 
diseases is, that the mercurial is to be administered for a 
comparatively brief period-two or three days at the out- 
set-and not to be relied upon for prolonged use, nor to 
be frequently resorted to in states of chronic indigestion ; 
that is, if the conditions recur, and tend to become 
chronic. The old method of an occasional blue-mass pill 
is insufficient for the purpose ; other treatment is coinci- 
dentally required to stimulate the sluggish portal circu- 
lation. 
" In dysentery, fractional doses of calomel, combined 
with ipecac and opium, although an old, is a still justly 
accredited mode of treatment. Its value is increased 
when associated with the newer method of systematic ir- 
rigation of the bowels. The so-called method of Law, origi- 
nally applied to peritonitis, by which calomel, grain, 
was administered hourly, is still valuable, for in this way 
much more of the drug can be introduced into the sys- 
tem than when it is given in massive doses-or, possibly, 
a larger amount is converted into bichloride, and thus 
becomes a potent disinfectant to the putrid contents of the 
intestine. 
"No opposition has ever been raised to the adminis- 
tration of mercury in infantile syphilis, except by the 
fanatics that profess to cure adult syphilis without mer- 
cury. The bichloride, Van Swieten's liquor, is a conven- 
ient form, and can frequently be tolerated for a long 
time without causing gastric irritation. If this occur, 
the medication must, of course, be interrupted, or re- 
placed by mercurial inunctions. These, as well as bi- 
chloride baths-grains vij. to a bath-are well suited for 
the cutaneous and articular lesions of syphilis. Citrine 
ointment, diluted four times, is best adapted for syphi- 
litic vegetations around the anus and genitals. The mer- 
curial treatment should be continued, with interruptions 
at intervals of six or eight weeks, for a period of two 
years." 
Surgical Practice.-A full discussion of the antiseptic 
properties of mercurials in surgery does not properly come 
within the scope of this article, and it will be sufficient to 
refer briefly to the methods now in vogue, and which are 
set forth in the annexed communications. It should be 
stated that the value of corrosive sublimate as an anti- 
septic may be modified by various conditions, namely. 
temperature, albumin, bacteria, and light in the presence of 
organic matter, so that although immediately available, 
its power for good may not long remain, and thus a false 
sense of security is given the surgeon. Professor N. 
629 IHercury. 
Methylene Blue. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Senn, of Chicago, expressed his continued confidence in 
it as follows: 
" I have tried many substitutes, but always fall back 
upon corrosive sublimate. I use for disinfection of 
hands and field of operation, a 1 to 1,000 solution ; for dis- 
infection of infected wounds, 1 to 1,000 to 10,000." 
Professor Roswell Park, of Buffalo, who seems to 
have followed closely the teachings of Sir Joseph Lister, 
is favorably impressed with the mercury-zinc cyanide. 
He writes as follows : 
' ' Mercuric chloride and mercury-zinc cyanide I ordi- 
narily apply or employ in my surgical work. The latter 
comes very near being an ideal antiseptic, in my estima- 
tion. When either of these is used with judgment, it is 
capable, I think, of giving the greatest satisfaction. 
Still, I think we have now so many antiseptic drugs to 
choose from, that one may succeed in any branch of 
surgical work without using mercurial preparations. 
This is especially true since aseptic methods have been 
introduced. Indeed, every operator learns to place reli- 
ance on one or two drugs for this purpose in accordance 
with his training, his surroundings, or his personal idio- 
syncrasies. I do think, however, that we could dispense 
with mercurials as antiseptics, were we compelled to, 
without perceptible loss. 
" For occasional internal use, as intestinal antiseptic 
agents and general alteratives, it does not seem to me 
that we could make substitutions without serious loss. 
" The mercury-zinc cyanide solutions which I employ 
are usually 1 to 2,000. Compresses are used wrung out 
of a solution, 1 to 500. For disinfecting hands I ordi- 
narily use hydrogen dioxide in full strength. Instru- 
ments I boil, usually in a two per cent, soda solution. 
For the hands I use green soap with five per cent, lysol, 
and after that, frequently, the permanganate bath with 
bleaching in oxalic-sodium hypophosphite solution." 
Hypodermatic Medication.-Calomel by intra-muscular 
in jection was first used by Scarenzio as early as 1864, but 
owing, perhaps, to the faulty methods and lack of anti- 
septic precautions, it was not brought prominently to the 
attention of the profession until advocated by Neisser, of 
Germany (1885), wdio in 1888 modified Lang's formula 
for " gray oil." By the observance of strict antisepsis, 
it is said, abscesses are of rare occurrence. Wilson 
(Medical News, vol. lit, 1888, p. 593) reports twelve cases 
treated (sixty-nine injections) with very satisfactory re- 
sults. A grain of calomel, rubbed up with glycerine 
(TTt xv.), to which is added at the time the operation is 
performed a few minims of recently boiled water, and 
thoroughly shaken, constitutes the medicament. These 
injections are given at intervals of a week or ten days. 
In a private communication to the writer, dated March 
10, 1893, Dr. Wilson says he has continued to use the 
treatment in proper cases since that time without modi- 
fication of importance. 
Lang's original formula (Brit. Med. Jour., June 16, 
1888) for gray oil (oleum cinereum) is as follows : 
Mercury, 
Lanolin each 3 parts. 
Olive oil 4 parts. 
M. Sig.: For hypodermatic use ; contains thirty per 
cent, of mercury. 
The dose of gray oil is 0.10 to 0.15 c.c., introduced 
deep into the back or nates every five to eight days. 
Neisser's modification (oleum cinereum benzomatum) is 
given herewith : 
Mercury 20 parts. 
Liquid paraffin 40 parts. 
Benzine-ether 5 parts. 
M. 
One cubic centimetre contains about six grains of mer- 
cury. The dose is 0.25 c.c. at the same periods as the 
gray oil, and treatment is interrupted from time to time. 
When resumed, smaller doses are used, and the injections 
practised more frequently, as it has been found that the 
small dose at short intervals is better than the large dose 
at longer intervals. The gray oil can also be used as a 
topical application at points affected by the specific poison. 
-bone disease, specific disease of the larynx and nares. 
It is claimed that the gray oil subcutaneously has shown, 
special benefits in cases where the disease affects the ear, 
the Eustachian tubes, or the forehead. 
Lang has published the following conclusions : " (1) 
Gray oil is efficient with the least dosage of mercury ; 
(2) it is convenient for both patient and physician ; (3> 
dangers of reaction are but slight; (4) no abscess has at- 
tended several thousand injections ; (5) can be employed 
in all cases where a mercurial is indicated ; (6) can be- 
used in the immediate neighborhood of syphilitic le- 
sions." 
Watraszewski (Archiv fur Dermatologic und Syphilis, 
1889), in comparing the therapeutic adaptation of calo- 
mel, yellow oxide of mercury, and gray oil, gives a de- 
cided preference to the yellow oxide in the dose of two- 
thirds to one grain. Mucilage is preferred as a vehicle 
for the following reasons : (1) It can be made of proper 
consistence to hold the powder in suspension ; (2) it has 
no local irritating effect ; (3) it does not decompose the 
mercurial salt; and (4) it excites no general disturbance. 
Notwithstanding the favorable evidence in favor of 
these preparations, the probabilities are that corrosive- 
sublimate is more extensively used in this country than 
any other mercurial for hypodermatic medication. 
Dr. Yvert, of Paris, some years ago submitted to the- 
Academy a note on the value of the bichloride as an anti- 
cholera vaccine, giving in evidence an account of forty- 
five patients so treated in Tonkin, with nine deaths (twenty 
per cent.), while the mortality in that section of Asia 
averaged sixty-six per cent. The dose administered 
ranged from one-third to two-thirds of a grain, when the 
patients were seen within twenty-four hours after the 
first manifestations of the disease. As a prophylactic it 
proved efficient. 
Topical Applications.-For boils and felons the citrine 
ointment is usually recommended, but it is less efficient 
than the biniodide, 1 part to 10 of benzoinated lard. The 
affected area should be covered with a thin layer of the 
ointment, and allowed to remain for two, three, or four 
hours, according to the tenderness of the skin, when it is 
thoroughly removed, internal medication being depended 
upon to complete the absorption. Mercurials are used 
as caustics in specific ulcerations and chancroids, but in 
ordinary cases they have been supplanted by other more 
acceptable products. As previously noticed, the oleate 
is very generally employed, and by means of ingeniously 
constructed instruments a powder can be deposited in the 
urethra in the treatment of urethritis. 
Mercurial inunctions have lately been more favorably 
received than hypodermatic injections in the treatment 
of syphilis, and at the recent Paris Congress there ap- 
peared to be a strong sentiment against the latter method, 
some going so far as to assert that it was dangerous. It 
is said the method has been abandoned by Schuster, Ka- 
posi, Julien, Fournier, and others, who have all returned 
to the earlier methods. John Aulde. 
METHACETIN (Para-oxymethy-acetanilide). This 
compound is a derivative of acetanilide, introduced in 
1888 by F. Manhert as a substitute for phenacetine, to 
which it is closely allied. Its formula is C6H1OCH3- 
NHCHSCO, which differs from acetanilide, C«II6NH- 
CII3CO, by substituting for one atom of H one atom of 
the oxymethyl group OCH3. In phenacetine, C6H4OC2- 
HsNHCHsCO, the ethyl group replaces the methyl 
group of methacetin. 
It forms in white, glistening, scaly crystals, without 
color or faintly reddish ; odorless; melting at 127° C.; it 
has a slightly bitter saline taste ; is soluble in water at 60 
F., 1 part in 530; in boiling water it dissolves in 12 
parts ; is freely soluble in alcohol, chloroform, glycerine, 
and fatty oils. Methacetin possesses antipyretic, anti- 
septic, and analgesic properties similar to those possessed 
by phenacetine, which it resembles therapeutically, as. 
well as chemically. The advantage claimed for it over 
630 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
mercury. 
Methylene Blue. 
all other antipyretics is its freedom from toxic effects or 
any injurious action on the blood-corpuscles. It is said 
not to cause any depression, malaise, tinnitus, or any of 
the lesser annoying symptoms. It is recommended par- 
ticularly for children and enfeebled persons. The only 
unpleasant effect is the production at times of free perspi- 
ration. Further experience has shown that it is not so 
devoid of these unpleasant symptoms as is claimed, as in 
addition to the profuse sweating, it occasionally causes 
very decided symptoms of collapse. It is, however, the 
most harmless of similar antipyretics. 
It has proved very serviceable in typhoid fever, typhus, 
pneumonia, phthisis, and all febrile diseases. It pro- 
duces a rapid fall of temperature, sometimes in fifteen or 
twenty minutes. The fall usually reaches its minimum 
in about three hours, remains stationary for about an 
hour, and then rises rapidly. With small and more fre- 
quently repeated doses the temperature may be kept low, 
but not at an apyretic point. The action of the drug 
also varies according as it is given with the daily rise or 
fall of the fever, and its most marked action occurs when 
it is given to act with the normal decline. In typhoid 
fever its effect is also more decided in the latter periods 
of the fever with the remissions than during the con- 
tinuous stage. Its power of lowering temperature is also 
evident during health. The dose is from two to three 
grains, to be repeated in three or four hours if required. 
Larger doses of five and seven grains are frequently 
given when a rapid and decided effect is required. 
In acute rheumatic fever and painful febrile troubles, 
as pleurisy, etc., five-grain doses prove very satisfac- 
tory in reducing the swelling, pain, and fever. As an 
analgesic in neuralgia and migraine it has not proved as 
useful as phenacetine and acetanilide. Although its 
employment is accompanined by fewer unfavorable 
symptoms, it has not replaced phenacetine, which it 
most resembles in action, its antipyretic properties being 
less marked, and as an analgesic it has proved very much 
inferior. 
Physiological experiments have proved that forty-six 
grains will cause death in a rabbit, producing spasms in 
the posterior, and later in the anterior, half of the body. 
After death there is found hyperaemia of all the organs, 
and the heart flaccid and filled with blood-clots. No 
haemoglobin is found in the urine. Beaumont Small. 
METHYL CHLORIDE (Monochlormethane). A color- 
less gas with a sweetish taste and an ethereal odor. It is 
soluble in one-fourth its volume of wTater, much more so 
in ethyl and methyl alcohol, and freely in ether and 
chloroform. The gas is not very inflammable; when 
ignited it burns with a greenish flame. At a temperature 
of -13° F., or under a pressure of five atmospheres, it is 
converted into a liquid, with a specific gravity of. 9915, 
neutral to test-paper. This liquid boils and becomes a 
gas at a temperature of -5.8° F., the change of con- 
dition being accompanied by the absorption of a great 
amount of heat. On account of the rapidity of this 
change an intense degree of cold is produced, amounting 
to a fall of 40° or 50° F. or more. 
The use of this refrigerant action was applied by De- 
bove, in 1884, as a local anaesthetic for neuralgia and 
other painful affections. It has been used in sciatica, 
pruritus, spinal pains after railway accidents, and in the 
painful joints of rheumatism, and in pleurisy. The dura- 
tion of relief from pain is never prolonged or permanent; 
from one hour to three or four hours is the average. In 
the latter conditions the relief has not been satisfactory, 
and any such use is beyond the scope of the remedy. 
The most important application of this compound has 
been as a freezing mixture for the performance of minor 
surgical operations. It has been used with decided suc- 
cess in circumcision for phymosis, evulsion of toe-nails, 
excision of cancer of the lip, opening of mammary ab- 
scess, incision for empyema, and many similar painful 
procedures. 
Methyl chloride is very extensively used for this purpose 
in the Paris hospitals, where it is prepared and stored 
in specially formed flasks, resembling those in which 
nitrous oxide is supplied. These are so arranged that 
the spray may be made to issue as required, without any 
trouble or waste. 
A stream of the spray may be applied directly to the 
part, in an oblique direction, for one or two seconds, or 
it may be directed upon a tampon of wool which is sur- 
rounded by floss silk and covered by thin silk. The 
tampon becomes saturated with the liquefied gas, which 
rapidly evaporates and absorbs heat from the adjacent 
parts. This latter method is more suitable for the relief 
of pain ; for operative purposes the spray is to be desired. 
The first effect on the part is to render it pale and blood- 
less and insensitive ; a continuance of the cold produces a 
dried, parchment-like appearance, and this is the time to 
operate. The application of the spray must be guarded, 
as it is not without its disadvantages. If it is used too 
long it causes death of the part, with vesica'tion and es- 
chars according to the depth and extent of the injury. 
Frequently, where the action has been only of short du- 
ration, the part remains red and tender for several days, 
Dr. S. E. Berezovsky made a number of experiments 
upon dogs to determine the local effect of the spray. 
They showed that, 1, a spray of two minutes' duration, 
when directed against intact integuments, produces com- 
plete anaesthesia lasting from fifteen to twenty seconds, 
the tissues remaining sufficiently soft to allow cutting; 
2, a spray of five seconds' duration, while inducing a 
somewhat longer anaesthesia, freezes the skin to an in- 
convenient degree ; 3, a seven-seconds spray gives rise to 
consecutive local congestion and inflammation ; 4, a 
twenty-seconds spray causes sloughing of the tissues down 
to the muscular layer ; 5, a convenient and harmless anaes- 
thesia, induced by a two-seconds spray, can be easily pro- 
longed up to five minutes by repeating the spray at short 
intervals ; 6, sufficient anaesthesia of exposed bones can 
be produced in the same way ; 7, the spray does not 
cause either gangrene or thrombosis of blood-vessels. 
Methyl chloride is a decided improvement upon ether 
spray as a means of producing local anaesthesia, but it 
has a powerful rival in the recently introduced ethyl 
chloride, which is milder in action but equally efficient. 
The disadvantage of methyl chloride is its powerful and 
rapid action, which is difficult to control both in extent 
and degree. 
It has also been suggested as an anaesthetic, and a mixt- 
ure of ether and chloroform, saturated with the gas, was 
suggested by Richardson, but no advantage was apparent, 
and it has failed to receive much recognition. 
Beaumont Small. 
METHYLENE BLUE (Tetra - methyl-thionine Chlo- 
ride). An aniline derivative, its formula being (C8H3N- 
(CII3)aCL)2NS. Chemically pure methylene blue occurs 
in small indigo-colored scaly crystals, with a bronze-like 
tinge and dark green in transverse fracture. Slightly 
soluble in water, forming a deep blue solution, which is 
changed by sulphuric acid to a dark green, and from 
which a strong potash solution throws down a dark 
violet precipitate. The methylene blue of commerce 
(ethylene blue O) is a double chloride of zinc, and tetra- 
methylthionine. 
This aniline product was introduced into medicine in 
1890, by Drs. Ehrlich and Lippmann, as an analgesic of 
some value. Professor Ehrlich had investigated the 
action of the drug on nervous tissue as a staining reagent, 
and had demonstrated that it had a peculiar selective 
action on the axis cylinders of motor and sensitive nerves. 
Further experiments showed that when taken into the 
stomach, or introduced subcutaneously, it rapidly spread 
throughout the system and gave relief to all neurotic 
pains, and the pain in rheumatism of the muscles, joints, 
and tendons. A two per cent, solution was used, by means 
of which one grain was given hypodermically. It was also 
used in capsules, the powder being given in doses of 1| 
to 4 grains ; as much as fifteen grains were given in one 
day. No ill effects accompanied its administration, and 
no change in appetite, digestion, pulse, or any of the nor- 
mal functions. The drug was absorbed very quickly, and 
a quarter of an hour after the smallest dose the urine be- 
631 Metliyleue Blue. 
Microscopy. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
came a bright green, after two hours a dark green and 
after four hours a dark blue. No albumin was present. 
In the saliva a bluish tinge was detected, but there was 
no discoloration of the mucous membranes or conjunc- 
tiva. The anodyne effect began in about two hours, and 
was gradually produced; it had no effect on any fever 
or inflammatory condition. When administered in full 
doses it is liable to produce symptoms of strangury and 
increase the amount of urine, for which powdered nut- 
meg has been used with success in Germany. Other ob- 
servers have found it of value in nervous headaches, 
herpes zoster, alcoholic depression, migraine, and in the 
pleuritic pains of tuberculous patients. Doses of 2 to 5 
grains have been given three times a day. 
In the following year, 1891, Ehrlich and Guttman an- 
nounced that the drug was also a remedy for malarial 
troubles. They were led to experiment upon this dis- 
ease from the fact that the plasmodia of malarial disease 
was readily stained by this body, not only in prepared 
specimens but also in fresh blood. They used the remedy 
in two cases of malarial fever-one quotidian, the other 
tertiary. They found that the drug had a decided cura- 
tive power over the disease ; the periodical attacks ceased 
within a few days, and at the end of eight days all plas- 
modia had disappeared from the blood. A dose of 1| 
grain was given ten or twelve hours before the expected 
attack, and repeated every two hours until five doses had 
been taken. The treatment should be continued for 
seven or eight days after all malarial symptoms have 
subsided. Other European observers have reported the 
results of a trial of this remedy, generally with less bene- 
ficial results; its action was uncertain and frequently 
failed. It, however, produced a cure in many instances 
with different observers, and proved particularly useful 
iu neuralgic pains of a malarial origin. Laveran experi- 
mented with it without obtaining any success. He 
injected it into the blood of pigeons affected with the 
luematozoon, and although the color was seen in the blood 
no effect was exercised upon the parasites. He also 
treated two patients affected with the disease, without in- 
fluencing the paroxysms or destroying the malarial or- 
ganism. 
Dr. W. S. Thayer, in Jolins Hopkins Hospital Bulletin, 
May, 1892, gives a detailed report of seven cases treated 
by this method. He concludes that-1. Methylene blue 
has a definite action against malarial fever, accomplish- 
ing its end by destroying the specific organism ; but it 
is materially less efficacious than quinine, failing to 
accomplish its purpose in many cases where quinine acts 
satisfactorily. 2. Reaction appears to be rapid, the chills 
disappearing on the temperature, in remittent cases, fall- 
ing to normal during the first four or five days; but 
later, however, if a sufficient number of organisms have 
resisted the drug, they appear to develop again directly 
under its influence, causing a return of the symptoms. 
3. Methylene blue seems to have no advantages over qui- 
nine which would warrant its further use. 
Methylene blue has also been given in tuberculous con- 
ditions. In pulmonary phthisis a dose of 1| grain was 
given the first day, increased on the second day to 3 
grains, on the third day to 4£ grains, and so on until 24 
grains were given in the twenty-four hours. The usual 
improvement of symptoms is said to follow its use. 
In tuberculous pharyngitis the powder may be applied 
to the affected part, and in scrofulous glands of the neck, 
and for irrigating empyemic cavities a ten per cent, so- 
lution has been used. A solution of the same strength 
has also been recommended in diphtheria. 
Beaumont Small. 
METHYLOL. This compound is the dimethylate of 
methylene, CH2(OCH3)2. It was first prepared by Mala- 
gati. in 1839, and suggested as an anaesthetic. Its use as 
such has not been adopted on account of its rapid evapora- 
tion, and its less agreeable effects than chloroform and 
ether. It is prepared by distilling a mixture of methylic 
alcohol, sulphuric acid, and peroxide of manganese ; the 
product is formiate of methyl and methylol. By agitating 
this with caustic potash the formiate of methyl is de- 
stroyed without attacking the methylol. It is a limpid, 
very mobile liquid, specific gravity, .855, with a burning, 
aromatic taste. Its odor is penetrating, and recalls that of 
chloroform and acetic ether. It dissolves in three parts 
of water, in alcohol, ether, and the fixed and volatile 
oils. It boils at 107.6° F. and its vapors are not inflam- 
mable. 
It has recently been introduced as an hypnotic. Its 
first effect is a transient period of excitement, followed 
by a deep and quiet sleep. It augments the heart-beats, 
slightly lowers the blood-pressure, and causes slower and 
deeper respirations. It leaves no bad after-effects. It is 
advised in all cases of insomnia and restlessness due to 
cerebral anaemia or inanition, and is contra-indicated in 
cerebral hyperaemia. It has been suggested that its hy- 
podermic use is superior to other methods of administra- 
tion-one and one-half minims in ten minims of water- 
but this has been found to prove irritating. The dose is 
from fifteen to thirty minims, which may be increased 
to one or two drachms ; it is very pleasantly combined 
with syrup of orange-flower and water. 
It has been employed extensively as a soporific in men- 
tal diseases, and found to be very useful in all condi- 
tions, except the commencement of simple mania. A 
tolerance is established, if its use is persisted in for any 
length of time, and the dose must be increased or the med- 
icine stopped for a few days. It has also been found of 
service in the insomnia of delirium tremens. Professor 
Richardson found it of service in angina pectoris, when 
combined with amyl nitrite, in the proportion of nine 
parts to one. It lessens the rapid action of the amyl ni- 
trite and prolongs its effect. It has been found to relieve 
the spasms of strychnine poisoning ; its antidotal action 
is of no value if large quantities of the poison have been 
taken, but it is said rather to hasten a fatal termination 
under this condition. 
It is used as a local anaesthetic in the form of an oint- 
ment-one part to six of almond-oil in simple cerate. 
Beaumont Small. 
MICROCIDINE. An antiseptic preparation introduced 
by Dr. Berlioz, of Grenoble, which is prepared by add- 
ing to fused naphthol-beta half its weight of caustic soda, 
and allowing the mixture to cool. It should contain 
seventy-five per cent, of naphtholate of soda, the remain- 
der consisting of mixed naphthol and phenol compounds. 
It is a whitish powder, soluble in three times its weight 
of water, yielding a brownish solution. It is a powerful 
antiseptic, very slightly toxic, is not caustic, and does 
not injure instruments or clothes. It is said to be weaker 
than sublimate, but is ten times more powerful than 
phenol, and twenty times more powerful than boric acid. 
A solution of three parts to the thousand is used as a lo- 
tion and to prepare dressings. Under its influence, ul- 
cers and suppurating wounds heal quickly, and disagree- 
able odors are checked. A solution of the same strength 
may be used for irrigating the bladder, uterus, and sup- 
purating cavities. 
It may be employed as an internal remedy in doses as 
high as thirty grains a day. It does not produce any 
irritating effect. The urine is rendered strongly anti- 
putrescent, its action being similar to that of salol, but 
less irritating to the kidneys. Beaumont Small. 
MICROSCOPY, CLINICAL. This article is intended 
to supplement the article "Microscopy, Clinical," by 
Dr. George Wilkins, Vol. IV., p. 775. As a large num- 
ber of staining methods, etc., for bacteria are described 
in the articles " Histological Formulae, etc.," and " Bac- 
teriological Technology " (in the present volume, pp. 77 
and 424), the reader is referred to these for further infor- 
mation. 
Microscope and Accessories.-Bacteriology forms 
so important a factor 'n clinical medicine that a micro- 
scope provided with some sort of sub-stage condenser and 
homogeneous immersion lens has become indispensable. 
Wide-angled dry lenses, such as A A and DD Zeiss, on 
account of their" superior illumination, are gradually re- 
placing those with narrower aperture. For clinical work 
632 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Methylene Blue. 
Microscopy. 
the expensive apochromatic objectives are not neces- 
sary. 
With the increasing demand for accuracy of methods, 
the habitual use of the micrometer, camera lucida, polar- 
iscope, microspectroscope, etc., is becoming more general. 
A rack-and-pinion coarse adjustment and mechani- 
cal stage are very convenient adjuncts in working with 
high powers. In selecting a mechanical stage, one 
which can be manipulated by the left hand alone is to be 
preferred. 
Of nose-pieces (revolvers), one with sockets for three 
lenses should be selected when both bacteriological and 
anatomical work is to be done, as then some combination 
of lenses like AA, I)D, and Homog. will suffice for 
all purposes without having to change objectives. 
Microphotography has not yet become sufficiently sim- 
plified to be of much use in clinical work. It is prefera- 
ble to have a separate microscope stand, with sliding nose- 
pieces, constantly set apart for this work alone, and kept 
always ready for use, as the amount of time required in 
adjusting and centering the apparatus before a single 
negative can be taken is greater than that required to 
photograph a dozen different objects when everything 
is in readiness. 
Light.-None of the substitutes for daylight, so far 
available, can be considered satisfactory, but the incan- 
descent light, the electric light, the albo-carbon light, or 
the use of a blue glass screen sufficient to neutralize any 
excess of yellow rays, renders working with artificial light 
less fatiguing to the eye. 
lieagent Bottles.-The dropping-bottles recently intro- 
duced, where a pipette stopper is ground 
into the bottle and fitted with a rubber cap, 
cannot be too highly recommended for con- 
venience and cleanliness (Fig. 424). 
Labels.-Small sheets of gummed paper, 
which can be cut or torn into any shape or 
form desired, effect a great saving of time 
and trouble as compared with ordinary 
labels. 
Forceps.- The blunt-pointed, self-closing, 
forceps, devised by Cornet, are extremely 
convenient for working with cover-glass 
preparations. With these it is impossible to 
lose track of the smeared side 
of the cover slip (Fig. 425). 
Reagents.-Fixing and 
Hardening.-For giving accu- 
rate results, two fluids are 
specially to be recommended : 1.-Alcohol 
in the strength of ninety to ninety-six per 
cent., and 2.-Flemming's fluid, made by 
mixing 4 parts of two per cent, osmic acid 
solution, 15 parts of one per cent, chromic 
acid solution, and 1 part glacial acetic acid. 
This fixes in two to four days, when, after 
thorough washing in water (five to twenty- 
four hours with frequent changes), harden- 
ing can be completed in alcohol. 
Corrosive sublimate in a saturated watery 
or alcoholic solution also gives good results, 
but does not penetrate deeply into the tis- 
sues. 
Pieces of tissue to be treated by Flem- 
ming's solution should not be more than 
one-twelfth of an inch thick. The use of 
bichromate solutions is to be avoided where 
the structure of nuclei is to be studied, as 
these become materially altered in solutions 
like Muller's fluid. 
Section Cutting. - Sections may be cut 
fresh in the freezing microtome, in which case it is best 
to avoid the use of gum, etc., for embedding. The sec- 
tions can be received in one-half per cent, salt solution, 
and either examined unstained or else placed for one to 
two minutes in Loeffler's methylene blue, washed, and 
mounted in glycerine. To fix the blood in tissues the 
specimens should be thrown into boiling water for a few 
seconds previous to freezing. It is better to keep a 
(SUPPLEMENT.) 
small microtome specially for cutting frozen sections 
than to use the freezing attachments furnished with the 
sliding microtomes. 
For obtaining sections of hardened tissues, a sliding 
microtome of the Thoma-Jung or Weigert-Schanze 
model is necessary. Those made by Bausch & Lomb 
are cheap, and give excellent results. 
For sharpening microtome knives the attachment fur- 
nished by Jung will be found invaluable to those who 
(like the writer) have not naturally the gift of sharpening 
instruments. By having the razor blade mechanically 
held at a proper angle, no one, however unskilled, can 
fail to sharpen his knife satisfactorily. 
Fig. 426.-Attachment for Microtome Knives, by which the blade is held 
at a constant angle while stropping. (Jung.) 
Under proper conditions, sections of tissue only 10 
to 15 p in thickness should be obtained at each cut. 
When time is of value, the tissue, after a few hours' 
hardening in strong alcohol, may be clamped between 
pieces of hardened amyloid liver or elder pith, or, bet- 
ter still, glued to a cork by Meyer's glycerine jelly. 
This is prepared by mixing 1 part of gelatine, 2 parts of 
water, and 4 parts of glycerine, over a water-bath till 
thoroughly dissolved. Take a lump of the jelly as large 
as a pea, melt it upon the blade of a hot knife, and after 
transferring to the surface of a cork, press the tissue to 
be cut into it. As soon as the surface hardens place in 
absolute alcohol for a few hours. This method is prefer- 
able, as a rule, to the use of the freezing microtome, 
when a few hours' delay is admissible, as fixed tissue 
stains far better than fresh, and the definition of the 
nuclei is much sharper. 
For delicate tissues, or very thin sections, embedding 
in paraffine or celloidin should be employed. (See " His- 
tological Formulae, etc.," Supplement, p. 424, and " His- 
tological Technique," vol. iii., p. 658.) 
In staining specimens the method of staining each sec- 
tion or series of sections upon the slide has come into 
very general use. A few drops of the (filtered) dye are 
poured upon the slide and allowed to remain until under 
a low power the nuclei can be distinctly seen as deeply 
colored points. Then, after washing with water, a few 
drops of absolute alcohol are allowed to remain for a few 
seconds in contact with the section, and then replaced by 
a few more. In this way the section becomes dehy- 
drated in less than a minute, and can be clarified by drop- 
ping on a little xylol before mounting in xylol-balsam. 
Should the xylol produce turbidity, it is due to the fact 
of some moisture being still present, and alcohol must 
again be dropped on. With complete dehydration af- 
ter treating with absolute alcohol the section may be 
rapidly dried with blotting-paper, and xylol-balsam ap- 
plied at once, omitting the step of clarification. With 
picro-carmine apply a drop of glycerine without wash- 
ing the section. By carrying out the staining on the 
slide itself all unnecessary handling of the specimen is 
avoided, and time is saved. 
With sections cut in paraffine it is well to first attach 
the section, still in paraffine, to the slide (or cover-glass) 
by smearing on the thinnest possible film of a filtered 
solution of equal parts of egg-albumin and glycerine, 
(which may be kept indefinitely in a stoppered bottle 
by adding a small piece of camphor). On the slide, or 
cover-glass so prepared, the section is spread out with a 
soft brush. By heating the slide for a few seconds over 
a flame or water-bath, till the paraffine is seen to melt, 
the albumin will be coagulated and the section will ad- 
here firmly to the glass, and can be manipulated with the 
same ease as cover-glass preparations. Staining can only 
be accomplished after removing the paraffine by xylol 
followed by alcohol and water, in the following order: 
(1) xylol, (2) alcohol, (3) alcohol again, (4) water, (5) stain. 
Sections cut in celloidin can be fastened to the slide by 
simply pressing upon them firmly with folded filter-pa- 
Fig. 424. 
Dropping-bottle 
with Rubber 
Cap for hold- 
ing Reagents. 
Fig. 425. 
Cornet's For- 
ce p s for 
Cover - glass 
Prepara- 
tions. 
633 Microscopy. 
Microscopy. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
per. When a series of sections has to be attached in a 
definite order, a slide should be first coated with a thin 
layer of collodion and allowed to dry ; then the sections, 
moistened with alcohol, are placed in position and are 
partly dried with blotting-paper and covered with a sec- 
ond layer of collodion, the section thus lying between 
two layers of collodion. 
A useful method of obtaining very thin (1 to 5 
sections from objects embedded in paraffine, is to coat 
the surface of the block with a layer of thin collodion 
just before each section is cut. This thin film of collo- 
dion will prevent even the thinnest and most brittle sec- 
tions from falling to pieces. 
The methods mentioned above for paraffine and collo- 
dion have long been practised in connection with normal 
histology and embryology, but are only now beginning 
to be appreciated by pathologists. 
Examination of Blood.-The estimation of the per- 
centage of haemoglobin present is a point which should 
never be neglected in connection with the microscopic 
examination of blood. The haemoglobinometer or hae- 
mometer of von Fleischl has come into very general 
use, owing to its simplicity as compared with those of 
Hayem and Malassez. In estimating the amount of 
haemoglobin the cell is filled with water, and one of the 
small capillary pipettes, filled with blood, is mixed with 
the water on one side of the partition in the cell. The col- 
ored glass plate is then moved until when beneath the 
uncolored half of the cell it gives the same depth of tint 
Hamatokrit.-Daland (Univ. Med. Magazine, March, 
1892) has described a method of estimating the volume 
occupied by the corpuscles and deducing their number 
from this. He employs a centrifugal machine. The 
blood, diluted with an equal volume of 2.5 per cent, bi- 
chromate of potassium solution and thoroughly mixed in 
a watch-glass, is drawn into a glass tube 35 mm. long and 
having a calibre of 1 mm. The tube is closed at each end 
by a rubber cap and rapidly rotated until the mass of cor- 
puscles which collects at the periphery attains a constant 
volume (with the above solution a constant volume is 
reached after about ten thousand revolutions, requiring 
about seventy seconds' time). 
The tube is scaled in fifty parts, and therefore to ex- 
press the volume of corpuscles in percentages, it is neces- 
sary to multiply the number shown on the scale by four. 
The volume per cent, in normal blood is 51.6 for red, 
and one per cent, for white corpuscles, making the value 
of each volume per cent, about 100,000 red cells, so that 
51 x 100,000 = 5,100,000 per cubic millimeter, a number 
corresponding closely to that obtained by means of the 
haemocytometer. 
Ehrlich's Method.-A new method of examining blood 
is that of Ehrlich, based upon the affinity for basic and 
acid anilin dyes, of certain minute " granulations" found 
in the colorless corpuscles. The blood must be spread 
in a very thin film upon cover-glasses, and fixed by 
heating at a temperature of 120° C. This is best at- 
tained by using a flat brass bar placed over a petroleum 
oil stove, and, when a constant temperature is attained, 
placing the cover-glasses a little nearer to the flame than 
the point at which a drop of water is found to boil. To 
give good results, heating for from one to twTo hours is 
necessary. The writer has employed a mercury bath 
upon which the cover slips are floated, the temperature 
being controlled by means of a thermometer. 
In staining, Ehrlich at first employed a solution com- 
posed of aurantia, indulin, and eosin, each 2 grammes ; 
glycerine, 30 grammes ; but the stain he now recommends 
is composed of saturated watery solution of orange, 125.0 ; 
concentrated solution of acid fuchsin in twenty per cent, 
alcohol, 125.0. Mix, and add alcohol, absolute, 75 ; sat- 
urated watery solution of methyl green, 125.0 (Biondi's 
reagent). 
As the action of this stain is very variable, and as it is 
very difficult and tedious to obtain the right proportion 
of each dye, it is advisable to obtain it ready made, either 
in powder or solution, from Grubler, of Leipzig, or from 
his agents, Eimer & Amend, New York. 
The staining is complete in from two to five minutes, 
when the superfluous dye should be washed off, the cover- 
glass dried with blotting-paper, and the specimen mount- 
ed in xylol balsam. In a successful specimen the nuclei 
are stained greenish, the red corpuscles orange, the eosin- 
ophilic granules red, and the neutrophilic granules violet. 
As the results of the stain are uncertain and depend upon 
the exact temperature at the time of fixing, it is best 
to lay several cover-glasses on each side of the line 
which represents the boiling-point on the heated bar, 
in which case some of the specimens are sure to turn 
out well. 
Ehrlich has described five forms of granulations found 
in blood which have each a specific staining reaction. 
They were named empirically at first as a, ft, 7, 8, and e 
granulations, but the only ones having pathological sig- 
nificance for human blood are : 
The a or oxyphilic granulations, which have affinity 
for acid anilin dyes, such as eosin, acid fuchsin, or picric 
acid. 
The 7 or basophilic granulations, analogous with those 
found in plasma cells (Mastzellen). These stain with 
basic anilin dyes. 
The e or neutrophilic granulations, which stain of an 
intermediate tint in a mixture containing both acid and 
basic anilin dyes. This form is the one most abundant 
in normal human blood. 
The ft or amphophilic granulations represent an ill- 
marked form intermediate between a and 7; the 3 granu- 
lations, a transitional step between 7 and e. 
Fig. 427.-Von Fleischl's Haemometer. 
as the diluted blood ; the reading on the scale then gives 
the percentage of haemoglobin. The light used should 
be gas or petroleum, not daylight. The instruments 
usually record a little too high, but are accurate within 
about ten per cent. 
Aimore exact and scientific method would be to deter- 
mine the intensity of both the red and the yellow tints 
separately in the blood, by the use of standard tints (Lovi- 
band's scale), as is done in water analysis, but no appara- 
tus has yet been contrived for this purpose. 
Graeber has arranged the following table as giving the 
diagnostic results of blood examination, but it is looked 
upon by other observers as being too arbitrary : 
Haemoglobin. 
Number of red cells. 
Diagnosis. 
Reduced. 
Reduced. 
Simple anaemia. 
Reduced, 
Normal. 
Chlorosis. 
Reduced, but increased rela- 
Greatly re- 
Pernicious 
tively to number of red cells. 
duced. 
anaemia. 
Poikilocytosis and occurrence of nucleated red cells is 
commoner in cy togenic than in secondary anaemias but may 
occur in all forms of anaemia, leucocytosis, or leukhaemia. 
634 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
microscopy. 
microscopy. 
In blood the following forms of colorless corpuscles 
occur : 
1. Lymphocytes, 7 to 9 in diameter, about the size 
of red-blood corpuscles, with relatively large nucleus and 
small surrounding protoplasm. They resemble the white 
cells of the lymph glands, from which they are probably 
derived. They contain no granules. 
2. Polynuclear leucocytes (neutrophiles), diameter 
double that of the lymphocytes ; somewhat smaller than 
the mononuclear leucocytes; nuclei irregular in form, 
curved, S-shaped, or multiple; protoplasm filled with 
fine neutrophilic granules. Derived from bone-marrow. 
3. Mononuclear leucocytes ; larger than those last 
named ; nucleus large, round, or oval. No granulations. 
4. Eosinophilic leucocytes (eosinophiles); of same size 
or larger than the polymorphous neutrophilous nucleus ; 
round or polymorphic. Protoplasm filled with coarse 
eosinophilic granulations. Derived from the bone-mar- 
row. 
Normal blood contains the above-mentioned varieties 
in about the following proportions (Erlich) : Lympho- 
cytes, twenty to thirty per cent. ; polymorphic or neutro- 
philic leucocytes, sixty to seventy-five per cent. ; mono- 
nuclear, six per cent. ; eosinophilic, two to four per cent. 
(From 100 to 1,000 leucocytes should be counted in each 
case.) In addition, a few transitional forms are seen 
having a polymorphic nucleus, but with non-granulated 
protoplasm. 
As far as has yet been determined the pathological 
significance of these cells is that- 
1. In simple leucocytosis, or in leucocytosis accom- 
panying the severe secondary anaemias following large 
losses of blood or other exhausting discharges, the num- 
ber of white cells is simply increased, both absolutely and 
relatively to the red, without any marked disturbance in 
the relative proportions between the different forms of 
leucocytes. 
2. In lymphatic leukhaemia the lymphocytes prepon- 
derate. 
3. In splenic and splenic-myelogenous leukhaemia, 
there is no absolute increase of the lymphocytes, whose 
proportion, relatively to the total white cells, may fall to 
one or two per cent. Great absolute and relative increase 
of polynuclear forms. Great absolute but little or no 
relative increase of the mononuclear and eosinophilic leu- 
cocytes. 
4. In purely myelogenous leukhaemia, great increase in 
eosinophile cells. 
5. In splenic and myelogenous leukhaemia a special 
form of mononuclear cell appears, known as the myelo- 
cyte. This is larger than the ordinary leucocyte, and is 
filled with fine neutrophilic granules. It does not possess 
the power of amoeboid movement. 
6. In all forms of leukhaemia, and in both primary 
and secondary anaemias, the red corpuscles may show, 
besides diminution in number, irregularities in size and 
form (poikilocytosis = increased plasticity), and nucle- 
ated red corpuscles may be present. Erlich's method is 
admirably adapted for demonstrating nucleated red cells. 
7. In slight degrees of splenic myelogenous leukhaemia, 
and during the remissions which occur during the prog- 
ress of the disease, the condition may be diagnosed with 
certainty by (a) the relatively small number of lympho- 
cytes, and (b) the presence of myelocytes. 
There are now some bacteriological grounds for sup- 
posing that leukhaemia is an infectious disease due to a 
specific micro-organism. 
When the blood is simply examined in the fresh or 
unstained condition it should be spread in the thinnest 
possible layer by using a perfectly flat slide and very 
thin cover-glass, and examined with a -fa immersion lens. 
The presence of rouleaux of corpuscles shows that the 
film of blood is too thick to be of service. 
A very good account of the application of Erlich's 
method is given by Dr. W. S. Thayer,* of Johns Hop- 
kins University. 
(SUPPLEMENT.) 
Biondi has introduced a special method for examining 
blood in sections. He recommends collecting a few 
drops of blood in 5 c.c. of a two per cent, osmic acid 
solution. After twenty-four hours the supernatant fluid 
is withdrawn by a pipette and the sediment embedded in 
liquefied agar-agar (five per cent.), which, after solidify- 
ing in a mould, is hardened in eighty-five per cent, alcohol 
and cut in the microtome. For staining, Biondi's reagent 
(see above) is suitable. 
Malaria.-For the detection of the plasmodium ma- 
lariae Plehn recommends fixation of the cover-glass prep- 
arations in absolute alcohol for a few minutes, and stain- 
ing in concentrated aqueous methylene blue solution, 
60 c.c. ; one-half per cent, eosin solution in seventy-five 
percent, alcohol, 20 c.c. ; distilled water, 40 c.c. ; add 12 
drops twenty per cent, caustic potash solution. The 
flagellate forms are stated to be stained by this method. 
Laveran's method is as follows : The cover-glass is 
fixed by heating in the usual way, and stained first in a 
saturated watery solution of eosin, which is then dried 
off with blotting-paper, and a saturated solution of methy- 
lene blue allowed to act for about one-half to one minute. 
The flagellate forms do not stain well. 
By either of the above methods the parasites are 
stained blue and the blood-cells pink. Care must be 
taken to avoid mistaking precipitation of the blue pig- 
ment in the red cells for the endoglobular parasites. 
Some clinicians with large experience in the diagnosis 
prefer the direct examination of unstained specimens 
under a immersion lens to the staining methods (Osler, 
Celli). A striking feature in these unstained specimens 
is the very pale anaemic condition of those red cells 
which contain the parasites. 
The method of making microscopic observations at 
body temperature by surrounding the microscope by a. 
water-jacket having a glass front, which has recently be- 
come very general in laboratories, is simply a modifica- 
tion of a method in use by Sachs, many years ago (Fig. 
428). 
Sputum.-Tubercle Bacilli.-Of the large number of 
new methods published in the last few years, probably 
the most satisfactory is that known as Gabbett's method, 
by which the decolorizing and counter-staining of the 
specimen is combined in a single act by the use of a 
solution of two per cent, methylene blue in twenty-five: 
per cent, sulphuric acid. After staining with Neelsen's 
carbol fuchsin (fuchsin, 1 ; alcohol, 10 ; carbolic acid, 
5 ; water, 100), putting a few drops of staining fluid on 
the cover-glass and boiling it, by holding directly over a 
low flame for one-half to two minutes. The cover-glass, 
is dipped in the acid methylene blue for one-half to one 
minute, washed, and examined. Although it is claimed 
that this method is practically the same as that of B. 
Frankel, who decolorized and counter-stained simulta- 
neously in a mixture of methylene blue, alcohol, and ni- 
tric acid, I have found that the Gabbett method invariably 
gives clean preparations free from granular precipitate, 
while Frankel's method does not do so. The contention 
of Czaplewski, that fluorescin dissolved in alcohol or oil 
of cloves tended less to decolorize the tubercle bacilli 
than the treatment by alcohol, has been shown by Nut- 
tall to be erroneous. 
Nuttall * has devised an extremely ingenious and accu- 
rate method for estimating numerically the number of 
tubercle bacilli in sputum, but, unfortunately, the details 
and precautions to be observed are so numerous as to 
prevent it from being applied for ordinary diagnostic 
purposes. McFadyean and others recommend, where 
the bacilli are very scanty, that the film of sputum 
should be smeared upon a glass slide, instead of a cover- 
glass, as a larger field for examination is obtained in this- 
way. The writer has found this modification of con- 
siderable service. 
When only a very few bacilli are present the sputum 
should be liquefied either by Biedert's method of boiling 
with soda, or by allowing it simply to putrefy till quite 
fluid and then examining the sediment. 
♦Johns Hopkins Hospital Bulletin, 1891, and Boston Medical and 
Surg. Journal. 1892. 
♦ Johns Hopkins Hospital Bulletin, 1891. 
635 Microscopy. 
Microscopy. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Heart failure Cells.-In sputum of persons suffering 
from heart disease, with red induration of the lungs, E. 
Wagner has described as heart-failure cells certain large 
epithelioid cells containing brown haematin granules, and 
whose presence is significant of chronic pulmonary con- 
gestion, with dilatation of the capillaries. Recently 
other writers have made observations showing the diag- 
nostic value of this sign. Although undoubtedly of 
service in establishing the fact of organic pulmonary 
change, when they can be found, the general utility of 
this phenomenon as a means of diagnosis is greatly dimin- 
ished by the fact that it is impossible in nine-tenths of 
the cases of chronic heart disease to obtain any sputum at 
all. 
Leprosy.-In cases of genuine leprosy a scraping from 
a leprous nodule, or a drop of blood from it, is invariably 
found swarming with enormous numbers of the lepra 
bacilli, which take the stain characteristic of the tubercle 
bacillus. There is no danger of confounding this condi- 
tion with lupus, as in the latter disease the bacilli are ex- 
tremely scanty or may be entirely absent. 
The value of microscopic methods alone in the detec- 
tion of tetanus, glanders, and diohtheria is limited, as 
(SUPPLEMENT.) 
still uncertain, owing to the want of uniformity in the 
observations of different independent observers. 
Urtne.-The recognition of casts, blood, etc., in the 
urine has been greatly facilitated by the introduction of 
Litten's centrifugue. 
A small test-tube filled with uriue is rapidly rotated for 
Fig. 429.-Litten's Hand Centrifuge. 
about two minutes, at the end of which time the sedi- 
ment will be found collected at the bottom. Where a 
deposit is very scanty the sediment of a quantity of urine 
may be collected by using tubes having a small con- 
striction near the bottom. After rotating, so as to drive 
the sediment into the bulb at the bottom, the fluid in the 
upper part of the tube can be poured off, replaced by 
fresh urine, and again concentrated. The original con- 
tention that bacteria could in this way be collected from 
urine has not been found to be the case. 
The recognition of tubercle bacilli in urine can be ac- 
complished by the ordinary fuchsin and staining meth- 
ods, but is very difficult when a small number only are 
present. 
F.eces.-The recognition of the amoeba coli has proved 
of great service in the diagnosis of tropical dysentery. 
This organism is found not only in stools, but in ab- 
scesses forming in different parts of the body, especially 
in the liver. Councilman and Lafleur, in a case of severe 
anaemia, without any intestinal symptoms, found enor- 
mous numbers of amoeba coli to be present in the stools. 
An important medico-legal bearing of the examination 
of faeces was recently brought out by Austin Flint, who, 
in a case of murder, where the interest centred on the 
question as to whether stains found on the clothing and 
beneath the lingers of the suspected criminal were de- 
rived from ordinary faeces or from the contents of the 
small intestine, proved the latter to be the case, by de- 
monstrating the presence of bilirubin and tyrosin, which 
are normally found in the small intestine, but become 
decomposed in their passage through the colon. 
The detection of typhoid bacilli in the stools has been 
found too uncertain and difficult to afford a sure indica- 
tion of typhoid fever, even where culture methods are 
employed. 
The detection of the cholera spirillum in the stools of 
acute cases can sometimes be made by the microscope 
alone, as this organism may be present almost in pure 
culture in the small, flocculent particles which occur in 
Tig. 428.-New Form of Warm Stage (Lautenschliiger's), regulated by 
means of a thermostat. 
the microscopic characters in these are not of themselves 
sufficiently distinctive to enable the diagnosis to be made 
with certainty, and culture methods must be employed. 
Quite recently peculiar organisms have been described 
as occurring in typhus by Hlava, and other authors 
have described monad and coccidia forms in scarlatina, 
measles, small-pox. and syphilis, but their significance is 
636 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Microscopy. 
Microscopy. 
the rice-water evacuations ; but of course for scientific 
accuracy the use of culture methods is always necessary. 
From the parallel arrangement of the comma bacilli 
Koch found (Zeitsch. f. Hyg., xiv., p. 319), in his labora- 
tory, that a microscopical diagnosis was possible in fifty 
per cent, of the cases. In no instance was this shown to 
be erroneous by the result of the cultures. 
Sporozoa in Malignant Tumors.-Besides the or- 
ganism found in the blood of malaria (see above), lowly 
organized animal forms were found by Darien associated 
with Paget's disease of the nipple and molluscum conta- 
giosum. The pathological significance and the precise posi- 
tion which these organisms occupy in the animal kingdom 
are not yet decided, in the absence of culture methods. 
Cancer has been staled to contain sporozoic-like or- 
ganisms, but their nature and significance are still a mat- 
ter of dispute. For their detection sections should be 
prepared from tissues fixed in alcohol or sublimate, and 
stained with logwood and eosin or by anilin dyes, prefer- 
ably saffranin. In sections fixed in Flemming's solution 
good results are obtained by Biondi's reagent. 
Examination of Tissues.-The microscopical diagnosis 
of the tissues obtained at operations or autopsies has be- 
come an important part of clinical microscopy. In addi- 
tion to the examination of teased specimens, sections pre- 
pared by the freezing microtome form the chief means of 
diagnosis. 
In recognizing parenchymatous degeneration it is im- 
portant to distinguish it from the granular appearance 
which is simply the result of post-mortem changes, and, as 
pointed out by O. Israel, the differential point to be at- 
tended to is the fact that the cell elements are swollen 
(cloudy swelling, but different from that observed as 
post-mortem change) and increased in size. 
Virchow has recently called attention to certain patho- 
logical changes which can only be recognized with cer- 
tainty by the use of the microscope. They are as fol- 
lows : 
1. Diffuse fatty metamorphosis of the interstitial cells 
in the brain, spinal cord, and nerves. 
2. Parenchymatous and fatty metamorphosis of the 
muscles, heart-fibres, kidney, liver, and the parietal cells 
of the peptic glands. 
3. Fragmentation of the heart muscle. This forms 
an extremely common and hitherto unrecognized alter- 
ation, which directly accounts for sudden death in a large 
number of cases. It can be best recognized in rather 
thick sections, either fresh or hardened in Muller's fluid. 
4. Ganglion-like swelling of the nerve-fibres. Best 
recognized by drawing out the nerve-fibrils from their 
sheath and examining either directly in water, or in 
glycerine, after fixing in one per cent, osmic acid. 
5. Calcification of the ganglion cells. Recognized by 
the presence of highly refracting, lumpy, angular, or 
rounded masses, which dissolve in weak mineral acids, 
with the evolution of gas. 
6. Fat embolism of the lungs and kidneys. Recog- 
nized either by examination of fresh specimens, which 
can be prepared by snipping out small portions of the 
tissues with scissors, or better, by cutting sections of the 
tissues, after hardening twenty-four hours in Muller's 
fluid to which one-fourth bulk of osmic acid has been 
added. 
7. White hepatization and red induration of the lungs. 
Recognized by the filling of the alveoli with small round 
cells in the first case, and by the presence of brownish 
haematin pigment in the walls of the alveoli in the lat- 
ter. 
8. The early stages of proliferation of the tissues. Rec- 
ognized by the increase in the number of nuclei, espe- 
cially the swelling of the endothelial nuclei of capilla- 
ries. 
9. Slight degrees of amyloid degeneration. Recognized 
in sections by red reaction with methylene violet, or by a 
brown stain when iodine solution is employed. 
In addition to these microscopical features the ex- 
amination of tissues, fluids, etc., for bacteria, by both 
staining and culture methods, is often of very great im- 
portance. In many cases of otherwise unexplainable 
(SUPPLEMENT.) 
death the fatal issue is caused by septicaemia, due to the 
presence of one form or another of the septicaemia organ- 
isms (occasionally of the bacillus coli communis) in the 
blood. This auto-infection by bacillus coli is common in 
the later stages of both acute and chronic exhausting dis- 
eases, especially in those affecting the intestinal tract. 
Thrombosis.-The presence of thrombi in the capil- 
laries, with or without hyaline degeneration of the ves- 
sel walls, is a matter to which, recently, much pathological 
significance has been attached. The occurrence of the 
so-called liver-cell thrombi, detected first in the vessels 
of the brain by J urgens, afterward in the smaller ves- 
sels of the liver by Klebs, is a phenomenon the ex- 
planation of which is by no means clear. It has been 
looked upon as explaining the fatal issue in cases of 
eclampsia. 
Rabies.-Babes has recently stated that a rapid micro- 
scopical diagnosis of rabies may be made by cutting sec- 
tions of the nerve-tissues which have been hardened in 
alcohol for several hours. The appearances considered by 
him to be characteristic consist of swelling of the nerve- 
cells, granular condition of the protoplasm, enlargement 
of the endothelial cells, and the occurrence of capillary 
ecchymoses. Although in the hands of an expert accus- 
tomed to histological examinations of rabic tissues, these 
appearances may be sufficiently striking, it is doubtful if 
the observations of ordinary microscopists, on this head, 
could be received with confidence. In any case, the in- 
oculation methods should not be omitted, and diagnosis 
by the microscopic appearances alone should only be 
resorted to where the material at disposal has been re- 
ceived in spirit. The rapidity of the process, by which 
the diagnosis is completed in the course of a few hours, 
is, of course, a great point in its favor compared with 
the delay and uncertainty of inoculation. 
Frozen sections of fresh brain or cord may be fixed by 
leaving for one hour in pure piridin (Goodall). 
In the diagnosis of tumors which have been extirpated 
a chemical reaction has been described which appears of 
value. This consists in smearing the tissue with strong 
nitric acid, which causes connective tissues to swell up 
and become translucent, ■while epithelial tissues become 
an opaque yellowish-white color. As in this way in- 
filtration of carcinoma in muscles, etc., can be definitely 
established in the course of a few moments without any 
microscopic examination, the method should be of valu- 
able assistance to surgeons in extirpating cancers. Sar- 
comata do not show the characteristic reaction. 
The diagnosis of decidual remnants in cases of sus- 
pected abortion is a matter of considerable importance. 
The villi of the chorion, when present in their typical 
branched form, with clump-shaped extremities, are highly 
characteristic. Sections of suspected tissues may show 
large, flattened endothelioid cells with distinct round nu- 
clei. 
The diagnosis of malignancy of tumors from the mi- 
croscopic examination of small portions excised, is a 
matter which should always be undertaken with consid- 
erable caution. Although such fragments are usually 
sent to pathologists for diagnosis, far more valuable re- 
sults could be obtained if the examination were made by 
those in charge of the case, as the signification of the mi- 
croscopic appearances often depends more on the rela- 
tions of the parts than on their histological type. In 
cases of suspected squamous carcinoma (epithelioma) it 
is well to bear in mind that, on the one hand, infiltration 
of the epithelial cells into the deeper interstitial tissues 
is not pathognomonic of epithelioma, but also occurs at 
the margins of lupoid ulcers ; and, on the other hand, 
cases of malignant epithelioma occur, in which, in the 
early stages, no deep infiltration of epithelium has taken 
place. Butlin insists that chronic ulcers, occurring about 
the mouth, in which the surface is covered with squa- 
mous epithelium, should be regarded as malignant and 
treated as such. The writer had the opportunity of ex- 
amining a case wdiere the tongue wTas excised for a sus- 
picious ulcer in a very early stage, and where, out of 
some hundreds of sections from all parts of the growth, 
none showed deep infiltration of the epithelium, though 
637 microscopy. 
military Hygiene. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
the patient subsequently died from secondary epithelioma 
commencing in the submaxillary gland. Klebs insists 
upon the diagnostic importance of dilated lymphatic 
spaces in the submucosa beneath the epithelial layer for 
the diagnosis of cancer of the larynx. 
Cornil is less inclined to place reliance, in the case of 
■specimens obtained for diagnosis from suspicious ero- 
sions of the uterus, upon the relation of the epithelial 
tissue to the deeper parts than upon absence of the base- 
ment membrane, which he considers to be highly char- 
■acteristic of carcinoma. In order to place reliance upon 
the absence of the basement membrane or the arrange- 
ment of the cells, however, it is necessary that the por- 
tions of tissue should be placed, immediately after re- 
moval, in strong alcohol and well hardened before cutting, 
as a delay of a few hours will so alter the appearance as 
to make an accurate diagnosis impossible. 
The study of the cellular changes, especially the mi- 
totic appearances of tumors, though of great interest, 
does not afford any reliable information as to the malig- 
nancy or otherwise of the tumor ; possibly in the future, 
by great care in the employment of proper methods of 
fixation, our knowledge of the microscopic appearances 
■of cells may become more extended. 
Literature.-Out of a large number of works on 
medical microscopy which have recently appeared, the 
older standard works of Peyer, Friedlander (edited by 
Eberth), and Bizzozero still hold their place. Von 
Jaksch, " Klinische Diagnostik ; " Klemperer, " Grun- 
-driss der Klinischen Diagnostik;" v. Kahlden, "Tech- 
nik der Histologischen Untersuchungen," and Ranvier, 
" Technique d'Histologie," may be mentioned as among 
the best productions of the recent literature on the sub- 
ject. Behrens, " Hilfstabellen ftir Mikroskopische Ar- 
beiten," and the latest edition of the " Microtomist's 
Vade-Mecum," contain valuable recipes, embracing all 
the common formulae. For details of the bacteriological 
methods, special works upon the subject should be con- 
sulted. On the subject of the blood, besides the imposing 
monograph of Hayem, which contains over one thousand 
pages, shorter monographs have been written by Graeber 
and von Limbeck. The publications of Erlich, especially 
the collection of reprints entitled " Farben-analitische 
Untersuchungen zur Histologie und Klinik des Blutes," 
presents, in a compact form, a good deal of information 
upon its author's peculiar methods, which was formerly 
very widely scattered. Unfortunately this work is not 
yet completed. Most of the important literature upon 
medical microscopy, however, still lies scattered through 
the medical and microscopical periodical literature. 
Wyatt Johnston. 
MILITARY HYGIENE. The principles of military 
hygiene have undergone no change during the last six 
years, but there have been some modifications of its ap- 
plication to United States troops which deserve notice 
here and consideration by those who may be intrusted 
with the care of State troops and of armies yet to be 
raised. Some points omitted in the original paper may 
also be stated. 
Clothing.-Duck.-The issue of white cotton-duck 
sack-coats, trousers, and overalls is now authorized as 
uniform in extreme Southern latitudes in summer, at the 
discretion of department commanders. The anticipated 
theoretical objections to the use of cotton do not seem to 
have been realized, and the increased comfort to the men 
by the relief from the oppressive woollen is a sanitary ad- 
vantage. But light mixed woollen and cotton underwear 
should accompany cotton uniform. The effort to have 
authorized a dust-colored uniform, one-third wool and 
two-thirds cotton, should be encouraged for those regions 
where long-continued high temperature enervates. 
Collars.-Among the disadvantages of tight collars, 
sometimes worn in uniform, is the very serious military 
one of affecting the vision through disturbance of the 
cerebral circulation. This is not apt to occur frequently, 
but it should be guarded against as a possibility. 
Leggings of brown canvas duck, to be worn on the 
march or in campaign, are now required for all foot 
(SUPPLEMENT.) 
troops. Their utility in a prolonged campaign is yet un- 
proved. The disadvantages are those of extra pieces of 
clothing to be looked after, a slightly additional weight, 
and, particularly, difficulty of adjustment, especially 
when most required, in wet and mud. When tight 
enough to remain in place, they are liable to be too tight 
and to cause the feet and ankles to swell. Cotton and 
light canvas wrinkle into bands, and light leather be- 
comes harsh after wetting. 
Boots.-All mounted troops spend more time on foot 
than in the saddle, and in this country cavalry will doubt- 
less, as heretofore, continue to fight much dismounted-to 
be veritable dragoons. The cavalry boot is only suitable 
for the horseman when mounted, for it is apt to chafe in 
walking. The comfort and efficiency of the cavalry 
would be increased by substituting for the boot a shoe, 
with a heavy detachable leg and stiff brace, to be worn 
only when mounted. 
Barrack Shoes.-Shoes with canvas uppers are now is- 
sued for barrack use. They are much lighter and more 
comfortable for this purpose than the marching shoe. 
Carriage of Weights.-As set forth in Vol. HI., 
the transportation upon his person of the clothing and 
accessories necessary for the independence of the modern 
soldier in the field has only been accomplished with great 
personal discomfort and fatigue, and by the expenditure 
of so much vital force as seriously diminishes his effec- 
tive strength. An equipment devised by Colonel Mer- 
riam, Seventh Infantry, practically solves the problem. 
By it rations, underclothing, extra ammunition, and 
blanket can be conveniently carried by one piece of equi- 
page, without constriction of the chest or of the arm-pits. 
The weight is supported by the hips, with some assist- 
ance from the collar-bones, and there is practically no 
pressure upon the back, and absolutely none upon the 
breast. Numerous actual trials have demonstrated its 
efficiency, and there can be no question as to the practi- 
cal value of this device, and its great superiority over the 
official blanket-bag. But it has not yet been formally 
adopted, and experimental issues continue to be made. 
A very recent device of Lieutenant Dodge, Twenty- 
fourth Infantry, to support the blanket-roll, havresack, 
and canteen, is a flexible wooden strip to which the roll is 
lashed. It passes over the shoulder and rests against the 
opposite side, as the blanket would. The presumed ad- 
vantage of this wooden support or yoke is that it very 
slightly interferes with motion, and that its elasticity 
takes all pressure from the chest and back. Where the 
curve passes over the collar-bone, a leather strap, like 
that used on a crutch-head, takes off the rigid bearing. 
How far it will comply with the conditions of active 
service is yet undetermined. Trial samples are to be 
issued. 
Food.-The unwritten custom of the service that 
served three meals a day in garrison, is now formally 
recognized in the regulations. The Quartermaster's De- 
partment now supplies certain cooking utensils and table 
furniture, thus relieving for food money formerly di- 
verted from the company fund. A greater improvement 
has been the abolition of the post fund (Vol. III., p. 755), 
and the direct division of the profits of the bakery 
between the various companies, in proportion to the num- 
ber of flour rations turned into the bakery by each. 
This releases the ration from an indirect tax for articles 
other than food. 
Bread.-The standard ration of bread remains at eigh- 
teen ounces, where fresh vegetables can readily be ob- 
tained. But it may be increased to twenty-two ounces 
by post commanders, on the recommendation of councils 
of administration. 
Fresh Vegetables.-A recent law adds one pound of 
vegetables to the ration, an allowance ample for all sani- 
tary requirements. This may be issued as 100 per cent, 
fresh potatoes ; or, 80 per cent, fresh potatoes and 20 
per cent, fresh onions ; or, 70 percent, fresh potatoes and 
30 per cent, canned tomatoes or other vegetables. No 
savings from these are purchased by the Subsistence 
Department. Partly on account of their bulk, and partly 
from their perishable nature, there will be great difficulty 
638 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Microscopy. 
Military Hygiene. 
in the actual issue in campaign or under adverse climatic 
conditions ; that is to say, just when most needed will 
be the greatest risk of failure. But the recognition of 
their importance and the attempt to supply them consti- 
tute a sanitary advance. In receiving canned tomatoes 
it is to be remembered that the contents of the so-called 
two- and three-pound cans fall short of their nominal 
weight. 
Vegetables shrink about ten per cent, in cooking, ex- 
clusive of waste. 
(Theese.-Cheese is no longer supplied as an alternative 
part of the travel ration. It is, nevertheless, recommended 
as an occasional addition by purchase to the mess table. 
Beef.-The beef ration is estimated as the raw issue. 
There is a waste of 5 per cent, in cutting up the carcass, 
and a shrinkage of about 25 per cent, in cooking. Beef 
should be killed twenty-four to thirty-six hours before 
issue in temperate, and eight to ten hours in hot cli- 
mates. 
Bad and Diseased Meat.-Decomposing meat should 
not be eaten, although some abnormal palates and edu- 
cated digestive organs regard it as a delicacy. Diseased 
animals ordinarily should be condemned as food, but such 
emergency issues may be made in the prolonged absence 
of other meat. Cattle dead of the rinderpest and horses 
dead of glanders have repeatedly been eaten with impu- 
nity. But it is essential that such meat be thoroughly 
cooked, and it is much safer that all the blood be drained. 
Tuberculous meat and milk may affect the consumer ; 
but it is probable that actinomycosis, a less communicable 
disease, is often mistaken for the former. Animals with 
malignant pustule are always dangerous, and their car- 
casses should be burned, not buried. Beef and pork may 
communicate tape-worm, and pork, trichina, when im- 
perfectly cooked. Thorough cooking of all doubtful 
meat is very necessary. Sausages and meat-pies some- 
times become toxic from the development of a substance 
not yet isolated ; and hash prepared over night in warm 
weather, and stale mixed dishes, are liable to induce intes- 
tinal disorders. 
Baking and Cooking.-To Bake Bread.-In the field, 
portable ovens will probably be used for large commands, 
but baking will generally be done by company.cooks for 
brigades or less. Flour grown on soil deficient in lime 
may make bread that, after rising well, becomes heavy 
and sour on cooling. The use of strong lime-water in 
making-up such dough corrects this defect. Of the 
various methods of baking in the field, the simplest is to 
fill a small hole in the ground with a wood fire, and 
when this has thoroughly burned out to place therein, 
on a stone, a mixture of flour, salt, and water, covered 
with a tin plate and surrounded by hot ashes. Unless the 
heat is kept below 212° F. the bread will be tough. Or, 
two mess-pans may be taken and the rim of one be cut 
down all round, so as to leave a jagged border. Fill 
the cut pan two-thirds with dough, and invert over it 
tlie perfect pan. Place both in a hole eighteen inches 
deep, where a wood fire has burned several hours and 
from which all the embers except two or three inches 
have been removed. Cover them with hot ashes and 
with earth, and leave them five or six hours. The rough 
edges of the cut-pan allow the gases to escape. 
To Cook Meat.-For boiling, the piece should be as 
large as possible and be plunged in boiling water, to re- 
main five or ten minutes. This coagulates the albumin 
in the outer layers and thus retains the inner juices. As 
at above 170° F. the meat would become hard and indi- 
gestible, the temperature of the water should be reduced 
to 160° F., and the meat should remain in it fifteen min- 
utes for every pound of its own weight. Baking, which 
is not roasting, as it is ordinarily called, is treating meat 
exactly similarly to boiling, and for the same reasons, ex- 
cept that a dry heat is used. In frying, so called, the 
slowly heated fat exudes acids, generally injurious, 
that envelop the particles of meat with an indigestible 
coating. Stewing, properly conducted, is admirable. 
Small pieces of meat should be kept for about two hours 
in a little water at not far from 134° F. This partly ex- 
tracts the juices, keeps the albumin semifluid, and en- 
(SUPPLEMENT.) 
riches the accompanying liquid which must be served 
with the meat. Stewing is the exact opposite of boiling 
or baking, both in theory and practice. For cooking or 
baking in the field, the Buzzacott field-oven is well 
adapted for company use. 
Habitation Sites.-Soils to be avoided are those 
that hold moisture. Granite and the metamorphic rocks 
are usually healthy. So are clay slates, but drinking- 
water will be scarce. Deep gravels, unless dominated 
by adjacent ground, are always healthy ; and gravel hil- 
locks are the best of all sites. Sand, when pure and deep, 
is healthy, but such a site soon becomes charged with 
refuse, which passes through it laterally as well as per- 
pendicularly. Water is sometimes held by clay under 
dry sand and becomes hurtful. Clay and alluvium are 
generally suspicious from the contained moisture, but 
well-cultivated soils, rice-fields excepted, are desirable. 
Topographical Sites.-Enclosed valleys, ravines, or the 
mouths of ravines, any ill-drained grounds, the neigh- 
borhood and especially the lee of marshes, the northern 
side of mountains or high hills, and in warm latitudes 
the northern banks of rivers, are to be avoided. 
Vegetation in Relation to Sites.-Close-lying grass, 
kept well trimmed, is always healthy. Rank vegetation 
should be cut in the heat of the day and be burned be- 
fore decay; but the soil should not be disturbed, nor 
heavy brush near a marsh. Belts of trees and tall shrubs 
are a barrier against malaria, but decaying vegetation is 
harmful. The eucalyptus by its evaporating power an- 
tagonizes the production of malaria in frostless climates, 
and the sunflower guards against it in others. Trees 
break cold winds in cold climates, and cool the ground 
in hot climates ; they are hurtful only when they cut off 
the light and air from a domicile, making it dark and 
damp. 
Quarters.-Ordinary houses when used as quarters 
may be estimated to accommodate, in rooms fifteen feet 
wide, one man to the yard in length ; in those between 
fifteen and twenty-five feet in width, two men ; in those 
more than twenty-five feet wide, three to the linear 
yard. 
Marches.-The latest drill regulations abandon " com- 
mon" time, and require the " double" step to be 36 in- 
stead of 35 inches. Unless otherwise directed, all move- 
ments are in " quick " time, at the rate of 120 steps, 30 
inches in length, a minute. 
Water-Supply for Military Purposes.-In the 
field, on halting for camp, the water-supply should be 
immediately protected against waste, against pollution, 
and against the turbidity that follows trampling the 
margin into mud. The less the supply the greater the 
care, and an officer should be in charge when the quantity 
of water is disproportionately small. In the case of a 
small spring the supply will be increased by digging it 
out and sinking a barrel or other casing. In a shallow 
stream immediately create a small reservoir for drinking 
by a temporary dam, with one lower down for the horses 
and one still lower for washing. When the camp is per- 
manent and the supply relatively small, preserve the 
water that flows by night in reservoirs, conduct the over- 
flow into a succession of half-barrels, all connected by 
little gutters to avoid waste, for the horses, and detain 
the surplus in a still lower reservoir. Horses drink 
better and more rapidly when the water is five or six 
inches deep, each horse taking about a gallon and a half 
at a time and requiring three minutes for drinking. If 
allowed all they will drink they consume six to eight 
gallons a day, according to season and work, and about 
three gallons a head is needed for grooming and police. 
On the march a man requires for drinking and cooking 
six to eight pints a day, according to climate, and an 
equal amount for washing the person. In barracks the 
allowance should be ten gallons a head for all purposes 
except water-closets and baths; with these, twenty-five 
gallons. The foregoing are minima figures, requiring to 
be increased in hospitals by several times as much, de- 
pending on the character of the cases. 
Ice.-The sources of domestic ice-supply for military 
posts, as for other settlements, should be carefully se- 
639 Military Hygiene. 
Military N urging. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
lected and guarded ; for water by no means parts with 
all its impurities in freezing. 
> For the special discussion of sewers and the disposal of 
waste water-supply, disinfection, the avoidance of dis- 
ease in permanent posts, and similar subjects that affect 
civil as well as military life, reference must be made to 
the papers devoted to them. But it is always to be borne 
in mind, and to be impressed upon commanding and 
other officers, that deodorants are not necessarily disin- 
fectants, or that to replace one bad smell by another 
rarely antagonizes the poison that may sap health. Es- 
pecially are those in control to be taught that polluted 
water is practically without remedy-that the only safety 
is in keeping the water-supply inviolate. 
Alfred A. Woodhull. 
MILITARY NURSING.-In military practice the nurs- 
ing of the sick is placed in the hands of privates of the 
hospital corps. These soldiers are either transferred to 
the hospital corps after one year's service in the line, or 
they may be enlisted from civil life and instructed for a 
short period in one of the two schools of the hospital corps 
before being sent to the various army hospitals for duty. 
By these methods there is secured for nurses a body of 
men who have been disciplined by a military training, 
and who are thus supposed to be fully alive to the neces- 
sity of subordination to authority and implicit obedience 
to orders. 
These soldiers when received into the hospital corps 
are entirely ignorant of the duties of a nurse, and they 
must be instructed by lectures, demonstrations, and ac- 
tual experience in the ward. This combination of 
military instruction and training school for nurses re- 
sults in methods of nursing somewhat different from 
those found in civil life. In the theoretical rules for 
nurses in time of peace there can be no difference in 
civil and military practices, but it is more in the details 
that changes arise. Many of these changes are due to 
the peculiarities of military life, as, for instance, the ne- 
cessity of having the nurses under complete control in 
case of active service in war, or in time of epidemics. In 
such times service must be compulsory, for it is not 
practicable to depend on nurses volunteering in the cause 
of humanity, as would be the case in civil life. This ar- 
ticle will not deal therefore with things common to the 
two, but will be confined to pointing out the differences, 
where such may be supposed to exist. The matters to be 
discussed will be presented under the following head- 
ings : 1, The Nurses ; 2, The Management of the Ward ; 
3, The Management of the Patient; 4, Nursing in the 
Field. 
1. The Nurses. 
Qualifications.-Before a man can be transferred to the 
hospital corps he must have the following qualifications : 
He must have served at least one year in the line, must 
desire the transfer, must be unmarried, under forty years 
of age unless he is a good cook or nurse, must be in good 
physical condition, of good habits, and possess a good 
character ; be able to read and write, have good general 
intelligence, and an aptitude for his duties, and must 
give assurance that he intends to serve out his full five 
years of service, and not seek his discharge beforehand, in 
any of the numerous ways now available. 
The pay of the private of the hospital corps is eigh- 
teen dollars per month, which is five dollars higher than 
that of a private in the line, and his money allowance of 
clothing is that of a corporal. This inducement of 
slightly increased pay and allowances should be the 
means of getting a very good class of nurses, particularly 
as the above restrictions are thrown around the matter 
of transfer in order to exclude undesirable men. The 
constant instruction that these men receive is slowly but 
surely building up a good class of nurses, notwithstand- 
ing the frequent changes by discharge and re-enlistment. 
Should all the plans in this direction prove successful, the 
United States soldier, when sick, should receive the con- 
stant supervision of trained nurses whose efficiency 
should be excelled by none in civil life. 
The military nurse is a soldier, and as such is subject 
to all the rigid discipline of military life. This has its 
advantages as well as its decided disadvantages. Such 
discipline enables the surgeon to exact the most punctili- 
ous attention to the details of nursing and the execution 
of orders, under penalty of court-martial for neglects and 
disobediences. Every physician knows how advanta- 
geous this is in certain critical cases where he is desirous of 
having his plans carried out to the letter. In such cases 
where the faithfulness of the attendants is not aboye sus- 
picion, the physician's anxiety is far greater than it 
should be. If the nurse can be depended upon, there 
is no doubt that lives are often saved where it is a mat- 
ter of good nursing. 
There is a bad side to the discipline which exacts an 
implicit obedience to orders. The private soldier is us- 
ually under someone's orders, and has all his thinking 
done for him. This course of life undoubtedly weakens 
his independence of thought and action in emergen- 
cies. He is too apt to be on the lookout for orders, and 
unless some are forthcoming he may be entirely at sea. 
Modern methods of military instruction are trying to 
overcome this by teaching each soldier his individual 
importance in battle. On the same plan, the instruction 
in nursing aims partly to undo the results of the disci- 
pline that turned the man into a machine. The nurse is 
taught to observe his patients closely, watch for unfavor- 
able signs, think for himself, make frequent reports to 
superiors, and to prepare the way for changes of treat- 
ment his teaching tolls him have been made necessary by 
the change of symptoms. 
In civil hospitals when a nurse proves himself to be 
unfitted for his duties by reason of inappropriate tem- 
perament, viciousness, or incorrigible stupidity, he can be 
unceremoniously discharged, but not so in military life. 
Courts-martial are extremely conservative, fight shy of all 
innovations, and not being composed of medical officers 
they are difficult to convince in the matter of the offences 
of nurses. The disadvantage of military custom in this 
respect cannot be avoided and must be tolerated. Thus 
it happens that not infrequently improper nurses are 
retained when their absence from the hospital would be 
more desirable than their presence in it. 
The military nurse has the same kinds of difficult, 
fatiguing, and disagreeable duties as in civil hospitals, 
and must possess the necessary qualifications of good 
health, patience, forbearance, kindness, and great self- 
control. Truthfulness, honesty, habits of punctuality 
and order, and the ability to work according to a sys- 
tem and not hap-hazard, are also important, as well as 
the ability to keep secret his confidential knowledge of 
the patient's private affairs. Many of these qualifications 
are brought out and strengthened, if not generated, by 
the military training which every military nurse receives 
before his transfer to the hospital corps. 
Not every man has the temperament necessary for a 
good military nurse. Nervous and excitable men are 
entirely unfitted for such work in any hospital, either 
civil or military, because they worry and excite the 
patients by their manner, and they may do irreparable 
mischief. The sanguine, hopeful man is unfitted for 
military nursing because he is too apt to be depressed by 
misfortunes, rebuffs, thoughtless and unjust reprimands 
from immediate superiors, and the thousand and one 
annoyances inseparable from military life. He so loses 
heart under adversity that he will neglect highly im- 
portant duties while suffering from these annoyances. 
The man of phlegmatic tendency, whose sensibilities are 
not too acute, and who is hard to excite, comes nearer to 
the ideal nurse than the others. He is not especially an- 
noyed by the most exasperating circumstances, and is 
cool and collected in times of excitement. 
In military practice the surgeon is often unable to 
obtain professional assistance of other surgeons. It is 
absolutely necessary for him to have skilled assistants in 
operations that are not only exceedingly difficult, but 
made far worse by the adverse surroundings of military 
life. The nurse must be relied upon, and for this 
reason the lectures and other instruction to the hospital 
640 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Military Hygiene. 
Military Nursing. 
corps must go much further into the details of the theory 
and practice of medicine and surgery than is usually 
deemed necessary to qualify nurses for work in civil life. 
Though military custom steps in to prevent any marked 
confidences between surgeons and nurses, and though 
there is an official barrier between the two that cannot 
be broken down, yet it is true that the surgeon must be 
brought much closer in contact with the men under his 
orders than is the case in the line. This close rela- 
tionship comes from the necessity of the surgeon receiv- 
ing from the nurse confidential reports of the patients, 
their actions, symptoms, and conversation. Soldiers are 
very apt to malinger for the purpose of escaping duty or 
of obtaining discharge from the service and subsequent 
pension. Of course they will hide everything they can 
from the surgeon ; but the nurse, from his intimate asso- 
ciation with the patients, learns the true state of affairs, 
and is often depended upon for true reports. The sur- 
geon must know the truth in these matters, for upon his 
report depends in great part the action taken in each 
case, as to compelling the malingerer to do his full duty. 
In other cases false reports may have been the cause of 
such action on the surgeon's part as will result in great 
injustice to a worthy soldier. It will be impossible for 
the surgeon to be informed, unless he can induce the 
nurse to feel that there is a confidential relation between 
them that is necessary for the proper performance of 
duty. The nurse must therefore be sufficiently intelli- 
gent to be able to hold such relations without detriment 
to himself, the surgeon, or the United States service. 
From all that has been said it can easily be under- 
stood why so much is expected from a military nurse, 
and why such great efforts are made to obtain a desira- 
ble class of men. The pay and allowances, including 
board, clothing, lodging, free medical attendance and 
medicines, are the equivalent of about $55 to $60 per 
month to a city laborer in civil life. This is not small 
pay when it is considered that the Government has taught 
the man his trade whereby he earns this amount. Never- 
theless the actual money allowance, $18, is not great 
enough to attract that high class of men which the fore- 
going shows would be the ideal army nurse. 
Duties.-The nurse in charge of the ward of a military 
hospital in peace times has numerous duties to perform, 
some of which are purely military, while others are 
police duties requiring him to keep the ward and every- 
thing connected with it in a cleanly and orderly condi- 
tion. These duties are exactly the same as those of sol- 
diers of the line as far as the barracks are concerned, and 
the nurse is supposed to go about these duties without 
special instruction. Beyond his military duties as a 
soldier, and his combined duties as a room orderly and in 
charge of the ward, there are his more important duties 
relating to his care and treatment of the patients. These 
duties as a nurse are the most responsible, and therefore 
the most important ones he has to perform while on hos- 
pital duty. In the field, and occasionally in the hospital, 
he may have the important duty of rendering first aid to 
the sick and wounded in emergencies during the absence 
of steward or surgeon. The necessity of having efficient 
men who can perform these two duties of nursing and 
giving first aid, is one of the most important reasons for 
the establishment of the hospital corps. It is just as im- 
portant for the wounded soldier to be attended by trained 
nurses as it is for wounded civilians, and the army, in 
this respect, is following directly in the path of civilian 
practitioners, who have long ago found out the necessity 
of having elaborate training schools for the special in- 
struction of nurses. 
Instruction.-A system for the higher theoretical in- 
struction of army nurses has not yet been completed, as 
sufficient time has not yet elapsed to see how much can 
be done in the short period of service. The nurses are 
apt to leave the service at expiration of the period of en- 
listment and not return. If two or even three years of 
constant instruction are requisite to make a thoroughly 
competent trained nurse, it is evident that as soon as 
the army nurse becomes proficient his services are lost. 
Nevertheless much good work can be done, and there is 
no reason why the military nurses should not in time be- 
come as proficient as any others. 
The instruction is by lectures on elementary anatomy, 
physiology, the rules of hygiene, and such knowledge of 
medicine and surgery as will enable the nurse to perform 
efficient emergency or first aid service. Then there are 
series of lectures on such topics as the observation of 
symptoms, thermometry, temperature charts, pulse, ad- 
ministration of medicines, counter-irritants, disinfect- 
ants, preparations for surgical operations, the giving of 
anaesthetics, instructions in special diseases, and indeed 
the large number of topics usually found in the man- 
uals for the theoretical instruction of nurses. In times 
of peace it is not possible to give nurses the varied prac- 
tical experience that is desirable, but it is found that 
they learn quickly and remember fairly well the methods 
used in each case attended. Every opportunity is seized 
to impress upon them any practical points in nursing 
each case, and many medical and surgical cases serve as 
material for clinical instruction to the whole detachment 
of the hospital corps present. 
The military nurse is not expected to be expert in 
methods of massage, of giving inunctions, fumigations, 
electrical applications, baths, and kindred special sub- 
jects, although they may be included in a general way 
in the system of instruction. The cases requiring such 
special treatment are too rare to give sufficient practical 
experience. When a case does occur, special inst ructions 
must be given to the nurse in charge of the case. 
He is taught the importance of his duties by explana- 
tions of cases in which it is not so much the medical 
treatment as it is the careful attention to the patient's 
wants, and efficient nursing, that carries the patient 
through his illness. It is also sought to impress on 
him the high professional attainments he is expected to 
acquire, if he is to be depended on to assist the surgeon in 
different operations in certain circumstances already 
mentioned. 
There is a threadbare proverb, which is repeated with 
nauseating frequency by military men, " In times of 
peace prepare for war," and to no one is this any more 
applicable than to the military nurse. In peace he has 
ordinary routine cases, with but little to do, but he may 
be aroused from this with startling suddenness. An 
Indian war may arise, and he find himself loaded with 
work, with far more patients to look after than he ever 
imagined, and it is necessary, therefore, to have his work 
so well systematized that he can do the greatest good to 
his sick and wounded charges. The system that is aimed 
at in the above instruction should be so designed as to 
be applicable to the sudden emergencies when each hos- 
pital is loaded down with wounded. 
Women are more careful and tender in their attentions 
to the sick, and on that account are said to make better 
nurses than men. On account of woman's instinctive 
tact, which is the knowledge of what to do for the sick 
and how to do it, there is not so much written or said 
on this part of the subject of nursing as might be. It is 
all left to her instincts. Now, female nurses cannot 
be obtained for army hospitals, and indeed in small 
hospitals where all kinds of cases are put in one ward, 
the presence of women would be undesirable, and per- 
haps quite indelicate. The army nurses must, therefore, 
be men, and not being possessed of those instincts of 
gentleness and sympathy with sufferers that go so far to 
make the sick well, or rather hasten their recovery, they 
must try to make up for their deficiencies by careful 
attention to all the little details of nursing that come so 
naturally to women, and which, taken all together, go to 
make up what is called a good nurse. In times of war, 
where large numbers of sick and wounded are collected 
into immense hospitals, there can be a separation of cases, 
and in the majority of wards women can be admitted 
to perform all those necessary attentions to the sick, 
leaving the male nurses in charge of the wards free to 
devote their time and energies to the general manage- 
ment of the cases and the performance of those duties 
that the women cannot do. In times of peace and in 
small hospitals the privates of the hospital corps must 
641 military Nursing. 
military Nursing. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
themselves in as perfect a condition of health as possible. 
Particular care is necessary in the case of nurses who in 
times of epidemics are apt to be closely confined and 
much overworked. People who are called upon to 
nurse near relatives who are prostrated by illness usu- 
ally make a very great mistake by supposing that they 
are doing the greatest good by giving unremitting atten- 
tion to the patient's condition and none to their own. 
They usually break down, and then there are two pa- 
tients to be taken care of instead of one. The nurse can 
do the greatest good to his patients by attending to his own 
health. In a general way it may be said that he should 
avoid all excesses, either of eating, drinking, exercise, 
or anything else; he should cultivate the most regular 
hours and try to get a half hour or hour's exercise in the 
fresh air every day. The last direction is of great im- 
portance, for although the ventilation of wards is made 
as complete as possible, it can never be made perfect, and 
the inmates are sure to breathe air that is impure to at 
least a slight extent. 
A drunken spree so lowers a man's vitality that he is 
extremely liable to contract the diseases with which he 
comes in contact. This lowered vitality and the expos- 
ure to cold during the drunkenness fully explain the 
great prevalence of pneumonia among drunkards, and its 
mortality. From a medical standpoint it cannot be 
said that a very small amount of alcohol does any par- 
ticular harm to a man in ordinary employment, but for 
a nurse, whose health should be perfect without any 
stimulants, it can be truly said that a small amount, usu- 
ally called " moderate drinking," is very apt to do him 
harm, and on the score of his health alone he should be 
a total abstainer. If he attends cases of a contagious 
disease, his total abstinence may be his salvation by aid- 
ing him to escape infection. Of course this refers to his 
conduct when off duty. When on duty, even the slight- 
est drinking can never be tolerated. But on or pff duty 
there are various other reasons that make it impossible 
to tolerate drinking in a nurse. If but slightly under the 
influence of liquor he is too dangerous to have near the 
sick, for he is liable to make very serious mistakes. If 
he is addicted to drink, no liquors can be placed in his 
care, and he is useless from this point alone. It is 
therefore a rule in civil or military hospitals to discharge 
as soon as possible any nurse who is found to have been 
drinking while on duty. If he gets drunk while off 
duty, he is too undesirable to be re-enlisted. 
Sleeping Rooms.-In civil hospitals it is a recognized 
principle that the nurse should not be compelled to spend 
all his time in the sick-room. He must have hours out 
of doors, and, most of all, he must have an entirely sep- 
arate sleeping apartment. Perfect health is supposed to 
be incompatible with any other arrangements. Upon 
this principle it is now the rule to have in military hos- 
pitals a dormitory or barrack-room to be used by the 
members of the hospital corps. The small number of 
patients that require attention at night does not necessi- 
tate the detailing of a night nurse. Consequently it has 
become the usual custom for the day nurse to sleep in 
the ward, an objectionable custom that can scarcely be 
obviated with the present arrangements. 
learn to do all. The instruction of the army nurse must 
therefore include such matters, pointing out as well as 
a man can, the humane thoughts and feelings which 
prompt women to do those things which are so grateful 
to the sick. 
In peace or war the army hospitals do not fall into 
that serious error sometimes seen in civil hospitals, of 
placing women nurses in complete charge of men's sur- 
gical wards. This error comes from the natural swing 
of the pendulum of public opinion, for when the training 
of women nurses became popularized, nothing would do 
but that the women should take full charge, even of 
cases that their modesty and sense of decency forbid 
them to touch, which they could uot attend to, and which 
were therefore neglected, often to the serious detriment 
of the patient. Men must be in charge of men's wards, let 
the women assistants be around as thick as bees if they 
want to. To depend on refined women to uncover men 
and inspect dressing of the groin for instance, to see that 
everything is undisturbed, is entirely out of the question. 
Personal Appearance.-A nurse should always be neat 
and clean in appearance. It would seem unnecessary to 
call a soldier's attention to this fact, yet it is unfortu- 
nately true that occasionally a nurse has to be warned 
that his personal appearance is enough to make a well 
man sick, and a sick man worse. If the nurse is clean 
and neat he certainly has an effect for good upon the pa- 
tients he attends. If his hands are dirty, and his cloth- 
ing dirty or disorderly, and in this condition he hands 
patients their food, or in bad cases feeds them, they are 
apt to be nauseated by the presence of so much dirt near 
their food, and thus recovery may be interfered with. 
In hospitals where there are many patients in one 
ward, one nurse cannot do all the work, and therefore 
scrubbers and helpers do all the cleaning up and the 
heavy work generally, leaving the nurses who come 
closest in contact with the patients freer to keep them- 
selves as clean as possible. In small military hospitals 
the nurse in charge of the ward must do all the work, 
and he must, therefore, exert special care to keep himself 
clean. After doing any work that would soil his hands, 
he should hasten to clean them, even if he do this dozens 
of times each day. By carefully arranging his work a 
nurse may manage to do at one time most of his dirty 
work of cleaning up the ward, and thus save himself 
much unnecessary trouble. In such small hospitals 
where one man does all the work of a ward, it is found 
by experience that his hands and finger-nails are not 
in the condition that makes perfectly aseptic surgery 
possible, if he is to handle instruments and dressings. 
This state of affairs gives considerable worry to the sur- 
geon who is compelled to exert himself to avoid even the 
slightest possibility of wound infection, and he is further 
compelled to attend to many details which in civil hos- 
pitals are looked after by the nurses. 
The habits of cleanliness which are instilled into sol- 
diers as a duty come to the nurses' aid as far as personal 
cleanliness is concerned, and make it easier for them to 
comprehend the instructions as to the precautions to be 
observed to prevent infecting themselves or other pa- 
tients. Nurses are taught to keep and use a tooth-brush, 
and keep the mouth in as clean a condition as possible. 
Beards are not worn, as they certainly increase the dan- 
gers of infection. 
As a means of furthering personal cleanliness and neat- 
ness, nothing is better than a white jacket, with or with- 
out a white apron extending from the waist to the 
knees. These always look neat, and as soon as soiled 
can be cleaned. When clothed in them the nurse is car- 
rying around with him a far less number of disease- 
germs than if he has on his military blouse that he has 
been wearing in the ward for several months. A dirty 
old blouse is a danger in any ward, and it would be far 
better for each nurse to have white clothing that can be 
washed as soon as soiled. 
Care of Nurse's Health.-Everyone knows that a strong 
healthy man is far less liable to contract diseases than 
one who is weak and run down in health from any 
cause. It is therefore important for nurses to keep 
2. Management of the Ward. 
Quiet.-One of the strictest rules for the management 
of a ward is that referring to quietness and order. No 
boisterous conduct, loud talking, or disorder of any kind 
is allowed under any circumstances. This is essential 
for sick men, who usually require perfect quiet and rest. 
Now the first step toward accomplishing this must be 
taken by the nurse. He should never talk in a loud tone 
of voice, nor should he be noisy in any of his actions. 
One of the rules in training-schools for nurses is that for- 
bidding the use of starch in their clothing, in order that 
they may move around quietly without making a noise 
that would disturb the patients. Another rule governs 
the kind of shoes, which must be of such soft material 
that squeaking noises will not be heard. Now male 
nurses should remember these two rules, although that 
642 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Military Nursing. 
Military Nursing. 
referring to starch in the clothing is not applicable to 
them. As far as the shoes are concerned, there should 
be no trouble in military hospitals, where slippers are sup- 
plied for the purpose. When on duty the nurse should 
use the regulation leather slippers. These permit him to 
move around at his work without the least noise or dis- 
turbance that could annoy the most irritable patient he 
may have. In everything he does, whether cleaning up 
the ward, sweeping, moving bunks, administering medi- 
cines, or giving directions to patients, he should keep 
constantly in mind the utmost necessity for order, quiet, 
and the general peacefulness of the ward. 
Visits of Friends.-When people are very sick they are 
excessively annoyed by the visits of friends, who are well 
meaning and make their visits under the impression that 
they are doing good. If the surgeon orders that no one 
is to be admitted to the sick-room, the nurse understands 
that such an order is given to protect the patient's life, 
and that the order must be carried out to the letter. 
Should an intruder force his way into the ward, and by 
his presence endanger the lives of patients, by making 
them worse, he should be ejected by force, if he does not 
leave when ordered. The nurse is there to protect his 
patients and preserve absolute quiet and order, and he 
must do it if he has to exert force. Of course this re- 
sponsibility is great, and he must never think of using 
force until he has exhausted other means, and even then 
he must think whether or not the disturbance would be 
increased by any forcible means used to stop it. In all 
cases wdiere it is practicable he should not depend on his 
own judgment but report the matter without delay. 
During convalescence the visits of friends may be looked 
at in an entirely different light. At this time a short 
visit may be very acceptable, as it introduces a pleasant 
change into a monotonous life, providing the visitor is an 
agreeable friend. Should the patient's condition be made 
worse by such visits, the surgeon will at once forbid re- 
petition of them for some time. 
The situation and surroundings of large civil hospitals 
make it difficult, if not impossible, for intruders to enter 
the wards and produce disorder ; it is different at military 
posts where the small hospital may be entered by visiting 
soldiers. The military nurse therefore has to look after 
the matter of visits of friends of patients, and must have 
definite instructions. 
In small army hospitals it is impracticable to have 
regular visitors' days as is the case in large civil hospi- 
tals. 
Visits of Clergymen.-The visits of clergymen to the 
sick come under a slightly different rule, as they are priv- 
ileged visits. As a usual thing the consolation they offer 
to the sick is decidedly quieting and soothing in its effects, 
providing, of course, that the patient understands the 
visit is made merely to help him bear his trials. On the 
other hand, if the patient imagines that he is in danger 
of death, the visit of a clergyman may confirm his worst 
fears and have a depressing effect. It is only in very rare 
cases, that are chiefly nervous, that the clergyman is ex- 
cluded along with everyone else. This whole subject is 
so. exclusively under the control of the surgeon that it 
may be said to be entirely beyond the sphere of the nurse's 
duties, except that report should be made if anything 
goes wrong. As the army chaplain is required by cus- 
tom and regulations to visit the hospital, the visits are 
encouraged, and the nurse, no matter what his individual 
religious opinions are, should make it his duty to show 
every courtesy possible to all clergymen, and assist in 
making their visits as profitable as possible. 
Inspection of Ward.-A hospital ward must be ready 
for inspection at all times, but as it is a rule in military 
hospitals to have a rigid inspection of the whole hospital 
in the morning, the greatest cleaning is done right after 
breakfast. This morning inspection should never be 
made the excuse for allowing a ward to get dirty or dis- 
orderly at other times. A nurse should so fully appre- 
ciate the importance of his work, and attend to it so w7ell, 
that there never should be any necessity for an inspec- 
tion. 
Temperature of the Air.-The nurse is absolutely re- 
(SUPPLEMENT.) 
sponsible for keeping the proper temperature of the room. 
What this temperature is depends upon circumstances. 
In windy, cold climates, it may be necessary to keep the 
temperature up to 75° or even 80° F., but in places where 
it is calm a lower temperature, 65° or 70° F., may be allow- 
able even in winter. Rooms full of colored soldiers must 
be kept warmer than others, for the negro seems to require 
a higher degree of heat for comfort than a white man. 
Whether or not this higher temperature is proper cannot 
now be discussed, but as the sick man must be made com- 
fortable as the first step towrard recovery, it is allowable 
to have the room temperature slightly higher to suit the 
negro. This permission must not be imposed upon and 
made the excuse for carelessly or deliberately allowing 
the temperature of a room to rise to such an improper 
height as 90° to 95° F., as it has sometimes been found. 
The nurse must carefully study in his wrard the ar- 
rangements made for regulating the temperatures. There 
may be heating by means of hot water or steam from 
radiators in the room. There may be hot-air registers, 
the air being warmed outside the ward by coming in con- 
tact with pipes of hot water or steam, or the hot surfaces 
of furnaces. In all frontier hospitals there are stoves. 
Whatever method is used, the nurse should thoroughly 
understand it, and if there are parts beyond his knowl- 
edge he should ask for information without delay. If 
the room gets too hot or too cold, he should, by the sim- 
ple turning of a valve, register, or draught, be able to 
remedy the defect. 
Ventilation.-The ventilation of the ward is just as im- 
portant as the heating. A nurse who does not know 
how to ventilate his ward and keep the air pure is not 
efficient. It is not necessary for him to understand and 
be able to explain all the different systems of ventilation 
that are in use in hospital wards, but by all means he 
should perfectly understand the particular system in the 
ward he has charge of. If there is any part of the sys- 
tem he does not understand he should inquire of steward 
or surgeon, and have thoroughly explained the whole 
apparatus, with its shafts, valves, registers, flues, the 
reason for the present positions, and the methods of 
stopping, increasing, or decreasing the flow of air. 
Care must be taken that the apparatus is not interfered 
with by patients. Soldiers, whether in ward or bar- 
racks, will always shut up every opening in cold 
weather unless they are looked after. Indeed, in some 
barracks the ventilators are found closed at every in- 
spection. These are closed on account of cold draughts 
or a low temperature of the room. In the latter case the 
fires must be looked after, and if it is found that the 
stoves will not keep the ward warm without closing ven- 
tilators, the matter should be reported to the surgeon for 
his action. 
The construction of many army hospitals on the 
frontier, and their small size, make it somewhat diffi- 
cult to manage the ventilating apparatus. In very cold 
weather-thirty to forty degrees below zero-no ventilat- 
ing system yet applied is efficient. In the wooden tem- 
porary structures much more air can come in through 
the cracks in the walls than one would suppose, partic- 
ularly in places exposed to the wind. The defects of the 
ventilating apparatus are balanced by the defects of the 
building. Many a nurse may have served a long time 
and never have noticed any necessity for looking after 
the ventilation. 
The nurse is expected to follow the practical rule of 
noticing, every time he enters the ward from out-doors, 
whether or not there is a perceptible odor. If there 
is, some change in the ventilation is necessary. Cold 
draughts are to be avoided as specially dangerous for the 
sick. 
Plumbing.-There should be, and usually are, no 
plumbing arrangements in the ward, except, perhaps, the 
pipes carrying gas when that is used for lights. All 
water-pipes, drains, urinals, wash-stands, and other 
plumbing arrangements are placed in ad joining rooms, 
separated from the ward by closed passage-ways. Yet 
these rooms are usually under the direct care of the 
nurse, and it is his duty to become familiar with them at 
643 Military Nursing. 
Military Nursing. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
once. It is an easy matter to follow up the pipes and find 
their uses. In the case of traps in the soil-pipes and drains 
he should know how they work, how they are cleaned 
out, and how accidents to them are to be remedied. A 
little care to these appliances saves many accidents, much 
inconvenience, and great expense for repairs. The least 
appearance of foul odors from the drainage system, or 
anywhere else for that matter, must be reported without 
delay. It is rare, indeed, to find plumbing arrangements 
so complicated that an intelligent nurse cannot under- 
stand their uses and methods of working if he spends a 
little time and thought on the subject. 
Amount of Light.-There is but little attention paid to 
the amount of light in the sick-room, although the sub- 
ject is quite important and comes directly within the 
sphere of the nurse's duties. Formerly the sick in a pri- 
vate house were placed in a dark and ill-ventilated room, 
under the impression that it was quieter and better. 
There seemed to be an idea that if it was quiet at night, 
somehow or other it was the darkness that caused the 
quiet, and that therefore the darker the sick-room was 
kept, the better it would be for the patient. As this idea 
has been exploded for a long time, we find the new ideas 
reflected in the army hospitals, which are built with a 
profusion of windows, so that there are no dark places, 
and light enters on all sides. 
This throws new duties on the nurse, who has a few 
points to attend to in regard to the lightness of the ward. 
While we have shown that darkness is to be avoided, 
this should not lead to the opposite extreme of making 
the room too brilliant. Dazzling light is painful to all 
sick men, and in certain nervous cases, too much light 
may make them worse. It is, for instance, very wrong 
to allow the sun to shine in the patient's face, or to turn 
his bed so that he looks directly at a brilliant white 
sky. The light must be evenly distributed and not brill- 
iant at only one place. If the day is dark, cloudy, or 
rainy, all shades are rolled up and shutters opened. If 
it is hot, and the sun is shining brilliantly, the shades are 
all drawn down completely on the light side of the room. 
Those peculiar days when there are very bright white 
clouds in the sky are particularly trying to the eyes, and 
the shades must be drawn down for protection. 
In the early evening <*fly sufficient lights are kept to 
give a fairly good light to read by. When patients are 
very ill and it is deemed necessary to darken the ward in 
the early evening to favor sleep, the patients who wish 
to read must go to the reading-room, or, if confined to 
bed, postpone their reading until the next day. On hot 
summer afternoons it is quite agreeable to all sick men 
to have the room darkened for a short time so that they 
can have a nap-a habit that most old soldiers acquire. 
At night a dim light is kept burning so as to permit of 
walking around. A hand lamp is usually kept burning 
for this purpose, and if patients require attention it can 
be carried where more light is needed. 
Army hospitals cannot be fitted up with a sun-room 
where convalescents can be exposed to the direct rays of 
the sun. In the rare cases that require such a sun-bath, 
the nurse must arrange the matter at some convenient 
window. 
Many of the instructions given to the army nurse in 
the matter of the light may appear to be trivial, but 
much attention should be given to this instruction, be- 
cause large numbers of the present hospitals are quite un- 
favorably situated on hot, dry, sandy plains in the West, 
where the light is very trying to the eyes. Unless these 
points are emphasized the matter is liable to be neglected. 
Cheerfulness of the Sick-room.-The army nurse can 
have little to do toward decorating a ward to improve its 
general tone as to cheerfulness. A ward is doleful 
enough under any circumstance, but in military hospi- 
tals, which are greatly affected by the rigidity and stern- 
ness of military life, the conditions as to cheerfulness are 
doubly bad. Nevertheless, the nurse should understand 
the good to be accomplished by making the room cheer- 
ful and bright, even though he is not able to carry out 
the plan in military hospitals. The decoration of sick 
rooms is carried to its greatest extent in those charitable 
(SUPPLEMENT.) 
hospitals devoted to children, who are usually and greatly 
influenced by their surroundings. These rooms are in 
certain cases little treasure-houses of such ornamentation 
as can be made with the little money that is usually 
available for the purpose. It has its effect in making the 
little ones almost as happy and contented as though they 
were well, and this is a great aid in treatment. As sick 
adults usually relapse into a kind of mental childhood, 
they are also greatly influenced for the better by cheer- 
ful surroundings. 
Cheap prints tacked on the walls, little bits of decora- 
tion by ribbons or hangings, a small bunch of flowers 
here or there, and a tasty arrangement of the plain and 
meagre furniture, are all great aids to the general cheer- 
fulness. The neatness and cleanliness of the bedside 
tables must be looked after as directly tending in the 
same direction. The table-covers are usually towels, 
and they get soiled quite soon and must be replaced. 
Little articles on the table must be kept in order and 
ready for immediate use. Indeed, all the directions as 
to cleanliness, order, and neatness of the ward, though 
given with the special view of aiding treatment, have an 
additional value as enhancing the cheerfulness of the 
ward. 
A word or two must be said about growing plants and 
cut flowers in the sick-room. The subject has caused 
great discussion as to whether or not it is injurious to 
the sick. We know that during the daytime growing 
plants give out oxygen and absorb carbonic gas, just the 
opposite of what man does. This has been the ground 
for arguing that they should be kept in the sick-room to 
help purify the air. It is not generally known that the 
amount of oxygen given out by the plants that can be 
kept in the sick-room is so small that in a week it would 
probably not equal the amount brought in through one 
good fresh-air register in one hour. On the other hand, 
during the night-time growing plants often act in the 
opposite direction, i.e., give out carbonic acid gas and 
absorb oxygen, and flowers do the same thing all the 
time. Here, too, the action is so small that it can 
be totally ignored in a properly ventilated room. When 
plants are present in too great number they keep out the 
light of windows and keep the air too moist, and are 
therefore objectionable, though there can be no reason- 
able objection to a very moderate number. As far as 
flowers are concerned, it can be said that an atmosphere 
heavily loaded with the odors of cut flowers is distinctly 
and decidedly depressing to sick people, and to well peo- 
ple also for that matter. A profusion of flowers must 
be excluded, therefore, under all circumstances. As 
with growing plants, a moderate amount of cut flowers 
that does not appreciably laden the atmosphere cannot be 
objected to -when tastefully arranged in places around 
the room, but is distinctly advantageous as increasing 
cheerfulness and brightness. In time of peace the army 
nurse may not have any occasion to exercise any discre- 
tion in the matter of cut flowers, but in time of war, in 
the large general hospitals, a possible occasion might 
arise. Charitably disposed women make it their duty to 
keep the hospitals supplied with flowers, and there may 
be an inclination to carry the matter to extremes, espe- 
cially in the case of wounded men whose achievements 
in battle have made them heroes. Special attention to 
one man by his friends may call for interference. 
Army hospitals having large wards do not permit of 
much separation of the sick, who must therefore be pro- 
tected from everything of a dismal or depressing nature. 
It is particularly horrifying to be compelled to witness 
the actions of dying men or the sufferings of one in great 
pain. Therefore all such cases should be carefully hid- 
den from view by arranging bed-screens around the 
bunk. For the same reasons, should a patient die, his 
corpse should be removed to the dead-house within a few 
minutes, or as soon as it can be done decently and with- 
out giving the impression of undue and unseemly haste. 
No one has the least desire to remain in the same room 
with a corpse, let alone sleep there. When surgical oper- 
ations are to be done in the ward, all other patients must, 
as far as possible, be removed to another room. It will 
644 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Military Nursing. 
Military Nursing. 
(SUPPLEMENT.} 
make them worse to be witnesses to anything of the 
sort. Of course this refers to serious operations, but 
such things as lancing a boil or dressing a wound are not 
particularly horrifying, and can be done in the view of 
the others. Nevertheless, it is a good rule to have the 
screens ready when anything of that nature is to be done, 
for this gives a grateful sense of privacy and seclusion to 
the patient operated on. To most men of a very sensi- 
tive organization any unnecessary exposure of their per- 
sons is very disagreeable, and the protection of screens is 
almost essential. It is just as wrong to give patients the 
least unnecessary mental pain as it is to give physical 
pain that can be avoided. 
The necessity for cheerfulness, neatness, order, and 
beauty in all the surroundings of sick people is not only 
the guiding principle in regard to the interior of hospi- 
tals, but also of their exterior. Wherever it is practica- 
ble, hospitals are found situated in large, open places, that 
are filled with trees, growing plants, grass-plots, flower- 
beds, and symmetrical gravel-walks, and the whole kept 
in the cleanest and most orderly manner. A special 
gardener is employed for the purpose when possible, but 
in the small army hospital a member of the hospital 
corps must be depended on for this work, and a detail 
as gardener, to keep the hospital grounds clean and with 
at least a respectable attempt at flower gardening, is di- 
rectly within the sphere of his duties. 
3. MANAGEMENT OF PATIENT. 
On Admission.-The military discipline maintained in 
army hospitals necessitates some change of the rules for 
the nurse's management of the patients. On admission 
to hospital the patient is to be undressed and put to bed 
at once. His valuables, watch, money, etc., are to be 
given to the steward to be placed in the office safe. His 
clothing is to be locked up in the closet supplied for the 
purpose, and under no circumstances should clothing be 
given to the patient until he is ordered out of bed by the 
surgeon. If he is dirty he is to be given a bath, if pos- 
sible, and all his underclothing removed, and hospital 
clothing supplied in its place. In large general hospitals 
all the patient's private clothing is immediately sent to 
be disinfected in the large steam sterilizers built for the 
purpose, and the parts that need subsequent washing 
are sent to the laundry. After being cleaned they are 
packed away until the patient is convalescent. In small 
army hospitals no such disposition of the clothing is nec- 
essary, except in rare cases, where a soldier may acciden- 
tally bring contagious disease into the ward. In that 
case special instructions as to disinfection will be received. 
Ordinarily the clothing will be clean and can be locked 
up at once. 
As soon as he is comfortably fixed in bed his tempera- 
ture is to be taken, and note made of any noticeable 
symptom, such as chill, paleness of face, or difficult 
breathing. He will then be ready for the subsequent at- 
tention of the surgeon, and the further attentions of the 
nurse in carrying out instructions for treatment. 
Kinds of Attention to Patients.-The kind of service 
that the nurse should render to the patient depends so 
entirely upon the degree and kind of illness that but few 
except the most general directions can be given applica- 
ble to all cases. Some of the soldiers sick in hospital 
are so slightly ill that scarcely any attention need be 
given them-they are fully capable of taking care of 
themselves. Other patients again are so sick that they 
cannot do a single thing for themselves. Beyond this 
there are cases of delirium, or patieftts in a very low con- 
dition, who not only cannot render themselves assistance 
but cannot tell their wants, and are so weak that they soil 
their bedding and clothing by involuntary discharges, and 
require constant supervision. Between these extremes 
there are all grades of cases requiring various degrees of 
care, and it is the intermediate cases which are often 
troublesome and irritating. 
As a general thing the nurse is to consider that all the 
patients are under his immediate care and subject to his 
orders. This is a great responsibility, for sick men rely 
entirely upon the nurse. They lose courage, energy, and 
interest in themselves. They cannot, in severe illness, 
even think of themselves, all thinking must be done 
for them, and they must be managed as children. There 
is an indescribable feeling of perfect security a sick 
man experiences when he realizes that he is in the hands 
of a good doctor and a thoroughly reliable and efficient 
nurse. He knows that he is properly managed, and 
he begins to feel as contented as possible under the cir- 
cumstances, and ceases to think of his troubles. These 
feelings bring with them the restfulness so important to 
recovery. 
Cheerful Manner toward Patients.-It is expected of a 
military nurse to drop any disagreeable air of authority 
he may have assumed under the false impression that it 
is military. He is to cultivate that cheerfulness which 
experience shows is so necessary for the sick. With this 
cheerfulness there must go an assured manner which 
tells each patient he is sure to recover. 
There is a great difference in this cheerful assurance of 
some nurses as contrasted with the dolefulness and timid- 
ity of others. Some have such a pleasing manner of 
doing all things that their very presence in a sick-room 
is a comfort. 
As a general rule sick men are made worse by listen- 
ing to the talk going on about other sick men and the 
dangers of such cases. This is one of the objections to 
having many sick people together where the melancholy 
or the sufferings of a few will make the others worse. 
Many invalids positively refuse to go to certain health- 
resorts because of the immense amount of suffering they 
would be compelled to witness. 
As far as possible there should be no reference to any 
such subjects as dangerous and painful diseases. Of 
course it is impossible for the nurse to stop all such con- 
versation, because men must and will talk of what is up- 
permost in their minds, and it would be foolish even to 
attempt to order them to stop. If the conversation is 
very evidently jarring on some sick man's nerves, of 
course it is perfectly justifiable then to order quiet in the 
ward, or better, report the matter for the steward's or sur- 
geon's action. It is by his example that the nurse can 
do the most good. He should never allow himself to 
discuss these forbidden subjects in the hearing of pa- 
tients who are still quite ill. The nurse's responsibility 
in this matter is just as great as the surgeon's, and we 
know that if the latter would speak in a patient's hear- 
ing of the dangers of his case, he would do very much 
harm. In civil practice a gossiping nurse is an abomina- 
tion, and physicians always refuse to employ her as soon 
as they find her out, because they know that she does 
great harm by her imprudent talking. 
Of course there never should be a word said to a sick 
man about the ability of the surgeon in charge. Such 
criticism is entirely uncalled for, and is not only a seri- 
ous military offence in the hospital corps, but may do 
actual harm both to patient and surgeon. The nurse is 
not a doctor, and in his ignorance of what a good doctor 
really is, he can form only a worthless opinion on the 
subject. Often it happens that the surgeon is taking the 
best, and perhaps the only justifiable, course in a case, 
and because that course does not include some active 
measures, the patient may have a feeling of being neg- 
lected. Should this feeling be noticed the nurse's loyalty 
to his superiors should prompt him to soothe the patient 
as much as possible. 
In military practice the attendance of the sick and 
wounded is purely an official duty, that must be per- 
formed by a certain person. Consultations are not rec- 
ognized nor provided for in any way, and a change of 
physician is, of course, entirely out of the question. The 
surgeon must see the patient through to recovery. In view 
of this it is particularly improper for the military nurse 
to do anything, by word or deed, that would in the least 
affect the confidence the patient should have in his phy- 
sician. This loyalty to superior officers must be incul- 
cated as a part of the nurse's duty, though it is putting 
up too high a standard to expect it to be always observed. 
There are tricks in all trades, and it seems to be a uni- 
645 military Nursing, 
military Nursing. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
versal trick to criticise adversely every other man's 
work. It 'is hard to call in a mechanic in some lines, 
without having him say that the last work was a botch. 
Now nurses are prone to do this also by "running 
down " other nurses. The hospital corps is no place for 
any such practices, for no good can come of them. If a 
good word cannot be said of others, nothing should be 
said. If the soldiers get it into their heads that the 
nurses are careless and neglect their duties to the sick, 
the feeling of apprehension of getting worse may do 
more harm than the surgeon can do good. The nurses 
should understand this and have enough "esprit de 
corps " to feel that any disparagement of one reflects 
upon the others. 
Confidential Relations of Nurses.-Should a nurse in 
civil life go to a new engagement and report her experi- 
ence in her last engagement, divulge family secrets that 
have come to her knowledge, and make disparaging re- 
marks about her employers or her patients, she is guilty 
of a most dishonorable action. She has been admitted to 
the house and treated as one of the family, and all her 
knowledge there gained is strictly confidential, and must 
be as closely guarded as the physician guards what is said 
to him. 
Now all this is applicable to the army nurse in every 
respect. He knows of secrets about patients that the 
others constantly in the ward do not even suspect, and 
under no circumstances should he divulge these secrets. 
To be sure, it is impossible to get much privacy in army 
hospitals, and for this reason soldiers suffering from dis- 
eases which they wish kept secret will not come to the 
hospital, but will take any kind of treatment rather than 
run the risk of exposure. Now as it is desirable to do 
the soldier as much good as possible, it depends upon the 
nurse to aid the surgeon in keeping perfectly secret any 
confidential knowledge he may have, and try to miti- 
gate that great publicity and lack of privacy which is 
inherent to the ward of an hospital. Worst of all, he 
should never boast of his knowledge of the patients as 
though he held them in his power. Such boasting is very 
low, and stamps the man as undesirable in the ward or 
anywhere near the sick. Nurses have been known to do 
this, and their influence is always bad. 
The confidences between a patient and his nurse serve a 
very useful purpose in bringing to light certain symptoms 
that would otherwise be hidden. It occasionally hap- 
pens that sick men, without either rhyme or reason, hold 
the doctor at such a distance that they are quite unwilling 
to talk freely to him. They have a false modesty in the 
matter although they have no hesitancy in talking to the 
nurse, hoping, and even knowing, that the matter will be 
at once brought to the attention of the doctor. The 
nurse thus becomes a medium through which valuable 
knowledge of symptoms is taken to the surgeon, who 
may at once act on this knowledge, and by tactful talk- 
ing to the patients sweep away their unnecessary reserve 
and get a full and complete grasp of their cases. The 
above is not mere fancy, for every experienced nurse can 
remember instances of this natural modesty, though of 
course marked instances of it, except in venereal com- 
plaints, are quite rare among soldiers who have been liv- 
ing together for years with but little or no privacy. 
It is curious also what persistence the sick will show in 
continually denying what they think reflects on their 
characters. Men will deny ever having had any venereal 
complaint when the scars of old chancres are in full 
view. The surgeon therefore is compelled to seek and 
get his information in all ways possible, for he cannot 
treat his patients by guess-work. It is the duty, then, of 
nurses to report facts coming to their knowledge confi- 
dentially, as they know such knowledge is a secret be- 
tween them and the doctor. 
Irritability of Sick Men.-The military nurse is partic- 
ularly to be warned of the irritability of sick men. Ev- 
erything in the way of insubordination is so quickly no- 
ticed in army life that the nurse is apt to misunderstand 
the natural peevishness of the sick. Special pains are 
therefore taken to explain the whole matter to the nurse, 
showing him why so many things are tolerated in the 
(SUPPLEMENT.) 
hospital ward which would not be tolerated in the barrack- 
room. 
On the other hand, a nurse should not accept every- 
thing a patient will do, for such a course would be equally 
disastrous in certain cases. If a sick man sees that all 
his peevishness and restlessness is allowed to go un- 
checked he is apt to presume upon such leniency and get 
more peevish, unless he is too ill to have any thoughts in 
the matter at all. Therefore a gentle firmness is neces- 
sary in refusing requests that cannot be allowed. With- 
out being cross, ugly, or mean, a nurse can give the pa- 
tient firmly to understand that he must be quiet, as the 
orders are to that effect. Again, patients who are of an 
ugly, vicious disposition are apt to be deliberately bad in 
conduct. Where the nurse is sure that such conduct is 
deliberate, or has his doubts in the matter, he must report 
it at once to the steward or surgeon for action. Upon 
the nurse's tact and skill in managing these cases will de- 
pend in great degree his efficiency in the ward. Special 
care given to this point of the irritability of sick men is 
of so much importance that it is easy to see the great- 
est difference in the general order and contentment in 
the ward under some nurses, and the ill-feelings and un- 
happiness under others. The former are even-tempered 
men who understand the sick, while the latter are apt 
to be thoughtless or ignorant of this part of their duty. 
Occasionally a nurse will be so cross to the sick that he 
will actually retard their recovery. By giving thought- 
ful attention to the one item of irritability of sick men, 
a good nurse will be able to prevent much trouble in the 
ward and preserve that degree of order and quiet so nec- 
essary for men recovering from sickness. 
Cleanliness of Patients.-It is a general rule that every 
patient, if his condition will permit, shall be given a 
bath upon his admission to the hospital. This rule is 
much less rigid in military than in civil hospitals, be- 
cause soldiers are required to keep themselves clean by 
frequent bathing, and if they are not inclined to be clean 
about their persons their comrades are apt to compel them 
to be. It is very rare, therefore, to have a soldier ad- 
mitted to hospital in a dirty condition, unless it is in the 
field after a long march without bathing facilities. In 
civil life the poor who are taken sick have probably had 
no bathing facilities, and when taken to the hospital are 
often in a filthy condition and must be bathed at once. 
In military hospitals in time of peace there is no need to 
be on the look-out for men who are dirty, but when one 
is found he must be attended to. In war times the re- 
verse is true. After a long campaign, where the clothing 
has been limited in quantity, and changes could not be 
made, and bathing facilities were absent, the soldiers are 
apt to become indescribably dirty, and the heat, dust, and 
smoke of battle have made them far worse. The wounded 
are not infrequently brought to the hospital in a terrible 
condition of dirt, so that in war times the rule about 
bathing patients is of prime importance and is usually en- 
forced wherever allowable. 
After the patient has been in hospital for a few days 
the nurse is to look after his cleanliness, giving the neces- 
sary sponge-baths, looking after the hair and beard, and 
the condition of the nose and mouth. These duties are 
in no respect different from those in civil hospitals. 
In war times it is quite common for soldiers to become 
infected with lice and "crabs," and on admission to hos- 
pital be an actual source of danger to the other patients. 
These cases may require the surgeon's care. It may be 
said that as a rule nothing will be of any use short of 
shaving hair from the face and head, under the arms and 
over the pubis. " Crabs" may be so numerous that the 
whole body, even the eyebrows and eyelashes, are in- 
fected. Though the eyebrows could be shaved off it may 
be requisite to pull out each hair of the brows or lashes 
having nits on them. The nits must be cut off and 
burned, for no drugs have any effect on them except such 
strong drugs as would injure the skin. Nits will hatch 
out in spite of all applications. 
All matters relative to the cleanliness of the patient are 
within the personal duties of the nurse, and he should 
attend to them without special orders. The surgeon usu- 
646 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
military Nursing, 
military Nursing;. 
ally has many things to think of when he sees his patient, 
and must keep in mind dozens of different points in pre- 
scribing the treatment, so that his mind should not be 
distracted by finding tht patient in a bad condition due 
to neglect by the nurse of those rules of cleanliness which 
he should carry out without special orders in each par- 
ticular case. The same general directions are to be ob- 
served as in civil hospitals regarding cleanliness and 
neatness of the bed, bedding, and bedclothing. These 
are looked after, kept neat and clean, and protected from 
contamination by infective discharges. Very old army 
barracks are quite apt to become infested with bed-bugs, 
and the soldiers wage a constant warfare against them. 
Hospitals at such posts are liable to get the pests intro- 
duced by patients, and in such situations the nurse is 
taught to exert special vigilance and by frequent and 
ample use of insecticides to exterminate the pests as soon 
as their presence is known. 
Observation and Report of Symptoms.-Military as well 
as civil nurses are required to observe the symptoms and 
report the facts to the surgeon. They must be taught 
that the patient is apt to exaggerate symptoms in certain 
cases and to hide them in others. The fact that a patient 
will make astonishingly erroneous statements as a result 
of dreams or slight delirium is to be kept in mind at all 
times. The military nurse is to be depended on in great 
part for that exact and detailed knowledge of patients 
necessary in military cases. In civil hospitals no special 
future harm may come to the patient, his relatives, or the 
community by the lack of records of any one case. It is 
entirely different in military hospitals, where every im- 
portant fact in regard to each patient must be recorded 
for future reference. Years after a soldier's death or dis- 
charge from hospital his relatives may make claims 
against the Government, which may be grossly false on 
one hand, or deserving in the highest degree, and nothing 
except the most accurate hospital records will permit of 
justice being done. Thus it happens that the nurse is com- 
pelled to carryout the spirit of all those exacting detailed 
reports that are usually denominated " Red-tape." 
Exaggeration of Symptoms.-There is a most important 
fact to be kept in mind by military nurses. In civil life 
where a man's pay depends upon the amount of work he 
does, and where he receives no pay if he is laid up by sick- 
ness, he is not apt to stop work for any trifling sickness. 
He goes on with his work willingly and cheerfully, even 
if he is slightly " under the weather," or suffering from 
slight injury. He knows that the matter is entirely in 
his own hands, and that no one can compel him to work. 
Laborers, therefore, become accustomed to working un- 
der difficulties, and it is astonishing sometimes to find 
under what disabilities they will go to their daily work. 
It is entirely different in military life, where every sol- 
dier knows that if he is able he must do his duty, whether 
he wants to or not. It would be a terrible state of affairs 
if, just before a battle, one-half of the soldiers would say 
that they are not feeling very well, and they guess they 
will lay off for a day or two. They must be excused by 
competent authority, and it must be made plain that they 
are not fit to work before they can be excused. The 
best soldiers never ask to be released from duty for any 
slight ailment, but there are a large number who feel 
very much aggrieved if they think they are working 
when they would " lay off " if they were their own mas- 
ters in civil life. Under such circumstances it is human 
nature for a soldier to exaggerate his sufferings. It is 
not malingering, of which more will be said later, but is 
a natural and involuntary attempt on his part to make it 
clear to the surgeon that the ailment is enough to neces- 
sitate the man's name being placed on the sick report. 
Men who would not stoop to the meanness of malinger- 
ing, and who would scorn a lie, will thus unconsciously 
deceive the surgeon as to the extent of their illness. 
A man often thinks so much of his troubles that he 
thoroughly believes he is sicker than he really is. Now 
a man cannot always think of his troubles, and after he 
is comfortably fixed in the ward and excused from duty, 
and his mind is occupied with other things he cheers up 
if depressed, forgets his imagined pains, and shows by 
all his conduct that he is not very ill. If the nurse 
observes this man's actions in the ward he is able to give 
the surgeon accurate and reliable information that would 
be a great aid in determining the proper treatment. 
Without this aid the surgeon is apt to treat the man as 
more ill than he really is, and, by greater restrictions than 
are needed, he might be giving the patient unnecessary 
confinement and unnecessarily harsh treatment. It must 
be kept strictly in mind that it is not intentional on the 
part of the soldier to appear more ill than he is ; and that 
he is an hohorable man who wants to do his duty if he can. 
By keeping these thoughts in mind the nurse is not apt 
to do him an injustice. As soon as the surgeon finds out 
the true state of affairs he can give the proper treatment 
and return the soldier to duty sooner than he otherwise 
would do. This course will save trouble and be far 
pleasanter to the soldier, who becomes satisfied he is bet- 
ter, and he returns to duty willingly in a very short time. 
This course is not only just to soldiers who suffer from 
slight ailments like all other human beings, but it is also 
just to the Government, because the man's labor is 
saved. 
It must not be thought that the surgeon excuses a man 
only in cases of sickness that causes a civilian to stop 
work, for this is not so. For instance, a man with a bad 
sore throat may go to his work and get well, but a soldier 
in the same illness could not stand guard with the ther- 
mometer forty degrees below zero. So that men are 
often in hospital with trifling ailments that would get 
worse under the exposures to which they might be sub- 
jected. 
Malingering.-By watching the symptoms of a case 
the nurse can often detect those mean men who deliber- 
ately state they are ill in order to escape duties which 
they are perfectly willing that their comrades should do 
for them. It is to the great credit of the American sol- 
dier that these cases of deliberate malingering are very 
rare, but now and then they do occur among the twenty- 
five thousand soldiers of our army. A malingerer oc- 
cupies the valuable time of the surgeon, causes much 
unnecessary worry in trying to find out what is the real 
disease, causes a loss of valuable drugs and extra diet in 
the treatment, puts much unnecessary work on the nurses, 
and, if he goes undetected, causes better men of the com- 
pany or troop to do extra guard or fatigue duty. It is 
only just to the good soldiers who are working extra that 
a malingerer should be detected and punished, and it is 
often due to an accurate, reliable, and just report from 
the nurse in charge that such detection is made possible. 
In peace, soldiers very rarely try to keep themselves 
ill so as to escape duty. In war, so many men are be- 
ing killed that a soldier is apt to welcome illness or in- 
jury that will enable him to get to a place of safety, and 
then go home, and possibly get his discharge. Hence it 
happens that occasionally a soldier may deliberately keep 
himself ill and refuse to take his proper treatment. 
To overcome this, it is customary to try such cases by 
court-martial. It may have to be shown to the court 
that the treatment was necessary to bring about a cure. 
Such trials are scarcely ever necessary in peace. In all 
cases the nurse may be an important witness to occur- 
rences in the ward. 
Administering Remedies.-In administering remedies 
there are usually no new directions for the nurse to ob- 
serve, beyond the necessity for watching the patient to 
see that he actually takes the medicine that is ordered. 
Soldiers who come into the hospital for trivial complaints 
for the purpose of escaping duty, have an old, w'orn-out 
trick of pretending to take their medicines, when in fact 
they do not. They must be watched by the nurse. 
As a rule, the stay of a soldier in hospital is made as 
pleasant as possible if he is ill. This is done in order 
to put nothing at all in the way of soldiers coming freely 
to the hospital for treatment as soon as they are taken 
sick. By such means it is possible to ward off serious 
illness, for it is highly probable that civilians who can- 
not easily stop work often suffer from serious com- 
plaints that could have been prevented by prompt treat- 
ment in the beginning. The old idea that the military 
647 Military Nursing. 
Military Nursing. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
hospital should be made disagreeable and dismal to dis- 
courage malingering is brutal and not in accordance with 
modern methods. Nevertheless, in rare cases, just as in 
civil hospitals, disagreeable methods of treatment are re- 
sorted to, in the attempt to find out if there is malinger- 
ing. In such cases bitter and disagreeable medicines 
may be ordered, and the nurse must exercise great care 
to see that the proper doses are actually taken. In all 
cases he is to be on the lookout for the standard tricks, 
and he must make it a habit to see that each dose of med- 
icine is taken exactly as ordered. 
Military hospitals are not furnished with all the mod- 
ern conveniences for making medicines palatable, and the 
nurse must resort to various methods for overcoming 
bad tastes and odors. In the fjpld there may be no facili- 
ties at all for fancy pharmacy. Pills may be covered 
with tissue-paper, powders mixed with sugar or clean 
drinking-water, citric acid lemonade be on hand for use 
after taking medicines, and various expedients resorted 
to as occasion arises. In the future no difficulty may be 
experienced, as the new field outfit contains medicines in 
tablet form ready for use. 
4. Nursing in the Field. 
Geneva Convention.-Away back before the Crimean 
War there was started a crusade against the prevailing style 
of nurses. Before this time it was considered that such 
work must be relegated to widows and worn-out women 
who had partly failed in the struggle for existence. In- 
deed, the more ignorant and cruel the woman, the more 
apt was she to take up nursing in her decline. Perhaps 
Charles Dickens may have done much to start the reform 
against the Mrs. Gamps and Mrs. Prigs, by describing 
with such honesty their habits and ability. In the 
midst of this reform the Crimean War broke out, and to 
England was brought those horrible tales of the suffer- 
ings of the sick and wounded soldiers, from privations 
and poor nursing. That great woman, Florence Night- 
ingale, who was then in the midst of the work of the 
great nursing reform, was sent to the Crimea and took 
charge of the hospitals. Her experiences in that war 
were written up, and the agitation resulting bore fruit in 
the Geneva Convention of 1864. This congress, com- 
posed of representatives from most of the civilized nations 
of the world, agreed to certain articles for the ameliora- 
tion of the wounded in armies in the field. They were 
not concurred in by the United States until 1882, and even 
then with reserve as to the additional articles of 1868. The 
Convention is given in full below. 
Original Convention.-Article 1. Ambulances and mili- 
tary hospitals shall be acknowledged to be neuter, and 
as such shall be protected and respected by belligerents 
so long as any sick or wounded may be therein. 
Such neutrality shall cease if the ambulances or hos- 
pitals should be held by a military force. 
Art. 2. Persons employed in hospitals and ambulances, 
comprising the staff for superintendence, medical service, 
administration, transport of wounded, as well as chap- 
lains, shall participate in the benefit of neutrality, while 
so employed, and so long as there remain any wounded 
to bring in or to succor. 
Art. 3. The persons designated in the preceding article 
may, even after occupation by the enemy, continue to 
fulfil their duties in the hospital or ambulance which 
they serve, or may withdraw in order to rejoin the corps 
to which they belong. 
Under such circumstances, when these persons shall 
cease from their functions, they shall be delivered by the 
occupying army to the outposts of the enemy. 
Art. 4. As the equipment of military hospitals remains 
subject to the laws of war, persons attached to such hos- 
pitals cannot, in withdrawing, carry away any articles 
but such as are their private property. 
Under the same circumstances an ambulance shall, on 
the contrary, retain its equipment. 
Art-. 5. Inhabitants of the country who may bring help 
to the wounded shall be respected and shall remain free. 
The generals of the belligerent powers shall make it 
their care to inform the inhabitants of the appeal ad- 
dressed to their humanity, and of the neutrality which 
will be the consequence of it. * 
Any wounded man entertained and taken care of in a 
house shall be considered as a protection thereto. Any 
inhabitant who shall have entertained wounded men in 
his house, shall be exempted from the quartering of 
troops, as well as from a part of the contributions of war 
which may be imposed. 
Art. 6. Wounded or sick soldiers shall be entertained 
and taken care of, to whatever nation they may belong. 
Commanders-in-chief shall have the power to deliver 
immediately to the outposts of the enemy soldiers who 
have been wounded in an engagement, when circum- 
stances permit this to be done, and with the consent of 
both parties. 
. Those who are recognized, after their wounds are 
healed, as incapable of serving, shall be sent back to 
their country. 
The others may also be sent back, on condition of not 
again bearing arms during the continuance of the war. 
Evacuations, together with the persons under whose 
direction they take place, shall be protected by an ab- 
solute neutrality. 
Art. 7. A distinctive and uniform flag shall be adopted 
for hospitals, ambulances, and evacuations. It must on 
every occasion be accompanied by the national flag. 
An arm-badge (brassard) shall also be allowed for indi- 
viduals neutralized, but the delivery thereof shall be left 
to military authority. The flag and the arm-badge shall 
bear a red cross on a white ground. 
Art. 8. The details of execution of the present Conven- 
tion shall be regulated by the commanders-in-chief of 
belligerent armies, according to the instructions of their 
respective governments, and in conformity with the gen- 
eral principles laid down in this Convention, 
Additional Articles.-Art. 1. The persons designated 
in Article 2 of the Convention shall, after the occupation 
by the enemy, continue to fulfil their duties, according to 
their wants, to the sick and wounded in the ambulance 
or the hospital which they serve. When they request to 
withdraw, the commander of the occupying troops shall 
fix the time of departure, which he shall only be allowed 
to delay for a short time in case of military necessity. 
Art. 2. Arrangements will have to be made by the bel- 
ligerent powers to insure to the neutralized persons, 
fallen into the hands of the army of the enemy, the en- 
tire enjoyment of his salary. 
Art. 3. Under the conditions provided for in Articles 
1 and 4 of the Convention, the name ' ' ambulance " ap- 
plies to field hospitals and other temporary establish- 
ments which follow the troops on the field of battle to 
receive the sick and wounded. 
Art. 4. In conformity with the spirit of Article 5 of 
the Convention, and to the reservations contained in the 
protocol of 1864, it is explained that for the appointment 
of the charges relative to the quartering of troops and of 
the contributions of war, account only shall be taken in 
an equitable manner of the charitable zeal displayed by 
the inhabitants. 
Art. 5. In addition to Article 6 of the Convention, it is 
stipulated that with the reservation of officers whose de- 
tention might be important to the fate of arms, and with- 
in the limits fixed by the second paragraph of that 
Article, the wounded fallen into the hands of the enemy 
shall be sent back to their country after they are cured, 
or sooner if possible, on condition, nevertheless, of not 
again bearing arms during the continuance of the war. 
There are ten other articles, concerning the marine. 
It is evident, therefore, that in the field, in civilized 
war, the military nurse is placed upon a very different 
footing than formerly. He is a privileged character be- 
cause he is engaged in the work of humanity, and to 
proclaim his privilege he wears on his left arm the badge 
of his calling-the Geneva Cross-a red cross in a white 
field. When so employed, and so distinguished by his 
badge, he becomes neutral, notwithstanding his nation- 
ality, and he cannot become a prisoner of war. When his 
648 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Military Nursing, 
Military Nursing, 
work of bringing in or succoring the wounded is finished 
he must be sent back to his own army as soon as possi- 
ble, unless he choose tp remain and work among the 
wounded. In warfare with a civilized nation that has 
not agreed to the Geneva Convention, it plays no recog- 
nized part whatever, though its principles may be carried 
out by both sides on the general grounds of humanity. 
In war against savage people the humane principles of 
the Convention will be disregarded, and a nurse is apt 
to be killed in the very act of relieving the suffering. 
The hospital flag may be as much riddled with bullets 
as any other, and the very existence of medical help 
seems to be unknown to the savage. Thus it happens 
that as almost all the active operations of the United 
States army are against savages, the military nurse re- 
ceives no benefit whatever from the Geneva Conven- 
tion, and its provisions may not be taken into considera- 
tion at all. 
On the March.-On the march the hospital corps de- 
tachment follows the regiment or brigade ambulances, 
the privates of the hospital corps being mounted. This 
is necessary to preserve their strength as much as possi- 
ble, because their work begins at the end of the day's 
march, when the soldiers of the line can rest. Those 
that are not mounted are allowed to ride on ambulances 
or other wagons. The duties on the march are to look 
after the comfort of the sick that are being transported 
from camp to camp, give them their required medicines, 
prepare for them such food as may be practicable en 
route or on the short halts. On long, hot marches sol- 
diers are apt to become exhausted and fall out of ranks 
to wait for the ambulances and the surgeon to come up. 
When such cases are met with the nurse secures their 
arms and accoutrements, places these in the ambulance, 
and then finds a seat for the patient and administers the 
remedies that have been prescribed. Cases of exhaus- 
tion are apt to be frequent when the campaign is pro- 
ceeding under the difficulties of deficient and improper 
food and clothing, or the troops have been exposed to 
the severity of the weather. It can be assumed that in 
such circumstances the nurse may have much to do un- 
der great disadvantages. 
In Camp.-On arriving at the end of the day's march 
the nurses all assist in making fires, preparing some light 
food for the sick, and making the latter comfortable in 
shady places, and attending to the usual routine duties 
of nurses. By the time this is finished the wagons with 
tents and rations have arrived ; all hands must turn to 
and unload them as quickly as possible. The cooks 
secure the rations and start the preparations for the prin- 
cipal meal at once. All others erect the tents, prepare the 
cots or bunks for the sick, and carry the sick into the 
tents. This temporary field hospital is thus established, 
and can be placed in running order within a few minutes 
after the arrival of the wagons, and from this time on 
until the next day the duties of the nurse are essentially 
the same as in any permanent hospital. 
There are so many things to be improvised in camp 
that it is almost useless to expect efficiency from the 
nurse unless he has had considerable experience as a 
camper-out, and has had much instruction besides. In 
the absence of bunks or cots he must know how to make 
a soft, comfortable bed of leaves or brush. He must 
know how to arrange the men in the tents so as to econ- 
omize floor space. He must be thoroughly conversant 
with the methods of pitching tents, excluding draughts 
of air from patients, excluding rain, erecting and caring 
for the stoves in cold weather, and the thousand and one 
little details of camp life that altogether will turn a 
primitive way of living into one of great comfort. In 
the early morning, if camp is broken, some patients may 
have to be sent back as unfitted to proceed with the com- 
mand. These must be prepared by the nurses, placed 
in the wagons with their accoutrements, and, if no nurse 
is to accompany them, they are to be given their medi- 
cines with instructions how to take them. The nurse is 
to do everything possible to make these men comfortable 
until they reach other hands. While this is being done 
the other patients that are to go forward are placed in 
(SUPPLEMENT.) 
the ambulances, and the tents are struck and everything 
loaded on the wagons and the march is begun. 
In more permanent camps the nurses must be expected 
to devise conveniences for the sick. To go into this mat- 
ter would only be to write an article on camping, which 
is not the intention here. It is sufficient to remark that 
in the months that might elapse before the camp is 
changed the nurses are continually making the field hos- 
pital nearer and nearer a permanent hospital of very 
rude construction. A nurse is expected to be handy 
with carpenter's tools, and ingenious enough to design 
from rough lumber and packing boxes all the little ap- 
pliances used in nursing. By a little ingenuity it is pos- 
sible with the materials in camp to give efficient vapor- 
baths for the relief of spasmodic retention of urine, to 
make various forms of counter-irritation with hot water 
and hot stones, to practise the method of firing, to make 
poultices, and to perform numerous operations usually 
deemed to require special apparatus. 
Battle.- When battle is expected the nurses are particu- 
larly busy in assisting to send the sick to the rear, and 
in getting everything ready for the work that is to come. 
Large quantities of fresh water are brought to hand, and as 
much water boiled as possible. The antiseptic solutions 
for irrigation are gotten ready, instruments and dressings 
brought out and prepared ; indeed it is the whole rou- 
tine of preparing for operation in a permanent hospital. 
It is a time of great excitement and hurry, and unless the 
nurses are well drilled and instructed there is apt to be 
abominable confusion. When the wounded are brought 
in, the nurse's duties are exactly as in permanent hospitals. 
The arrangements made for succoring the wounded on 
the battle-field have been fully described in former 
articles in this work. Nurses detailed for duty at dress- 
ing, collecting, or ambulance stations have no new duties 
to perform that are not already described. Between 
these stations and the fighting line is an area where 
nursing ceases, and the privates are concerned in bring- 
ing in the wounded on stretchers, travois, etc., and in 
rendering first aid in the way of stopping haemorrhage, 
reviving men from collapse, carrying water to the 
wounded, and all the other attentions to them that need 
not be detailed here. 
In the rapid dusty marches previous to a battle there 
is no chance for cleanliness, and the soldiers become ex- 
ceedingly dirty, as already explained. The wounds there- 
fore are extremely apt to be infected, and the hurry, 
overcrowding, and lack of proper care, always make mat- 
ters far worse. Thus it happens that wounds begin to 
suppurate or become gangrenous where they should heal 
kindly. This state of affairs is always seen in wars, and, 
as one of the means taken to prevent it, the nurses will 
be instructed to take the most particular pains to render 
everything aseptic and to be as cleanly as circumstances 
will permit. 
In advances or retreats the nurse will be ordered to 
new fields of duty by his commanding officer, and in his 
work of humanity he will find himself greatly assisted by 
the provisions of the Geneva Convention which now 
come into play. From all the foregoing it can be assumed 
that the proper instruction of the nurse in field duties is 
to include all things that can be done for the sick, so that 
the wishes of the surgeon can be anticipated. By these 
means the corps of nurses will make it possible for a few 
surgeons to give medical and surgical care to a very 
large number of patients in such busy times as accom- 
pany and follow battles. 
The future is to see a very great change for the better 
in the treatment and nursing of the wounded in the field. 
The advantage now taken by the concentrated medicines, 
extracts, compressed tablets, compact dressings, and intel- 
ligent methods of packing these in convenient shape has 
resulted in the magnificent new field equipment of the 
United States Army Medical Department. These are 
fully described in the last report (1892) of the Surgeon- 
General, and for convenience and efficiency this equipment 
is described as being in advance of that of any army in 
the world. 
Going hand in hand with the advances in new medical 
649 Military Nursing. 
Military Recruit. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
and surgical preparations is another advance, that of the 
preparation of food. This concerns us most here, as it is 
more intimately associated with the nursing of soldiers 
in the field. Ever since the most ancient times military 
men have been experimenting with the concentration 
and preservation of food for armies in the field. The re- 
sults have not been of much service to the surgeon, as he 
could not utilize them to any great extent in the treat- 
ment of the sick. Recent years have seen the successful 
manufacture of a host of foods for invalids, and from 
these the soldier in future wars will derive incalculable 
benefit. It has been described above how soldiers are 
taken ill on the march, how they become exhausted 
and have to fall out, to be picked up by the ambulances. 
The great point in the treatment and nursing of these 
men is to give them rest, stimulants, and nourishment. 
The latter has always been lacking. In the future the 
ambulance will be fully equipped with some of the 
myriads of prepared foods now in the market. A cup of 
water will be heated on an oil or alcohol stove, and in 
a few minutes a cup of the most nourishing and stimulat- 
ing soup can be prepared for the exhausted soldier. No 
doubt by such means it will be possible to restore to the 
fighting force numbers of men that in the past were sent 
to the rear or allowed to die in the roads. As soon as 
camp is reached the sick in the ambulances will be fed. 
This rest and nourishment will allow them to recuperate 
for the next day's work. 
Again, it is known that for many hours, or perhaps days, 
the wounded on the battle-field may lie where they fall, 
and a large percentage of them die of exhaustion. Nurses 
and attendants will be enabled with these prepared foods 
to save a large number of such unfortunates. The nurse 
will therefore be instructed in the preparation and use 
of the foods that will be carried along with the ambu- 
lances, medicine wagons, or special ration wagons. Beef- 
extracts and prepared soups will, of course, be the main 
articles, but advantage will accrue also from the digested 
foods prepared for invalids, and indeed also from that 
immense list of specially prepared and concentrated vege- 
tables and fruits for exceptional cases. 
Chas. E. Woodruff. 
MILITARY RECRUIT, PHYSICAL CHARACTERIS- 
TICS OF THE. The teaching in physical culture, and 
the encouragement that has been given to it by the vari- 
ous civil institutions of learning throughout this country 
and at the United States Naval Academy at Annapolis, 
Md., have, during late years, attracted much attention 
among army people, and have resulted in a revision, in cer- 
tain particulars, of the standard of physical requirements 
for the admission of officers and enlisted men to the 
army, and of cadets to the Military Academy at West 
Point, N. Y. 
The lax methods of examination that have heretofore 
been tolerated led to the acceptance of men with de- 
fects that were either latent or concealed, which, devel- 
oped by incidents of the service, resulted in an early 
breaking down and consequent retirement of many offi- 
cers, and to numerous discharges on disability certificates 
of enlisted men from the service. The remedy seemed 
apparent in the exercise of greater care when inquiring 
into the moral and physical qualifications of all classes of 
men, and in giving more explicit directions for the 
guidance of examiners in their work ; to this end the 
recruiting regulations have been modified, the require- 
ments for admission to the Military Academy at West 
Point have been more clearly set forth, and laws have been 
enacted by Congress providing for careful examinations 
into the physical condition of applicants from civil life 
for commissions in the army, and for similar examina- 
tions prior to the promotion of officers from one degree 
of rank to another. Many of the visual and aural defects 
that modern science has brought to light and defined are 
now officially declared as disqualifications, and tables of 
proportion, showing the relations which should exist be- 
tween height, weight, and chest measurement and mo- 
bility in the normal man, are published as aids to the 
recruiting officer. 
(SUPPLEMENT.) 
These several improvements in method are briefly out- 
lined under the following headings : 
The Legal Requirements eor Enlistment.-Any 
male person above the age of sixteen and under the age 
of thirty years, effective, able-bodied, and free from dis- 
ease, of good character, who does not appear to be of in- 
temperate habits, and who has a competent knowledge 
of the English language, may be enlisted, due attention 
being given to the restrictions in this article concerning 
minors. This regulation, in so far as it relates to age, 
does not apply to soldiers who may re-enlist, nor to those 
who have served honestly and faithfully a previous en- 
listment in the army. Applicants for enlistment are 
required to furnish such evidence of good character 
as they can obtain. With a view to determine their fit- 
ness and aptitude for the service, and to give them an 
opportunity to secure testimonials, as well as for the in- 
quiry and deliberation contemplated by the Second Ar- 
ticle of War, they may be retained and provided for at 
rendezvous, for a period not to exceed six days, after 
having signed the declaration of intention to enlist and 
passed the medical examination. Men so retained are 
known as recruits on probation. The enlistment papers of 
any such recruit who may be unfit or undesirable for the 
service, or who may not desire to remain in the service 
will not be completed. The enlistment papers of recruits 
who are accepted and duly sworn will bear the date on 
which the enlistment is completed by administering the 
oath (A. R., Art. LXXL, 908). . . . The Major- 
General commanding the army is of opinion that if sat- 
isfactory evidence of good character, habits, and condi- 
tion cannot be furnished by the recruit, or be otherwise 
obtained, the presumption should be against him and he 
should not be accepted ; and, further, that these views are 
concurred in by the Secretary of War and should govern 
in all cases (G. O., No. 1, Head-quarters Recruiting Ser- 
vice, 1890). 
These rules and articles shall be read to every enlisted 
man at the time of, or within six days after, his enlist- 
ment, and he shall thereupon take an oath or affirma- 
tion in the following form : " I, A. B., do solemnly 
swear (or affirm) that I will bear true faith and alle- 
giance to the United States of America ; that I will serve 
them honestly and faithfully against all their enemies 
whomsoever, and that I will obey the orders of the Presi- 
dent of the United States and the orders of the officers 
appointed over me, according to the Rulesand Articles of 
War." This oath may be taken before any commissioned 
officer of the army (Article of War). 
Every officer who knowingly enlists or musters into 
the military service any minor over the age of sixteen 
years without the written consent of his parents or 
guardians, or any minor under the age of sixteen, or 
any insane or intoxicated persons, or any deserter from 
the military or naval service of the United States, or any 
person who has been convicted of any infamous criminal 
offence shall, upon conviction, be dismissed from the ser- 
vice, or suffer such other punishment as a court-martial 
may direct (Article of War). 
Under a recent Act of Congress fraudulent enlistment 
is declared a military offence, and is punishable by court- 
martial under the Sixty-second Article of War ; the pro- 
visions of this law are fully explained to every applicant 
presenting himself for enlistment with the information 
that any person procuring his enlistment on or after the 
25th day of September, 1892, by false representations or 
other fraudulent means, will render himself liable to trial 
and punishment by court-martial. '"Fraudulent en- 
listment" is defined by the law officers of the depart- 
ment as " an enlistment procured by means of a wilful 
misrepresentation in regard to a qualification or dis- 
qualification for enlistment, or by an intentional conceal- 
ment of a disqualification which had the effect of causing 
the enlistment of a man not qualified to be a soldier, and 
who but for such false representation or concealment 
would have been rejected." 
The regulations above quoted sketch in outline the 
requirements for admission to the enlisted branch of the 
military service and the duties of officers in connection 
650 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Military Nursing, 
Military Recruit. 
therewith. For the recruiting officer an essential to suc- 
cess is a knowledge of men and their character, and for 
the medical officer a painstaking application of profes- 
sional skill. The duty is a most important one, and in its 
faithful and thorough performance these officers share a 
grave responsibility. The influence of their judgment 
and discretion is felt throughout the entire military 
establishment, the efficiency of which depends in great 
measure upon the sound mental and physical condition 
and the intelligence of its enlisted force. From the 
varied classes and conditions of men presenting them- 
selves for enlistment they are to eliminate not only those 
who are defective physically and mentally, but those who 
are defective morally, and if this duty be performed care- 
lessly or indifferently, men will be admitted to the ser- 
vice with defects which will soon render them unfit for 
duty, or with moral obliquities that will induce malin- 
gering and desertion. Although the result of such per- 
functory performance of duty may come to light during 
the probationary service of a recruit at a depot, it will 
certainly be shown in the company, from which his 
eventual discharge cannot fail to bring deserved censure 
upon the officers concerned in his enlistment. 
Re-enlistments.-Soldiers who are unable to pass 
the required examination in all respects will not be re-en- 
listed without special authority from the Adjutant-Gen- 
eral's Office, and then only for their former commands ; 
application for such authority should be recommended 
only when it is shown that any existing defects will not 
prevent the full discharge of duty as a soldier, and that a 
continuance in service will be a positive benefit to the 
army. 
Soldiers discharged as privates upon expiration of term 
of service and failing to re-enlist within one month, will 
not be again enlisted after they have passed the age of 
thirty-five years, unless for some good reason in the inter- 
est of the public service, and then only for their former 
commands upon special authority from the Adjutant- 
General's Office. 
This limitation as to age will not apply to a soldier 
discharged as a non-commissioned officer with excellent 
character, and desiring to again enlist for assignment to 
a former command (not already full), either at the station 
thereof, or at a recruiting depot, provided he passes the 
required examination and furnishes satisfactory evidence 
in regard to character and habits since discharge. 
Soldiers who have been discharged with good charac- 
ter under the provisions of law may be again enlisted 
without special authority after a period of two months 
from date of discharge, upon passing the required ex- 
amination and furnishing satisfactory evidence in regard 
to character and habits since discharge, provided such 
enlistment is not barred by any of the above provisions. 
Soldiers discharged before expiration of term of service 
for any other cause will not be again enlisted without 
special authority from the Adjutant-General's Office. 
These restrictions, which are intended more particu- 
larly to govern re-enlistments for the line of the Army, 
need not necessarily be applied to the Hospital Corps ; 
the approval of the Surgeon-General will be sufficient 
warrant for the re-enlistment of soldiers into that corps. 
Height, Weight, and Chest Measurements.- 
" The minimum height of a recruit is at present fixed at 
five feet four inches for all branches of the service, al- 
though recruiting officers are allowed to exercise their 
discretion as to the enlistment of desirable recruits (such 
as band-musicians, school-teachers, tailors, etc.) who may 
fall not more than one-fourth of an inch below the mini- 
mum standard of height; the maximum height for the 
cavalry service is five feet ten inches ; that for infantry 
and artillery is governed by the maximum of weight, 
to which should be applied the rule for proportion in 
height." 
" The minimum weight for all recruits is 128 pounds, 
except for the cavalry, in which enlistments may be made 
without regard to a minimum of weight, provided the 
chest measurement and chest mobility are satisfactory. 
The maximum for infantry and artillery is 190 pounds ; 
for cavalry and light artillery, 165 pounds." 
The standards of height and weight are, however, sub- 
ject to change, instructions to that effect being issued 
from the Adjutant-General's Office " from time to time 
as the requirements of the service may dictate." 
These standards are based upon results obtained by 
skilled observers who, after careful study and the ex- 
amination of large numbers of men in civil and military 
life, have established the fact that there is an average 
proportion in healthy, fully developed men between the 
height, weight, chest measurement, and chest mobility 
which will admit of slight variations without indicating 
a departure from health. The rules of this proportion 
may be formulated as follows : 
For each inch of height from 5 feet 4 inches to 5 feet 7 
inches, inclusive, there should be calculated 2 pounds of 
weight. When the height exceeds 5 feet 7 inches, calcu- 
late 2 pounds of weight for thewAoZe number of inches of 
height; add to this product 5 pounds of weight for each 
inch of difference between 5 feet 7 inches and the actual 
height ; the sum will be the normal weight in pounds. 
The chest measurement at expiration in men from 5 feet 
4 inches to 5 feet 7 inches in height should exceed the 
half height about half an inch ; in those from 5 feet 8 
inches to 5 feet 10 inches it should equal the half height, 
while in those from 5 feet 11 inches upward it should be 
slightly less than the half height. 
The chest mobility-i.e., the difference between the meas- 
urement at inspiration and expiration-should be at least 
2 inches in men below 5 feet 7 inches in height, and 2| 
inches in those above that height. 
The following table shows this concisely : 
Height. 
Weight. 
Allow for each 
inch of height: 
Chest measure- 
ment. 
Chest 
mobility. 
5 feet 4 to 5 feet 7 
inches. 
5 feet 8 to 5 feet 10 
inches. 
5 feet 11 to 
2 lbs . 
Half height plus 
half inch. 
Half height 
2 inches. 
2}^ inches. 
2% inches. 
f2 lbs., and 5) 
| lbs. addition- | 
■{ al for each 
| inch over 5 | 
[ feet 7 inches. J 
Slightly less than 
half height. 
For example, a man who measures 5 feet 4 inches 
should weigh 128 pounds-i.e., 5 feet 4 inches = 64 
inches ; 64 x 2 = 128, the normal weight. He should 
have a chest measurement of 324 inches at expiration, 
being half height; 32 inches plus 4 inch = 324; the chest 
mobility should be about 2 inches. 
A man who measures 5 feet 9 inches should weigh 148 
pounds-i.e., 5 feet 9 inches = 69 inches ; 69 x 2 = 138 ; 
difference between 5 feet 9 inches and 5 feet 7 inches is 
2 ; 2 x 5 = 10 ; 138 + 10 - 148, the normal weight in 
pounds. He should have a chest measurement of 344 
inches (his half height), and a chest mobility of at least 2j 
inches. 
It is not necessary that the applicant should conform 
exactly to the figures indicated in the rules, a variation of 
a few pounds from either side of the standard in the mini- 
mum, medium, and maximum weights, and of a fraction 
of an inch in chest measures being permissible if the ap- 
plicant is otherwise in good health and desirable as a re- 
cruit. The rules are given to show what is regarded as 
a fair proportion, but the weight must be at least 125pounds, 
except when less is especially authorized by the superin- 
tendent or the Adjutant-General. 
In such cases the recruiting officer's reasons and the 
superintendent's order should be noted in full on the en- 
listment papers. Any considerable disproportion, how- 
ever, of height over weight is cause for rejection ; but a 
marked disproportion of weight over height does not reject 
unless the applicant is positively obese. 
In order that an intelligent application of these rules 
and their variations may be made, the attention of re- 
cruiting officers is called to the manner in which a man's 
height is made up. 
The chest, containing the heart and lungs, is the most 
important division of the body. It contains the vital 
651 Military Itecruit. 
Monte Carlo. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
machinery and represents the staying power of the man. 
It must, therefore, be ample. The function of the legs 
is to transport the body ; they should be well formed and 
sufficient, but not unduly long, for length of limb at the 
expense of the chest is a disadvantage. A long-legged, 
long-necked man with a short chest is objectionable as a 
recruit. 
The average height of a youth of eighteen years of age, 
a " growing lad," is a little over 5 feet 4 inches, and in- 
creases gradually until he reaches the age of twenty-five 
years-the stage of physical maturity or manhood-when 
his average height is between 5 feet 7 inches and 5 feet 8 
inches. 
During the growing period the frame-work and vital 
organs receive their proper development, and consider- 
able departures from the given average of proportionate 
height to weight indicate an impairment of these organs 
which may, and probably will, develop into positive dis- 
ease after exposure to the hardships incident to the life 
of a soldier ; hence they are of greater significance in men 
of these heights than in taller men, who are presumably 
of greater age and more mature growth. 
After twenty-five years of age, the body being fully 
developed, the excess of nutritive material over and above 
that required for its maintenance in health is deposited in 
the tissues as fat, and it will be found that a dispropor- 
tion of weight over height occurs usually in adults or 
men in middle life. It is rare to meet in the recruiting 
rendezvous with very fleshy young men. 
The following table is given for convenience of re- 
ference : 
(SUPPLEMENT.) 
Rule.-For each inch of height, from 5 feet to 5 feet 
7 inches, calculate 1,85 pound of weight : above 5 feet 
7 inches, add to this standard 5 pounds for each inch of 
height; minimum chest measurement at expiration, from 
5 feet to 5 feet 7 inches, half the height plus half an inch ; 
from 5 feet 7 inches to 5 feet 10 inches, half the height; 
from 5 feet 10 inches upward, slightly less than half the 
height; minimum chest mobility, 2 inches. In excep- 
tional cases a minimum weight of 105 pounds may be 
accepted. 
Under recent regulations the examinations are held at 
the military post nearest the residence of the candidate, 
and simultaneously with the mental examination. 
Medical officers are instructed to record in each case, 
whether of acceptance or rejection, the results of their 
examinations on a form of which the following is a copy : 
To be sent to the Surgeon-General, United States Army. 
Form for the Physical Examination of a Cadet Candidate for 
Admission to the U. S. Military Academy, West Point, N. Y. 
This examination is to be made before the candidate is strippt d. 
Name ; birthplace; residence. 
Nationality of father ; of mother. If either or both parents, or broth- 
er or sister have died, state the cause. 
Do you drink intoxicating liquors, and, if so. to what extent ? Do you 
use tobacco, and, if so, in what form and to what extent? 
What diseases or injury have yon had. if any ? 
Vision : Right eye ; left eye. Color perception. 
Hearing : Right ear ; left ear. 
This examination is to be made after the candidate is stripped. 
Physique. 
Age. 
Height. 
Weight. 
Chest measurement. 
Years. 
Months. 
Feet. 
Inches. 
Pounds. 
Expiration. 
Inspiration. 
inches 
inches 
Table of Physical Proportions for Height, Weight, and 
Chest Measurement. 
Height. 
Weight. 
Chest Measurement. 
Feet. 
Inches. 
Pounds. 
At expiration: 
inches. 
Mobility : 
inches. 
54/u 
64 
128 
32% 
2 
5% 2 
65 
130 
33 
2 
5% 2 
66 
132 
33% 
2 
67 
134 
34 
2 
58/i2 
68 
141 
34 
2% 
59A2 
69 
148 
34% 
2% 
5*% 2 
70 
155 
35 
2% 
5H/12 
71 
162 
35% 
2% 
f> 
72 
169 
35% 
2% 
6Via 
73 
176 
36% 
2% 
Nutrition and Diathesis.-Note anything unfavorable in the general 
appearance, such as sickly aspect or unduly full habit. 
Integumentary System.-Note any skin eruptions, sores, or ulcers. 
Any tendency to catarrhs ? 
Nervous System and Organs of Sense.-Note any loss of faculties or 
other present derangement of function or any suspicion of serious lesion. 
Respiratory System.-Note any hoarseness, cough, or other present 
derangement of function, or any abnormity discoverable by auscultation 
or percussion. 
Vascular System.-Note rate and quality of pulse. [If excited, re- 
examine till you assure yourself of the normal rate.] Any intermit- 
tence or irregularity, or undue strength or weakness of heart-action ? 
Any abnormity discoverable by auscultation or percussion ? Any hae- 
morrhoids, varicocele, or varicose veins? 
Digestive System.-Note any present derangement of function, any 
enlargement of liver or spleen, or suspicion of organic disease of any of 
the abdominal organs. 
Remarks. 
certify that have personally examined the above-named candi- 
date, and, finding him physically qualified for the military service, 
(accept, reject) him. 
Surgeon, U. S. Army. 
. Surgeon, U. S. Army. 
Dated at , this day of , 189 . 
Charles R. Greenleaf. 
MOFFAT. A watering-place in Dumfries-shire, Scot- 
land. 
Location.-Moffat is a village charmingly situated 
among the lower hills of Scotland. It has a cold, sul- 
phurous, and saline spring of small importance, but 
is popular on account of the exhilarating and bracing 
quality of its atmosphere, and its general salubrity as 
a summer resort. Mineral-water baths are much em- 
ployed, and there is a hydro-therapeutic establishment of 
modest equipment. The water contains sulphuretted hy- 
drogen and has a disagreeable taste. Fogs are said to 
be rare at Moffat, but there is plenty of rain. The place 
is patronized by the Scotch and English, and is by them 
very highly spoken of ; but it has not yet acquired an 
international reputation. Summer season only. 
Edmund C. Wendt. 
MONOBROMACETANILIDE (Antisepsine, Asepsine). 
Very soon after the therapeutic value of acetanilide 
had been recognized, this bromine compound was in- 
troduced as an anodyne, analgesic, and antiseptic. It is 
A deviation from the rules of physical proportions may 
be made in the examination of candidates for admission 
to the United States Military Academy at West Point, 
and for members of the graduating class, wdienever this 
is deemed desirable by the Medical Examining Board. 
The Ear.-Recent instructions from the War Depart- 
ment require that all men enlisted for the artillery arm 
of the service at a military post, or assigned to that arm 
from a depot, shall, before such enlistment or assignment, 
besides undergoing the ordinary examination, be ex- 
amined especially with a view to establishing the fact of 
the patency of the Eustachian tubes and the integrity of 
the tympanic membranes, in default of which the men 
are untit for that arm. 
Physical Examinations of Candidates for Ap- 
pointment as Cadets at the Military Academy at 
West Point, N. Y.-The physical examination of can- 
didates for appointment to the United States Military 
Academy will be made after the methods prescribed in 
" Greenleaf's Epitome for the Examination of Recruits, 
and as they are final for admission to the Military Academy 
special care should be given to determine the condition 
of the heart and lungs. Normal vision (|H) as determined 
by the official test types is required, and color-blindness 
rejects. The following rule for proportionate height, 
weight, and chest measurement, is substituted forthat on 
pages 26-28 of the "Epitome," but it should be under- 
stood that this rule is intended merely as a guide, from 
which deviations are permissible in the judgment of the 
medical officer: 
652 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
military Recruit 
monte Carlo. 
formed from acetanilide, CeHaNHCsHsO, by the sub- 
stitution of one atom of bromine for one of hydrogen, 
its formula being Cs^BrNHCallsO. It occurs in white 
acicular crystals, and is tasteless ; it is insoluble in water, 
slightly soluble in glycerine, and very soluble in alcohol 
and ether. 
In doses of five-sixths of a grain, four times a day, it 
lowered the temperature in phthisis, typhus, and typhoid 
fever, slowing the pulse at the same time, but not affect- 
ing the respiration. In pneumonia it was found liable 
to produce cyanosis. It was also used in neuralgia with 
success, in doses of five to eight grains. 
The employment of this compound failed to become 
general, as it was found that prostration and cyanosis 
frequently accompanied its use. Several cases have 
been reported, in which two doses of five grains, taken at 
long intervals, produced very alarming symptoms. Lips, 
cheeks, and extremities became cyanosed, pulse rapid 
and small, noises in the head, and great restlessness and 
weakness. These symptoms diminished in a few hours 
and recovery followed in all the cases. 
As an application to wounds and ulcers it is thought 
to promote healing in a remarkable manner. It also was 
used to allay the pain of haemorrhoids and anal fissure, in 
the form of suppositories. Beaumont Small. 
MONOCHLORPHENOL. A derivative of carbolic 
acid by substituting one atom of chlorine for one of hy- 
drogen ; its formula is CsELClOH. It is a very volatile 
liquid, giving off vapors which are heavier than air. 
Under the name of chlor phenol, a mixture of mono- 
chlorphenol, alcohol, eugenol, and menthol, has been 
recommended as an inhalation in phthisis and pulmo- 
nary troubles in which an antiseptic is likely to prove ser- 
viceable. Dr. Passerini, of Casate-Nuovo, Italy, who in- 
troduced it for this purpose, has used it in a number of 
cases with beneficial effects. He states that it is a power- 
ful antiseptic, free from caustic and irritant properties. 
Fifteen to thirty drops are to be placed on a pledget of 
cotton in an inhaler, and the fumes inspired ; being heav- 
ier than air they are supposed to penetrate deeply into the 
bronchioles and alveoli. In cases in the incipient stage 
of phthisis the sputa were found to diminish and lose 
their purulent character, and in two months the patients 
were apparently cured. The advantages he claims for it 
are : 1, The inhalations are easily borne in advanced 
phthisis, and they are convenient of application ; 2, no 
injurious effects arise from the continuous use of the 
drug ; 3, changes in the quantity and quality of the pus 
continue until pus and bacilli disappear, the cough di- 
minishing, the fever being reduced, the appetite and 
sleep soon returning, the weight of the body increasing 
rapidly, and local improvement being speedily attained. 
Beaumont Small. 
MONTE CARLO. This Riviera resort is one of the 
most beautiful places along the north shore of the Medi- 
terranean. It is also one of the best sheltered spots, and 
would probably be the leading health-resort of the whole 
coast if it were not for the notorious gambling palace 
erected there. Monte Carlo is part of the little princi- 
pality of Monaco, and is only nine miles in an easterly 
direction from Nice, and about six miles westward from 
Mentone. 
Although Monte Carlo is chiefly visited by the vota- 
ries of pleasure, real invalids have of late years been at- 
tracted to the place on account of its undeniable advan- 
tanges as a winter station. In connection with the insti- 
tution of public gambling, the writer will here quote 
from his report on Monaco and Monte Carlo, which ap- 
peared in the Medical Becord of July 23, 1892 : 
" My experience on the Riviera enables me to state as 
a positive fact that many more people go to Monte Carlo 
to gamble from the various resorts near it than from the 
town itself. Cannes, Nice, Mentone, and even San 
Remo, send their daily quota of gamblers there in un- 
comfortably crowded trains. And those who have no 
inclination for the silly game may just as well live 
within a stone's throw of the Casino itself as miles away. 
(SUPPLEMENT.) 
I cannot, therefore, quite agree with those who would 
warn people away from Monte Carlo merely on account 
of the gambling going on there. If they are so weak as 
to have to yield to this particular temptation, they are 
better off at home than on the Riviera. It has seemed 
to me, however, that Americans are abundantly able to 
take care of themselves wherever they may happen to 
be. It is necessary to state my views on this point, 
because I believe Monte Carlo can be made one of the 
best winter stations on the whole coast. Even now 
every possible accommodation is offered there, and the 
only criticism one can justly make on that score is that 
the hotel and restaurant rates are often exorbitant. But 
if it is not a cheap place, it certainly can claim to be a 
good one, at least so far as the provision of American 
comforts and luxuries is concerned. This is considera- 
bly more than can be said for some other winter stations 
that are scattered along the coast here." 
In the same report the writer has also pointed out that 
Monte Carlo is one of the warmest winter stations on the 
Mediterranean coast. But it is not true that it enjoys a 
more equable temperature than all other resorts. Sudden 
thermometrical variations occur there just as elsewhere 
on the Riviera. Some parts of the principality are very 
well protected from winds, while others are decidedly ex- 
posed to them. The bare rocks rising up to a considera- 
ble height, immediately back of Monte Carlo, afford am- 
ple protection from cold northerly winds, and by reflect- 
ing the sun's rays appreciably raise the temperature in 
their vicinity. But when the sun has set, the succeeding 
chill is felt all the more violently, though the actual fall 
of temperature is less abrupt and less perceptible than 
our sensations appear to indicate. It would occupy too 
much space to go into details here concerning the physi- 
cal configuration of various sections of the Monegasque 
territory, but the reader may infer from these general 
indications that some well-sheltered and warm nooks can 
be found at Monaco. For well-to-do invalids the place 
will doubtless be made increasingly attractive, on ac- 
count of the large sums of money spent annually for im- 
provements. But people don't save money by going 
there, even when they gamble and win. 
The rainfall and the proportion of sunny days to 
cloudy ones arc about the same as at Nice or Mentone, 
and need not be specially considered. One advantage in 
favor of Monaco is that less dust is found there than at 
Nice, Cannes, or Hyeres. 
The drinking-water of Monte Carlo was not good at 
the time of the writer's tour of inspection. But it was 
about to be changed for a better supply. As regards the 
sewerage of the place, although an elaborate and expen- 
sive system of street drains exists, it is not as perfect as 
the authorities claim. As Monte Carlo and Monaco are 
rapidly growing this is a matter of great importance to 
their future claims as health-resorts. 
In the writer's article already alluded to, this point is 
referred to as follows : "Excepting the low-lying quar- 
ter called Condamine, Monaco affords every natural ad- 
vantage for a perfect system of drainage. Yet so far 
from being in good shape, this essential sanitary require- 
ment leaves much to be desired here. It is true, drains 
have now been established in all the principal streets, 
and most of them have a sufficient natural incline. But, 
as elsewhere on the Riviera, the house connections are 
insecure and dangerous. This applies more particularly 
to the old house-pipes that were subjected to the violent 
shaking up of the earthquake a few years ago. The 
authorities are only just beginning to realize that, in 
spite of the prevalent English closets, some radical re- 
forms may be needed. 
" Many of the old, poorly constructed, unventilated 
cesspools still exist, and receive the house-soil. As plenty 
of water is now used they would have to be emptied 
every two or three weeks. But house-owners, in order 
to avoid this expenditure, have, in spite of forbidding 
law, connected their cesspools by overflow pipes with 
the main sewers. Cut-off traps having been quite gen- 
erally omitted, the obvious consequence is that sewer- 
gas is almost certain to enter all hotels, villas, and lodg- 
653 monte Carlo. 
Mountain Sickness. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Fig. 430.-View of Monaco and Monte Carlo. 
654 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Monte Carlo. 
Mountain Sickness. 
ing-houses provided after this obsolete fashion. The 
evils of so reckless a system are to some extent coun- 
teracted by the winds that cleanse the polluted atmos- 
phere. But the night-air of such dwellings is bound to 
be dangerous, and, whenever possible, windows ought 
to be kept open all night. I am bound to state, however, 
that offensive odors, such as are so often justly com- 
plained of at Nice, are only rarely experienced at Monte 
Carlo. But Nice is eight times the size of Monaco, as 
regards population, and as the latter place grows, the 
present evils are sure to augment, unless proper precau- 
tions are taken. 
" The sewers, intended only for surface waters, now dis 
charge into the landlocked little harbor, which is an ad- 
ditional nuisance, fraught with potential danger for this 
place. In regard to the provision of amusements, more 
particularly concerts and theatricals, Monte Carlo stands 
without a rival on the Riviera." 
Patients should always be warned against visiting the 
Casino, even as lookers-on, for the dust-laden, stifling 
air of the unventilated rooms is responsible for many ill- 
nesses which could have been avoided. 
The indications for spending a winter season at Monte 
Carlo or Monaco do not differ from those which apply 
to the Riviera generally, and the reader is accordingly 
referred to the article on this subject which appeared 
in Volume VIII. of the Handbook. With Americans 
Monte Carlo is a favorite resort, and one is sure to meet 
numerous countrymen there every winter. 
Edmund C. Wendt. 
MONTMIRAIL. A watering-place in the Department 
of Vaucluse, France. 
Location.-Montmirail-Vacquarais is a small village, 
possessing several purgative and one chalybeate spring. 
It is not well known outside of France, but as the 
really efficacious waters are now exported in large quan- 
tities, it will probably soon acquire more of an interna- 
tional reputation. The place is pleasantly situated be- 
tween Orange and Carpentras. 
Access.-The village of Montmirail is reached by 
way of Orange, on the Paris, Lyons & Mediterranean 
Railroad. It is one and one-half hour's drive from the 
station. 
Analysis.-The principal spring of Montmirail is rich 
in sulphate of magnesium, and resembles the celebrated 
Seidlitz and Piillna waters. According to Mr. Henry 
one thousand grammes of the Source verte contain : 
Grammes. 
Sulphate of magnesium 9.31 
Sulphate of soda 5.06 
Sulphate of lime 1.09 
Chloride of magnesium 0.S3 
Chloride of sodium 0.18 
Chloride of calcium 0.18 
Bicarbonate of lime 0.37 
Bicarbonate of magnesia 0.16 
Calcareous phosphates, silica, alumina, sesquioxide of 
iron, and arsenical principle 0.39 
17.30 
Traces of iodides, salts of potash and ammonia, and 
organic matter. 
The sulphate of magnesium imparts a decidedly bitter 
taste to the water, but purgation is not accompanied by 
griping pains or other signs of intestinal irritation. 
Indications.-These waters are chiefly employed in 
gastro-intestinal affections with a tendency to constipa- 
tion, in dyspepsia, abdominal plethora, diabetes, and 
affections of the spleen, and in some of the constitutional 
effects of malaria. Season, May to September. 
Accommodation.-There is only one bathing and 
thermal establishment writh a fairly good equipment. 
The boarding arrangements are on a modest scale. 
There is an absence of fashionable life. 
Edmund C. Wendt. 
MOUNTAIN SICKNESS. Ger., Bergkrankheit ; Fr., 
Mal des Montaqnes ; Sp., Puna (?). Mountain climbers 
have often described a peculiar train of symptoms from 
(SUPPLEMENT.) 
which they suffered in first ascents after reaching a cer- 
tain height above the level of the sea, and which system- 
atic medical writers have grouped together under the 
name of mountain sickness. The first mention we find 
of the ailment was made over two centuries ago, but for a 
long time no special attention was paid to it, as it was sup- 
posed to be due merely to the unusual exertion of climb- 
ing, and to be nothing more than a form of fatigue. 
Within the past fifty years, however, several writers have 
described the affection at length, and have even made as- 
cents for the sole purpose of studying it, analyzing the 
symptoms observed, and endeavoring with more or less suc- 
cess to discover the true cause of their production. Not- 
withstanding that the facts upon which our knowledge of 
mountain sickness is based, and which have led writers 
to regard the affection as one sui generis and due to a spe- 
cific cause, have, as was just mentioned, been accumulat- 
ing for more than two centuries, and have been collected 
by scientists in special excursions made for that special 
purpose, they are even yet fragmentary and insufficient 
to warrant the formulation of a definite and satisfactory 
explanation of the symptoms. 
Among the most recent observers of mountain sick- 
ness was Mr. Edward Whymper, who made ascents 
of some of the highest peaks of the Andes with the 
avowed object, among others, of gleaning some new facts 
bearing upon the effects of high altitude upon the human 
body. He did not accomplish this object as fully as he 
had hoped, for, although he made twelve ascents to vari- 
ous heights, he suffered from but one pronounced attack 
of the malady. This occurred during his first ascent, and 
appeared suddenly when his party had reached an eleva- 
tion of 16,664 feet (barometric pressure 16.510 inches). 
He and his two Swiss guides found themselves suddenly 
incapacitated for work of any kind. Respiration was 
hurried and was accompanied by spasmodic gasps or 
gulps. All suffered from intense headache and a feeling 
of general malaise and exhaustion. The dyspnoea seemed 
to be the most marked feature of the attack, for the suf- 
ferers could breathe only with the mouth wide open ; 
conversation was abandoned, being literally a waste of 
precious breath ; smoking became distasteful, and was 
moreover too difficult of accomplishment to be indulged 
in, even had it been otherwise desired ; eating was impos- 
sible, because of the interruption thereby occasioned to 
the one important occupation of breathing; and even 
fluids had to be taken sip-wise and as it were in stolen 
moments between gasps. The temperature was some- 
what elevated (38° C., or 100.4° F.), and the pulse was 
markedly accelerated. Recovery was very gradual, and 
indeed was not complete until the party had descended to 
their camp, at some distance below the point where they 
had experienced the attack. Even after recovery seemed 
to have fully taken place, Mr. Whymper says, he re- 
mained very weak, became easily fatigued, and was 
troubled with shortness of breath on the slightest exer- 
tion. None of the party suffered from nausea or vomit- 
ing, but this may have been because they were all so 
"knocked out" that they were incapable of any exer- 
tion, and possibly they might have had some pronounced 
gastric symptoms had they been able to move about at 
all, and thus tax their little remaining strength. 
This attack was experienced upon the occasion of the 
first ascent of Chimborazo, and, as before mentioned, at 
an elevation of a little over 16,500 feet. But it never 
recurred in any of the eleven subsequent ascents (one 
of them up Chimborazo again), although at one time 
they reached a height of 19,500 feet (barometer, 14.750 
inches). They were able to remain at this elevation for 
twenty-six hours " without any serious inconvenience," 
although in all their ascents they experienced more or 
less lassitude and some dyspnoea, being always com- 
pelled, when in movement, to breathe with the mouth 
open. 
In looking about for an explanation of the phenomena 
of mountain sickness, Mr. Whymper naturally finds it 
in the diminution of atmospheric pressure, in the op- 
eration of which, however, he distinguishes two fac- 
tors, one permanent in its action and unavoidable, the 
655 fountain Sickness. 
Mountain Sickness. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
other temporary. The permanent factor, and the one 
for which he thinks it improbable that tolerance could 
ever be established, is the reduced value of the air that 
can be inspired by ordinary efforts in a given time. As 
a result of this it becomes necessary to inhale a much 
larger quantity of air, and therefore to make habitually 
a greater number of inspiratory efforts in a given time, 
in order to bring to the blood circulating through the 
pulmonary capillaries a volume of oxygen equal to that 
supplied to it by ordinary respiration nearer the level of 
the sea. The second factor is the reduced pressure upon 
the surface of the body, as a result of which the air or 
gas within the body expands and presses with more or 
less force upon the internal organs. The symptoms so 
produced are temporary, and pass away as soon as the 
equilibrium is re-established between the internal and ex- 
ternal pressure, and they may even be avoided altogether 
by making the ascent very leisurely, and pausing at fre- 
quent intervals to permit of a modification of the pressure 
within the body sufficient to equalize it to that of the sur- 
rounding atmosphere. 
Although Mr. Whymper's observations were carefully 
and intelligently made, they are less useful as a contri- 
bution to the literature of the ailment than they might 
have been had he not been an experienced mountain 
climber. Both he and his guides had made numerous 
Alpine ascents, and had thereby become more or less ac- 
climated, if such expression may be allowed ; and as a re- 
sult the affection was not manifested in them to the same 
degree that it would have been in others unaccustomed to 
exertion at great elevations above the sea-level. One of 
the characteristics of the malady is that, as a general rule, 
it affects a person severely only upon his first ascent to a 
height of from ten thousand to fifteen thousand feet. 
The second time the symptoms are usually less pro- 
nounced, if too long a time have not elapsed since the first 
ascent; and when frequent excursions are made at short 
intervals, the system becomes so adapted to the changed 
conditions that the unpleasant symptoms of the malady 
are no longer manifested. Expert mountaineers seldom 
experience any inconvenience save under very exceptional 
circumstances, as for example when ascending to an un- 
usually great elevation, or when suffering from the effects 
of some debilitating condition. 
The first symptom noticed is an increased rapidity of 
respiration, w'ith a feeling of constriction of the chest. 
The pulse is accelerated and there may be some irregular 
action of the heart; a sense of fulness and pressure in the 
head, increasing at times to a throbbing pain, is present, 
and the person complains of a peculiar weakness of the 
legs, sometimes accompanied by rather sharp pains in the 
knees. Ordinarily these early phenomena are of slight 
intensity, and may be dissipated by taking a few deep in- 
spirations. Not so, however, if the individual persists in 
his determination to ascend beyond this point. Under 
the combined influence of increasing rarity of the atmos- 
phere and of continued muscular exertion, the symptoms 
grow more and more severe, new ones of a more grave 
character appear, and finally the sufferer is compelled by 
sheer physical exhaustion reluctantly to give up the 
struggle and acknowledge himself beaten by the quiet 
but invincible forces of nature. Rest, especially in a re- 
cumbent posture, affords relief at once to the more press- 
ing symptomsand gradually effects a cure of the ailment, 
even though the person do not descend to any lower level. 
The improvement is often, however, very slow, and the 
less distressing symptoms, such as moderate dyspnoea and 
a feeling of fatigue on slight exertion, may persist for 
days, or even weeks. 
The severer manifestations of the malady are of two 
classes, the one seemingly due to insufficient oxygenation 
of the blood, and the other resulting from diminished at- 
mospheric pressure. In the first category we find, in 
addition to the shortness of breath, drowsiness and lassi- 
tude, vertigo and the appearance of black spots before 
the eyes, intense cephalalgia, eructations, and frequently 
nausea and vomiting. There is usually also considerable 
thirst, accompanied by a feeling of dryness of the mouth 
and fauces. The weakness of the legs and sense of fatigue 
increase, until the patient becomes utterly exhausted and 
incapable of any further exertion. At the same time the 
reduction of atmospheric pressure causes a fulness of the 
venous system. The superficial veins of the exposed 
portions of the body are visibly swollen, and haemorrhages 
frequently take place from the mucous surfaces. Epis- 
taxis is common, and in aggravated cases bleeding from 
the stomach and intestines has been noted. Dr. Poppig, 
who lived for a number of years at Cerro de Pasco, Peru, 
some 14,500 feet above the level of the sea, has stated 
that new arrivals there were often unable to shave for the 
first few days of their stay, owing to the extreme tendency 
of the skin to bleed. He mentions also an instance of a 
person who was forced to give up playing on the flute, as 
every attempt to do so caused him to spit blood. If all 
the inhabitants were similarly affected, it will be conceded 
that an exile at Cerro de Pasco would not be without its 
compensations. 
The process of acclimatization is apparently a slow- 
one, when the individual remains constantly at so great 
an elevation, for Dr. Poppig says that no European is able, 
during the first year of his residence at Cerro de Pasco, 
to exert all his former strength, and it is only gradually, 
in the course of the second year, that he acquires ability 
to do so. 
Mountain sickness appears much earlier and is more 
pronounced in those who are walking than in riders. 
Aeronauts can ascend to much greater heights without 
suffering than can mountain climbers, for they are sitting 
quietly in the car of the balloon and are husbanding their 
breath. So it is, in less degree, with riders or those 
travelling up the mountain side in wheeled conveyances. 
Thus Dr. Esserwein tells us of a journey he made by rail 
from Callao up to a tow-n in the mountains lying at an 
elevation of about 11,500 feet above the sea. While sit- 
ting quietly in the car he felt no inconvenience, but im- 
mediately upon alighting at the station he was seized with 
dyspnoea, constriction of the chest, rapid and irregular 
pulse, and apparently some elevation of temperature, 
though he was unprovided with a thermometer and could 
not determine the degree of fever. 
Animals, such as horses, dogs, pack-mules, etc., born 
in the lowlands, suffer in the same way as men when ta- 
ken up the mountains, but animals born at high eleva- 
tions are exempt. The native mountaineers are likewise 
untroubled by the malady, and can run, hunt, and labor 
hard in other ways at heights at which new-comers are 
utterly prostrated and incapable of the slightest muscular 
effort. Shepherds are found grazing their flocks in per- 
fect contentment, both in the Andes and in the Hima- 
layas, at elevations of about 16,000 feet, but they can 
seldom remain for any length of time at much greater ele- 
vations than this. The loftiest inhabited spot on the 
globe is said to be the Buddhist convent of Hanle, in 
Thibet, which is situated at an elevation of 16,533 feet. 
Here twenty priests pass their time in prayer and medi- 
tation. It is true, this occupation cannot be regarded as, 
physically, a very exhausting one, yet it must have re- 
quired heavy labor to build the convent, and it would be 
interesting to learn the medical history of the laborers 
employed in its construction. The highest point in the 
Himalaya Mountains at which exercise was possible, 
was found by the Schlagintw'eit Brothers (" Reisen in 
Indien und Hoch-Asien " ) to be 21,982 feet. In the case 
of pack-mules driven beyond their pow'ers, death from 
mountain sickness is not very unusual, and the malady 
has been known to result in death even in men, who were 
unused to mountain climbing, and who persisted in their 
upward struggles until the heart gave way under the 
unaccustomed strain. It is said that cats invariably die 
in convulsions if taken up much beyond 13,000 feet. 
Alpine climbers seldom suffer acutely from mountain 
sickness, probably because they make graduated ascents, 
not often going to very great heights on their first trial. 
And, as was mentioned above, old and experienced 
climbers seldom experience any disagreeable symptoms, 
unless they have been living a long time on the plains, or 
happen to be run down by fasting, cold, or extraordinary 
fatigue. De Saussure, however, in an account of an 
656 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Moiuitain Sickness. 
Mountain Sickness. 
ascent of Mont Blanc in August, 1787 ("Voyage dans 
les Alpes "), says that the guides suffered severely, when 
attempting to put up the tent in which they were to pass 
the night, at the comparatively slight elevation of 12,763 
feet. He himself suffered not a little from shortness of 
breath, weakness of the legs, and vertigo, but the dis- 
tressing symptoms disappeared almost entirely when he 
turned so as to face the strong north wind, swallowing it, 
as he said, in great gulps. 
M. Charles Martins made an ascent to the summit of 
Mont Blanc in July, 1844, going from Chamounix to 
the Grand Plateau three times. The third time he 
reached this point his guides had an experience similar 
to that of De Saussure's guides, half a century before, 
suffering quite severely from dyspnoea and weakness 
while engaged in shovelling away the snow in order to 
clear a space for the erection of the tent. Yet these same 
men had suffered no inconvenience of consequence in 
their two previous trips to the same spot. The reason 
why they were attacked more severely the third time was 
doubtless, as M. Martins says, because they had made 
the ascent with unusual rapidity. Dr. Auguste Lepileur, 
who accompanied M. Martins in this ascent, has described 
the physiological effects of the trip upon himself and the 
others of the party in an article in the Revue Medicale for 
1845. 
In August, 1869, Dr. L. Lortet, of Lyons, made two 
ascents of Mont Blanc, with the special object of study- 
ing the phenomena of the mat des montagnes. The first 
trip was made with a party of five, exclusive of the 
guides. The first night was passed at an elevation of about 
10,000 feet. No special symptoms were noted at this 
station, except that M. Lortet had most pronounced ano- 
rexia and was unable to swallow a morsel of food. The 
first suffering was experienced after the party had as- 
cended above 12,800 feet, the symptoms then complained 
of consisting of drowsiness, intense occipital headache, 
thirst, and dryness of the throat, complete loss of appe- 
tite, and nausea but no vomiting. In some of those ex- 
amined the pulse ran up to from 160 to 172 per minute. 
There was a wretched feeling of malaise, and the sufferer 
had a sense of utter indifference concerning his own fate 
or that of his companions, very similar to the apathy of 
the sea-sick. On arriving at the summit this malaise 
passed away, but there was still shortness of breath and 
palpitation on the slightest movement. One of the party, 
who had not previously suffered, was taken suddenly, on 
arriving at the summit, with giddiness and vomiting of 
mucus and bile, which did not cease until the level of 
the Grand Plateau was again reached. 
On the occasion of the second ascent, a few days after 
the first, M. Lortet felt only great drowsiness, but even 
this passed away under the stimulus of the cold wind, 
and of the snow beating against his face. He had no 
malaise during the trip, and could now eat with relish, 
having no return of the anorexia of the first ascent; but 
his shortness of breath was extreme. 
An analysis of the symptoms manifested by the vari- 
ous members of the party developed some rather curious 
facts, especially in regard to the body temperature. Dr. 
Lortet made a number of observations on this point, and 
found that during the violent exercise of climbing, when 
near the summit of the mountain, the sublingual tem- 
perature fell in a remarkable manner. While sitting 
quietly the temperature was normal or nearly so (36.3° to 
37° C. = 97.3° to 98.6° F.), but after a period of severe 
exercise it was greatly reduced, falling in one instance to 
a fraction below 32° C. (89.5° F.) ! After a few minutes 
of rest the mercury again indicated a normal tempera- 
ture. The writer remarks in support of the correctness 
of these remarkable findings, that subsequent experi- 
ments showed that violent exercise "would reduce the 
temperature of the body from three-tenths to seven- 
tenths of a degree centigrade (one-half to one degree 
Fahrenheit), provided the individual were fasting. He 
explains the phenomena as follows : When a person in 
the lowlands exercises violently there is a transformation 
of heat into force, but by reason of the fact that a suffi- 
cient quantity of oxygen is available, the production of 
heat within the body keeps pace with its loss, so that the 
temperature is constantly maintained at the normal fig- 
ure. In elevated regions, however, where the atmos- 
phere is rarefied, the expenditure of force uses up the 
body temperature more rapidly than the organism can 
supply it. This loss of heat is further increased by the 
rapidity of the circulation, the blood not having time to 
become properly oxygenated while passing through the 
pulmonary capillaries. As the blood is also driven to 
the surface, it is probable that increased radiation aids 
in still further cooling the body. M. Lortet's explana- 
tion is quite ingenious, but not very plausible. A much 
simpler elucidation of the problem is that the reduction 
of temperature was only apparent, or rather that it was 
purely local. During exercise the members of the party 
were forced to breathe through the mouth and thus the 
parts were cooled off; after resting for a while the 
mouth could be closed, and then its temperature rose 
again to that of the body. The writer has repeated M. 
Lortet's experiment of exercising in the open air at a 
moderate elevation, actively and even violently, while 
fasting, and he has never found any appreciable reduc- 
tion of the sublingual temperature as long as the mouth 
was kept closed. 
The author of these observations wras, however, so im- 
pressed with the startling fact of this reduction of tem- 
perature that he attributed the greater part of the phe- 
nomena of mountain sickness to it, although he was 
willing to concede that the vitiation of the blood by the 
accumulated carbonic acid might contribute to the 
results observed. He found that this loss of body heat 
did not take place in those who could eat regularly (pos- 
sibly because these same ones who were able to eat suf- 
fered less from dyspnoea), and this observation afforded 
him an explanation of the utility of the guides' habit of 
eating every two or three hours. Unfortunately, he 
says, it is not usually possible to make use of this discov- 
ery in the way of prophylaxis, as the novice in moun- 
tain climbing has such an unconquerable repugnance to 
food that he finds himself unable to swallow a single 
morsel. 
There are two other theories which have been advanced 
in explanation of the origin of mountain sickness. The 
more commonly accepted of these is that advocated by 
M. Paul Bert, who referred the production of the symp- 
toms chiefly, if not entirely, to the diminished supply of 
oxygen. He believed that man ordinarily inhales more 
oxygen than he actually requires, just as he usually con- 
sumes more food than is absolutely necessary for the 
support of life ; and just as one can accustom himself by 
degrees, and after more or less hunger and inconvenience, 
to a diet far below that which he ordinarily consumes, so 
he can gradually, at the expense of some dyspnoea and 
temporary suffering, habituate himself to dispense with 
this superfluity of oxygen. According to this theory the 
affection is due to the reduced oxygen pressure, as a 
result of which the red globules of the blood are able to 
absorb a smaller quantity of the gas than they do in the 
more condensed atmosphere of the lowlands.. The pro- 
cess of acclimatization is accomplished by an increase in 
the number of the red globules, whereby larger amounts of 
oxygen, proportionately to the inspired air, are absorbed, 
little or none of the gas taken into the lungs being wasted, 
as it is in the case of individuals living at or near the sea- 
level. M. Bert examined the blood of the llama of the 
Andes, and found that it was capable of absorbing, for 
every one hundred volumes, at least five more volumes of 
oxygen than was the blood of sheep feeding in the plains. 
It has been shown also by Regnard and Muntz, in ex- 
periments upon rabbits, that a reduction of atmospheric 
pressure, either natural on mountains or artificial under 
a bell-glass, was followed by an increase of the haemoglo- 
bin of the blood and a consequently greater power of 
absorption of oxygen. 
The other theory is one advocated with much skill by 
Dr. Georg v. Liebig, who believes that mountain sick- 
ness is not essentially due to a diminished supply of oxy- 
gen in the air, but that it is rather a consequence of one's 
inability to breathe properly at first in a rarefied atmos- 
657 JUountain Sickness. 
Naphthalene. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
phere. Similar symptoms, he says, are often observed 
under certain circumstances in the lowlands, as when one 
tramps, for example, in deep snow or in soft and yield- 
ing sand. In a person thus exerting himself one may see 
the veins swell and the face become purplish, his breath 
comes short and panting, his heart's action is labored and 
rapid, there may be even vertigo and momentary nausea, 
and he is forced to stop now and again as his legs refuse 
to do their duty. The origin of these symptoms is laid 
by v. Liebig to restricted respiration. As long as the 
severe exertion continues the abdominal muscles are tense 
and the belly is drawn in, the diaphragm is pushed up 
and cannot descend sufficiently to permit of full and deep 
inspiration, such as is needed to pump the blood out of 
the turgid veins into the right heart. The lungs also are 
more or less compressed, and while the bodily exertion 
creates a demand for an increased supply of oxygen, the 
impeded respiration permits of less being inhaled. The 
diminished supply results of course in imperfect oxygen- 
ation of the blood, and this in turn manifests itself in the 
muscular weakness, especially of the legs, and in vertigo 
and nausea. In this case the actual cause of the distress 
is to be found in the compressed position of the lungs, and 
although the malady is never so aggravated in the low- 
lands, disappearing always immediately upon the indi- 
vidual ceasing his exertion and resting, it is nevertheless 
the same in kind as mountain sickness. The origin of 
the ailment, in the one case as in the other, is to be referred 
to a disturbance of the respiratory function. In the low- 
lands the symptoms arise only upon great exertion, but 
at high altitudes they appear spontaneously or after mod- 
erate exercise and persist often even when the subject is 
at rest. In a rarefied atmosphere, v. Liebig claims, the 
lungs are compressed as a result of the diminished re- 
sistance to expiration, and full expansion is effected only 
by a conscious exertion. The result of this diminished 
respiratory power is seen in the gasps and hurried breath- 
ing, in the venous turgescence, and in the consequences 
of diminished oxygenation of the blood above detailed. 
Dr. v. Liebig therefore argues that it is to the change 
in the density of the air, rather than to the reduced quan- 
tity of oxygen contained in it, that the phenomena of 
mountain sickness are rightly to be attributed. He does 
not think that the haemoglobin theory is sufficient to ac- 
count satisfactorily for the facts of acclimatization, but 
holds that w'e can, in the course of time, so alter the 
rhythm of respiration as to accustom ourselves to breathe 
deeply and slowly, without being always conscious of 
the necessary expenditure of strength. 
Neither of these theories seems to the writer to be suf- 
ficient in itself to explain satisfactorily all the phenomena 
of mountain sickness and all the facts of acclimatization. 
It would appear hardly probable, for example, that the 
absorptive power of the blood could have been so rapidly 
augmented, or that the respiratory rhythm could have 
been so quickly changed as to confer a practical immu- 
nity upon Mr. Whymper and his two companions after 
their single unpleasant experience. It is true that their 
former mountaineering may have brought about a per- 
manent increase in the amount of their haemoglobin, or 
that their past experience may have taught them to alter 
their respiratory rhythm unconsciously and rapidly to 
meet the necessities occasioned by the rarefied atmos- 
phere ; but in that case they ought not to have suffered 
so severely upon their first ascent of Chimborazo. 
It is more easy to reconcile the second of these theories 
with the observed facts than the first, and it receives 
some support also in the writer's opinion from what has 
been observed in relation to sea-sickness. There are 
numerous points of resemblance between sea-sickness 
and mountain sickness, although in many respects they 
differ very greatly. One theory of sea-sickness is that 
the phenomena are the result of a disturbed respiratory 
rhythm, and a form of respiratory gymnastics has been 
proposed as an efficient mode of treatment for mild cases 
of the ailment. That the taking of prolonged and regu- 
lar inspirations is useful in relieving a moderate amount 
of distress at sea, the writer can affirm from personal ex- 
perience, though whether it would cure a pronounced 
attack of the malady he is inclined to doubt. The same 
procedure will relieve the first signs of mountain sickness 
also, but it may be permitted to doubt its efficacy in re- 
storing a sufferer at fifteen thousand feet to his" normal 
state. 
It is most probable that both these factors-diminished 
pressure and lessened respiratory value of the air-are 
active in the production of the symptoms grouped under 
the name of mountain sickness, "but it is possible also that 
there are certain meteorological or other conditions, im- 
possible of detection by our present instruments of pre- 
cision, upon the presence or absence of which variations 
in the intensity of the observed symptoms may largely 
depend. 
The treatment of mountain sickness requires but brief 
notice. Rest is, of course, demanded, but even that is 
insufficient to bring relief in aggravated cases. No 
doubt deep and regular inspiratory efforts would be ser- 
viceable, but the immediate need for air is often so urgent 
that the sufferer can only gasp, and cannot be persuaded 
to take the time necessary for a prolonged inspiration. 
Oxygen would without question be of value for the re- 
lief of certain of the symptoms, whatever theory as to the 
causation of the malady may be correct, but ordinary 
mountain climbers are usually sufficiently encumbered 
with their necessary traps and cannot carry with them 
the apparatus necessary for making oxygen gas. Whym- 
per made some trials of potassium" chlorate, which 
might theoretically be thought useful in furnishing 
oxygen to the tissues, but his companions had an aver- 
sion to drugs and would not lend themselves readily to 
his experiments, so that it was impossible to determine 
what the effect of the remedy might be when given me- 
thodically and in proper dose. Fortunately, few people 
are called upon to ascend high mountains in the ordinary 
course of business, and those who do so from a love of 
adventure or ambition must make up their minds to take 
tlie unpleasant along with the agreeable. Of course, no 
one whose thoracic organs are not in perfect condition 
should ever attempt the ascent of a high mountain. 
Thomas Lathrop Stedman. 
Literature. 
The following are some of the more important works and journal arti- 
cles on the subject of mountain sickness which have been consulted by 
the writer in the preparation of the preceding account of the malady: 
Meyer-Ahrens, C.: Die Bergkrankheit. oderder Einfluss des Ersteigen 
grosser Hohen auf den thierischen Organismus. Leipzig, 1854. 
Payot, A.: Du mal des montagnes consid6re au point de vue de ses 
efrets, de sa cause, et de son traitement. Taris, 1881. 
Whymper, Edward : Travels among the Great Andes of the Equator. 
New York, 1892. 
V. Liebig, Georg: Ueberdie Bergkrankheitund IndicationenfiirHohen- 
kurorte bei Lungenleiden, Deutsche Medicinische Wochenschrift, 
1880, vi., pp. 205 and 222. Die Bergkrankheit, Deutsche Medicinal- 
Zeitung, 1889, x., p. 305. 
Lortet, L.: Deux Ascensions au Mont Blanc en 1869 ; Recherches Phys- 
iologiques sur le Mal des Montagnes, Lyon Medical, I860, iii„ p. 79. 
Martins. Charles: Deux Ascensions au Mont Blanc, Revue des Deux 
.Mondes, March 15, 1865. 
MYELITIS. Little advance has been made during the 
last few years in our knowledge of this disease. Hayem 
and Parmentier have reported several cases of myelitis 
of blennorrhagic origin, but they are doubtful in char- 
acter. Dufour also reported a case which developed dur- 
ing the course of gonorrhoea, and the autopsy showed 
characteristic lesions in the spinal cord, but no bacterio- 
logical examination was made. 
Oppenheim has come to the conclusion that true pri- 
mary myelitis is a rare disease. He says that a revision 
of the clinical histories of the hospital cases under his 
observation shows that the large majority belonged to 
the category of so-called compression myelitis (generally 
from disease of the spine, latent caries) or, as in two 
cases, from a malignant tumor of the abdomen extend- 
ing to the spine. In some other cases post-mortem ex- 
amination showed syphilitic disease of the spinal mem- 
branes, which extended to the cord. Very rarely a case 
which had been regarded during life as myelitis was 
proved to be a neurosis, especially hysteria. Frequently 
a case which was first looked upon as myelitis was 
658 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, 
(SUPPLEMENT.) 
mountain Sickness. 
Naphthalene. 
found, in view of its subsequent course, to be a dissemi- 
nated sclerosis. A specially interesting case shows that 
a transverse myelitis may be simulated by a combined 
columnar disease : 
A woman, fifty-one years of age, was admitted to the 
hospital on October 24, 1888. Since August, 1887, she 
had suffered from weakness and pains in the legs, with 
formication, and has been paralyzed for the last three 
months. During the last few weeks there have been 
flexion contracture of the legs, disturbances of the blad- 
der, and a cincture feeling around the abdomen. At the 
present time she suffers from complete paraplegia with 
flexion contracture, increased tendon and cutaneous re- 
flexes, diminished sensibility to touch and temperature, 
incontinence of urine ; the upper limbs are normal. 
This condition remained unchanged except that the 
knee-jerk was subsequently lost. The case finally ter- 
minated fatally. The autopsy disclosed combined dis- 
ease of the posterior columns, the lateral and anterior 
pyramid columns. 
The diagnosis of chronic myelitis was also made very 
rarely (in four cases) by Oppenheim. When the cere- 
bral symptoms were taken into consideration, the large 
majority of the cases were found to be disseminated or 
multiple cerebro-spinal sclerosis. 
Oppenheim concedes that there is no longer any doubt 
of the intimate connection of disseminated myelitis (my- 
elo encephalitis) with infectious and toxic processes. It 
may develop : 1, in acute infectious diseases (variola, 
scarlatina, typhoid, erysipelas, gonorrhoea) ; 2, on the 
basis of syphilis, tuberculosis and malaria ; 3, in the 
puerperal state ; and 4, in the cachexia due to the growth 
of malignant tumors. 
Leyden divides the infectious diseases of the spinal 
cord into the following groups : 
a. Parasitic diseases in which the pathogenic micro- 
organisms develop directly in the cord. Such cases are 
very rare. They include acute myelomeningitis which 
occurs as the result of typical cerebro-spinal meningitis. 
Leyden has shown that in some cases the diplococci 
enter the cord along the connective-tissue septa, and pro- 
duce inflammation of the latter which extends to the 
white substance of the cord. Furthermore, capillary 
emboli appear in the cord as the result of ulcerative en- 
docarditis, the latter being due to the presence of staphy- 
lococci or streptococci. It is also probable that acute po- 
liomyelitis is an acute infectious disease, although the 
pathogenic micro-organism is still unknown. Spinal 
affections occurring in gonorrhoea are probably due to 
direct propagation of the gonorrhoeal process to the cord. 
b. Infectious myelitis due to the action of toxines 
formed during the infectious disease. One large group 
includes sequelae of acute infectious diseases. They 
generally appear as disseminated myelitis with coincident 
affection of the medulla and pons. This variety also 
occurs after traumatism, and after pregnancy and child- 
bed. 
c. Toxic myelitis which occurs after the excessive in- 
gestion of ergotin and spoiled maize, and in zinc work- 
kers (?). 
d. Anaemic or cachectic myelitis. Lichtheim found 
under such conditions myelitic processes in the posterior 
and lateral columns of the cord, but they did not possess 
a systematic character. 
The question with regard to the real nature of the so- 
called compression-myelitis of Pott's disease has not yet 
been definitely settled. The weight of evidence is in 
favor of the view that this condition is primarily a de- 
generation of the nerve-elements, due to the ischaemia 
which is consequent on the compression, but that at a 
later period an inflammatory condition develops in the 
degenerated parts. ' Leopold Putzel. 
MYRTOL. A constituent part of the essential oil, de- 
rived by distillation, from the leaves of myrtus com- 
munis, L. It is supposed to closely resemble eucalyptol. 
It is a clear liquid with a powerful but not unpleasant 
aromatic odor. It is recommended as a disinfectant and 
deodorant, but has no bactericidal action. In medicine 
it is used to replace the balsams in bronchitis, blenor- 
rhagia, and vaginitis. In small doses it improves the 
digestion and stimulates the appetite, but in larger doses 
it irritates the stomach. It is recommended particularly 
to remove the fetid sputum of bronchiectasis, and in gan- 
grene of the lung. It is administered in doses of two to 
five minims, in capsules, repeated two or three times a 
day. Beaumont Small. 
NAIRN. A Scotch sea-side resort of growing popular- 
ity. Nairn is a royal burgh of great antiquity, not f:y 
from Inverness, and pleasantly situated on the shore of 
the Moray Firth, at the mouth of the river Nairn. 
It is a healthy place, with a fine sandy beach, and is 
popularly referred to as the "Brighton of the North." 
According to Black (" Watering-places of England, Scot- 
land, and Ireland"), the climate of Nairn is "dry and 
bracing, and such is the influence of the sea on the air sur- 
rounding it that the extremes of temperature experienced 
at places more inland are not felt here. On no occasion 
during the last tw7enty-one years has the thermometer in 
the shade risen above 78.3° F., or fallen below 11.2° F. The 
annual mean temperature, calculated from a series of ac- 
curate observations, would seem to be 47.9° F. ; that of 
summer (April to September), <54° F., and of winter (Octo- 
ber to March), 41.8° F.; the difference between the means 
of these two seasons being 12.2° F. August, on an average, 
is the hottest month in the year, and February the cold- 
est. The air is driest in June and dampest in February. 
The mean annual height of the barometer, corrected to 
32° F., and reduced to the level of the sea, is 29.810 
inches. The highest elevation of the mercurial column 
thus corrected, during twenty-one years' observation, has 
been 30.881 inches, and the least, 27.998 inches ; the 
range of this instrument is smallest in June and greatest 
in November ; the annual average does not exceed 1.408 
inch. The yearly rainfall does not amount to more 
than twenty-six inches ; the greatest quantity falls in 
October and the least in April." 
Nairn has been recommended as a winter-resort, but it 
has no just title to be so considered, as the meteorological 
data just given amply demonstrate. 
Edmund C. Wendt. 
NAPHTHALENE. In addition to the external use of 
naphthalene in the treatment of parasitic and other forms 
of skin disease, and as an antiseptic dressing, it has been 
extensively employed as an internal remedy in all condi- 
tions in which an intestinal antiseptic is indicated. Its 
insolubility makes it a very safe medicine, and enables its 
antiseptic action to be continued throughout the whole 
course of the intestinal canal. Professor Rossbach, of 
Jena, first employed naphthalene in acute and chronic 
intestinal catarrh, and its use has been extended to cholera 
infantum, summer diarrhoeas of children, dysentery, and 
all forms of dyspepsia and intestinal indigestion, accom- 
panied by flatulency and fermentative changes. It is 
given in doses of 2 to 6 grains to children, and from 15 to 
20 grains to adults, repeated three or four times a day, its 
administration being preceded by a dose of castor-oil. 
Some have obtained good results in infants by giving 
it in f-grain doses every two hours. To adults it has 
been given in as much as 60 to 90 grains in the day. It 
has also been used as suppositories, 15 grains of naphtha- 
lene to 2| drachms of cacao-butter, introduced after an 
evacuation. It has proved of service in dysentery and in 
ulceration of the rectum when introduced as an enema : 
naphthalene, 5 parts, olive-oil, 200 parts. This may be 
introduced by means of an ordinary syringe, and repeated 
three or four times a day if required. 
Naphthalene has also been highly spoken of as an anti- 
septic for the treatment of typhoid fever. Its advocates 
claim for it a decided beneficial action in shortening the 
duration of the fever, a lessening of unfavorable symp- 
toms and complications, and a lowering of the death-rate. 
Dr. L. Wolff reported {Philadelphia Medical Wews. May 
23, 1891) a series of one hundred cases, with a mortality of 
only two per cent., excluding certain deaths from causes 
outside the fever, and a mean duration of the fever of 
659 Na plitlialene. 
Narcosis. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
24.3 days. On admission calomel and soda was adminis- 
tered to empty the intestine, and this was followed by 
five grains of naphthalene every four hours, alternated 
with a few drops of hydrochloric acid; no other medica- 
tion was permitted excepting chemical antipyretics and 
cold sponging for hyperpyrexia. Dr. Wolff found that 
although it has no direct effect in lowering the tempera- 
ture, its continued use speedily produced lysis and a nor- 
mal temperature ; in cases in which it was at once discon- 
tinued the temperature rose again. It was found 
necessary to continue the drug for some time after the 
temperature became normal. He considered that at the 
onset of typhoid fever naphthalene may inhibit the devel- 
opment of the pathogenic microbes, so far that the disease 
could be aborted ; and that at any period in the disease 
over-production of the chemical toxines may be pre- 
vented, and the fever made to run a mild course. Naph- 
thalene has been widely employed in hospital and private 
practice, and still receives its share of attention with other 
intestinal antiseptics. The results of this treatment, how- 
ever, has not been uniformly favorable, and this, together 
with its disagreeable odor and taste, has proved a decided 
disadvantage and tended to lessen its employment. 
Other antiseptics without these disadvantages, notably 
salol, have replaced it to a great extent. 
Naphthalene has been recommended as an anthelmin- 
tic by Dr. Mirowicz (The Lancet, December, 1891). He 
considers it superior to all other remedies on account of 
the certainty of its action and the absence of all toxic 
effects. It has proved of service against all kinds of in- 
testinal worms, and its action is prompt and effective. 
One dose has caused the expulsion of a tape-worm, the 
head included, and in thread-worms and ascarides it 
has proved equally beneficial. Previous to administer- 
ing the drug the patient should be dieted with salted, 
acid, and spiced foods. It should be given on an empty 
stomach, and followed by a dose of castor-oil. The 
quantity for adults is from 8 to 20 grains ; a dose of 15 
grains has usually proved sufficient; children may be 
given from 4 to 8 grains. It has also been used as an in- 
jection for pin-worms, the drug being mixed with one 
and a half to two ounces of olive-oil. 
The fumes of naphthalene have been employed with 
some success in whooping cough. A small quantity is 
to be placed in a dish and surrounded with hot coals ; it 
soon melts and fills the room with white fumes. To be 
effective the patient should inhale the fumes continu- 
ously until the cure is complete. 
The disagreeable taste requires it to be given in cap- 
sules or rice-paper, or in pill form. It may be formed 
into pills by mixing with half its weight of powdered 
marsh-mallow root and forming into a mass with muci- 
lage. When given as a powder it may be mixed with 
sugar, and its taste and smell disguised by a drop of oil 
of bergamot or peppermint. Beaumont Small. 
NAPHTHOL CAMPHOR. Camphorated Naph- 
thol.-The preparations and derivatives of naphthol, 
such as betol, beta-naphthol-benzoate, and microcidin, 
have in a great measure supplanted the drug itself, both 
for internal and external use. The combination of naph- 
thol and camphor, although known for some time, has 
recently been recommended for the treatment of tuber- 
culous glands, tubercular phthisis, diphtheria, and as a 
valuable antiseptic wherever such is indicated. 
It is prepared by rubbing together one part of beta- 
naphthol and two parts of powdered camphor. A viscid 
liquid results, insoluble in water, but freely miscible 
with oils. It should be kept in well-stoppered, dark- 
colored bottles, as it readily decomposes when exposed 
to air and light. 
Dr. Jules Reboul, of Marseilles, who advises its use in 
tuberculous glands, employs it by injecting eight drops 
directly into the gland tissue, and repeats the injection 
every second day. Should any matter have formed, it is 
first to be evacuated. In cases where the gland has been 
laid bare by ulceration, a tampon saturated with the 
naphthol camphor and placed in contact with the surface 
has produced a healing action, not only in the gland it- 
self, but also in the other affected glands in the neighbor- 
hood. The drug is absorbed and produces a beneficial 
action, both local and general in character. Its effect is 
prolonged, and the drug can be detected in the urine 
for twenty-four hours after an injection. The treatment 
is absolutely harmless and simple. In forty-seven cases 
reported by M. Reboul, twenty-eight were said to be 
cured and nineteen improved. It was also used in cases 
of tuberculous disease of the testicles with equal success. 
He injected four or five drops every eight or ten days 
into the tuberculous nodules on the epididymis and testes. 
In tuberculous disease of the lungs it is employed by be- 
ing injected directly into the parenchymatous tissue of 
the affected lung, two minims in two and a half drachms 
of olive-oil being used. 
As a local antiseptic it is said to be most active and 
effective. In diphtheria it has proved of much benefit, 
as it removes the false membrane and leaves a healthy 
healing surface. When applied to mucous surfaces it is 
frequently accompanied by pain, and requires an applica- 
tion of cocaine previous to its use. Beaumont Small. 
NARCOSIS, FROM ADMINISTRATION OF ANAES- 
THETICS. It is not the purpose of this brief article to 
trench on the broad field covered by the subject " Anaes- 
thetics," in this volume, nor to attempt to improve upon 
work there so ably done. Simply, in as practical and 
concise a way as possible, the writer will herein group, 
from the stand-point of clinical surgery, those methods 
of treatment of anaesthesia-narcosis in excess which seem 
to him valuable, beyond a peradventure ; and which 
should be clearly formulated in the mind of every oper- 
ator. Other modes of treatment, such as by electricity 
and by means of various drugs, of secondary or doubtful 
value, will not be touched upon. 
This accident is so appalling when actually at hand, 
and demands so cool a head and such instant resource, 
that no apology seems necessary for devoting to it a 
special, though short, chapter in this work. 
Following the teaching of Dr. H. C. Wood,1 in his re- 
cently repeated experiments, we agree that the treatment 
of both ether and chloroform narcosis should be identi- 
cal. And, while in experiments on dogs the respiration 
often seems first and chiefly at fault, experienced anaes- 
thetizers know that the heart (at least in the human sub- 
ject) often gives as early-sometimes earlier-warning of 
threatened failure. This is especially true of chloroform 
narcosis; and with either drug it behooves a careful 
operator to put an experienced man on guard, and not 
the usual tyro; and td see that both pulse and respira- 
tion are watched ceaselessly. 
It is, of course, best to prevent the peril under discus- 
sion, if possible ; and the writer firmly believes that with 
this idea in view it is always wise to administer, about 
fifteen minutes before the anaesthetic, as large a hypo- 
dermatic injection of morphine, guarded by atropine, as 
seems safe. For instance, gr. | to £ morphine sulphate, 
and gr. T|n atropine sulphate, in an adult. 
The reasons for this course are elsewhere fully dis- 
cussed (see Anaesthetics); one alone should be enough to 
determine the question, namely, that under this treat- 
ment much less of the anaesthetic is needed in order to 
keep the patient " under to the surgical degree." Con- 
sequently the dose of ether or chloroform being consid- 
erably lessened, the liability to poisoning is proportion- 
ally diminished. And incidentally it may be added, 
both morphine and atropine are agents of value to ward 
off shock due to the operation. 
Because of its great value as both a respiratory stimu- 
lant and a heart tonic, and for the reason named in the 
last sentence, the writer approves of the use for a day or 
two, in moderate doses, prior to any severe operation, 
of strychnine sulphate. Perhaps, when shock is actually 
present, it is of more value, if pushed to moderate strych- 
nization, than any other single drug ; and if this be true, 
its use in prevention of that shock when anticipated would 
seem sensible. 
As Dr. H. C. Wood has demonstrated,1 it is of decided 
value when used by needle during anaesthesia-narcosis; 
660 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Naphthalene,, 
Narcosis. 
and here again its use in prevention seems occasionally 
indicated. 
An ounce or two of whiskey or brandy, before the 
anaesthesia is begun, can have none but a beneficial effect ; 
of this the writer is convinced. Being itself (in modera- 
tion) a cardiac stimulant, the alcohol is a safe addition to 
our narcosis; and, as is the case with morphine, will, 
though to a lesser extent, render unnecessary so large a 
dose of the anaesthetic as otherwise would be needed. 
But, during the operation, should excessive narcosis 
supervene-with or without the preliminary use of alco- 
hol-then the writer can but agree with Dr. Wood in 
thinking that alcohol as a remedial measure would be 
folly, since it is a narcotic, and the patient is already 
suffering from too much narcosis. There are better sys- 
temic stimulants at hand which are not narcotics. 
" Nothing can be more prone to produce fatal syncope 
than the commencement of the operation before complete 
anaesthesia has been induced ; for here we have a lower- 
ing of the vital functions caused by chloroform, and the 
shock of cutting the skin, especially over a sensitive 
area, communicated along sensory nerves whose con- 
duction is not yet in abeyance. Records of death under 
these circumstances (incomplete anaesthesia) show how 
often the fatality arises in cases where trivial, although 
painful, operations, such as reduction of dislocated limbs, 
circumcision, etc., are performed."'2 
Finally, under this heading (prevention of dangerous 
narcosis) let us discuss a plan little advocated in print, 
but which has only to be heard to commend itself; 
namely, as a measure of precaution in a patient of feeble 
vitality about to be subjected to operation, maintaining 
a reserve-guard of pure blood, by accumulating this in one 
or more extremities ; to be released, however, in case of 
need from narcosis.* 
Of course, accumulation of blood in this way in the 
members is not a new thing at all ; but the purpose for 
which it is herein advocated is so, it would seem. 
Dr. A. C. Post, of New York, was, I think, the first to 
use this device in anaesthesia. Dr. Charles McBurney 
read a paper before the New York Surgical Society, about 
a year ago, speaking of the plan as one neglected and 
worthy of more frequent use. He demonstrated it there 
and then upon a man brought for that purpose. The 
technique as described by Dr. McBurney was as follows : 
" Immediately before anaesthesia is begun an ordinary 
Esmarch bandage has been placed on each arm and 
thigh, close to the trunk, and sufficiently tight to obstruct 
the venous return. The radial and posterior tibial ar- 
teries have been carefully watched, and only when the 
limbs have become loaded with blood (distinctly swollen) 
has the constriction been increased to such an extent 
that all circulation, arterial as well as venous, has ceased 
in the limbs. Anaesthesia is then begun, ether having 
been used by me in every case, and the inhaler being an 
ordinary one made of muslin and paper, and containing 
a little cotton. The storage of blood in the limbs has 
not affected the patient's facial appearance at all, and 
no peculiar sensation has been mentioned excepting a lit- 
tle complaint in one or two instances regarding the 
bands. The method has been applied to ten operative 
cases (and many more since this paper was written). At 
the beginning of the anaesthesia from one to two ounces 
of ether have been poured into the inhaler from a meas- 
uring-glass. The patients have been remarkably free 
from signs of irritation; that is, congestion of the face 
has not occurred, and struggling has been nearly en- 
tirely absent. Complete anaesthesia, so that the conjunc- 
tiva could be freely handled, has been accomplished in 
from three to five minutes. Coughing has occurred 
only once, and then for a very short time. Trembling 
of the limbs has not occurred at all. 
" The mouth has required wiping free from mucus only 
once. No mucous rales in trachea or bronchi have been 
heard in any case. During the operation the anaesthesia 
has been quieter and more perfect than is at all common 
with ether. ... As soon as the operation has been 
terminated and the dressings applied, the bands have 
been removed, and all four limbs raised. The rapidity 
with which patients have recovered from the effects of 
the anaesthetic has been very noticeable. Most of them 
have been able to talk intelligently and answer questions 
correctly within three minutes. Vomiting has occurred 
but once, and then to a slight degree only. None of the 
usual stupor has been noticed after the ether-cone has 
been removed." 
The purposes for which this device has heretofore been 
advocated are the relief of kidney and other overburdened 
emunctories, especially when these show signs of disease ; 
speed of anaesthesia and of waking therefrom ; less bleed- 
ing, during operations upon the head or trunk ; avoid- 
ance of deleterious effect of the anaesthetic upon more 
blood than is absolutely necessary ; shortening the period 
of bronchial and pulmonary irritation, which lasts until 
all the ether has escaped from the system ; prevention of 
vomiting ; and economy of anaesthetic. 
To these should now be added Dr. Webster's sugges- 
tion, which the writer has several times made use of 
practically when feebleness of the patient has made him 
fear anaesthesia-narcosis. Not all four limbs, as just de- 
scribed, but for this purpose one thigh will suffice. This 
is corded at the groin, at first slightly, permitting it to 
swell with accumulated blood, and then tightly enough 
to obstruct all flow in either direction. The limb should 
now be kept wrapped in a blanket, with warm bottles or 
bricks about it. In case of dangerous narcosis, release 
the band, elevate, and pour the great quantities of pure 
blood contained in the limb into the body surcharged 
with ether or chloroform. The good result of this needs 
no discussion. Of course the other and more usual plans 
of treatment are also to be used. 
Treatment of Narcosis.-Where respiration is mainly 
at fault, the heart being safe, Sylvester's method of arti- 
ficial respiration is our best treatment, beginning always, 
as in drowning, by the expulsive effort. The passage- 
way to the larynx must be kept free from blood, mucus, 
and vomited matters ; and either the tongue kept drawn 
well forward by a clamp on it (the mouth, meanwhile, 
being held open by a cork between the teeth, or any of 
the ordinary gags), or else Mr. Benjamin Howard's plan 
of raising the epiglottis should be employed, which is 
efficient if the nasal respiratory area is unobstructed. 
This latter plan is to over-extend the head as far as pos- 
sible. The mouth is closed, and " a chain of three links " 
is made tense by this position ; i.e., the genio-hyoid mus- 
cles, the hyoid bone, and the hyo-epiglottic ligaments. 
Consequently the epiglottis cannot fall over the entrance 
to the larynx, and the air passes in freely through the 
nose. 
Protrusion of the symphysis menti by the thumbs be- 
hind the rami of the jaw, is a plan often followed, in 
order to prevent obstruction of the larynx by the base of 
the tongue. The genio-hyo-glossi muscles are thereby 
drawn forward, in turn the glossi-epiglottic attachments 
are made tense, and the epiglottis thus lifted. 
Koenig's plan, suggested in chloroform narcosis, is 
intermittent pressure upon the chest, one of the thumbs 
being placed in a space over the heart (differing simply in 
this latter respect from Nussbaum's method) between the 
apex-beat and the sternum. And Maas' modification of 
this plan is one whereby the pressure aforesaid is made 
very rapidly-one hundred and twenty times per minute. 
Both, it would seem, must act mainly by frequent expul- 
sion of narcotized air, and admission of fresh ; and con- 
sequently must come under this heading-artificial res- 
piration. It is difficult to conceive that the thumb in an 
intercostal space over the heart can compress that organ 
appreciably or enough to excite it afresh to work, though 
we cannot deny the possibility. 
Inversion of the Patient.-This, the plan of Nelaton, is 
generally regarded as our first choice when the heart is 
* Dr. W. T. Aikens and Dr. L. M. Sweetnam, of Toronto, and Dr. 
Leonard Corning, of New York, have also all used and advocated this 
plan of sequestration of blood ; but not for the purpose mentioned by 
the writer of this article. He has not heard of its actual employment 
by others beside himself, in prevention of dangerous narcosis. The 
credit of the suggestion belongs, however, with Dr. David Webster, of 
New York. who. as the writer finds, published a note upon it in the 
New York Medical Journal for October 29, 1887. 
661 Narcosis. 
Nasal Surgery. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
mainly at fault, although artificial respiration also aids 
a flagging heart. Dr. Chisholm, of Baltimore, depends 
exclusively upon this ; and although his extensive record 
of operations under chloroform (ten thousand) without a 
death certainly makes his opinion deserving of respect, 
I think there are few who will, with him, refuse to use 
artificial respiration and other valuable aids to resuscita- 
tion in addition to inverting the patient. 
The latter, upon the appearance of signs of suspended 
animation with failing heart, should be held from sliding 
off the table, which is meanwhile so tipped that the pa- 
tient's head is downward, and almost vertical. 
It has been taught that cerebral anaemia is hereby over- 
come through gravity, and, consequently, the nerve-cen- 
tres controlling heart and respiration being better sup- 
plied with blood are enabled thereby to do more efficient 
work. To the writer it seems that this explanation is 
far from the true one. In only one way can blood from 
the lower part of the chest, the abdomen, and lower ex- 
tremities, reach the brain, if the patient be inverted ; i.e., 
by being pumped through the heart. Certainly not by 
gravity alone. And since we know that mechanical dis- 
tention of the chambers of the heart by the circulating 
fluid is a most important factor in exciting cardiac con- 
tractions, the proper explanation is not far to seek. 
Rapidly repeated compressions of the chest, with both 
the surgeon's hands, in its lower-epigastric-portion, 
meanwhile, will aid expulsion of narcotized air ; and fol- 
lowing each such emptying of the lungs by the surgeon, 
the Nelaton posture (by dragging on the pectoral muscles 
through the weight of the arms hanging by the sides of 
the patient's head) causes a mechanical inspiratory act 
after Sylvester's principle. So that if the patient be held 
sufficiently inverted, this position, with Nussbaum's 
treatment (just mentioned) will render Sylvester's need- 
less. 
The writer prefers this combined method (Nelaton- 
Nussbaum) to Sylvester's, where both heart and respira- 
tion are failing ; and this is certainly the rule rather than 
the exception. 
Heat.-It cannot be questioned that among methods of 
exciting a narcotized heart to resume work, one of the 
most efficient is heat. A quart of hot water injected by 
syringe into the rectum, while the patient is inverted as 
just described, is standard treatment. The patient's body 
and limbs should not be left unclothed to be chilled, 
but should be wrapped in warm blankets. The late Dr. 
Sands, of New York, has stated that he valued most 
highly moist heat over the heart. The writer has seen 
not only this gentleman, but others of the best-known 
surgeons in New York, cause a blister several inches 
square on the precordium by application of steaming 
hot cloths during dangerous anesthesia-narcosis. 
Dr. Charles McBurney has recently said in a letter' to 
the writer, " When the heart flags seriously in ether and 
chloroform narcosis, I regard very hot applications di- 
rectly over the heart as of decided value as a means of 
stimulating that organ to renewed activity. ... I 
like the idea of your arterial saline injections very much, 
and shall use it at the first opportunity." 
The latter sentence has reference to a plan, devised by 
the writer, whereby heat may, with infinitely more di- 
rectness and efficiency, be brought to bear on the heart. 
This is, to pump hot salt-water directly into the blood-cur- 
rent, and thereby stimulate both heart and respiratory 
centre in the medulla. 
This is so self-evidently a useful proposition as hardly 
to need argument in its defence. The wonder is that it 
was not long ago used for this purpose ; but, so far as the 
writer can discover, it has not heretofore been suggested. 
If, as is generally admitted, heat applied over the heart 
can stimulate that viscus-whether directly, by extension 
through the chest-wall until felt by the apex-beat, or re- 
flexly-how much more efficient must be that stimulation 
when that heat is brought into the heart-chambers, in the 
circulating fluid ! 
The temperature of the salt-water used should be as hot 
as the hand can possibly support. This will be 49° C. 
(120° F.) ora trifle less ; and therefore the thermometer 
need not be employed. A much higher degree of heat 
than this could safely be used ; since globulin only co- 
agulates at 70° C.3 (158° F.), and serum-albumin at 72° C.4 
(162 F.) ; or about 40° F. hotter than the hand can bear. 
At the temperature first mentioned (120° F.) the writer 
has recorded5 a number of cases of haemorrhage so treat- 
ed, with excellent results ; and Dr. Edwin Sternberg, of 
New York, two more, with recovery ; whereas others 
which he had treated also by saline infusion, but at bodily 
temperature, died. 
It is demonstrated both by the writer's kymographic 
experiments, heretofore reported, and by the foregoing 
cases,_ that very hot saline infusion is not only safe but 
best, in severe haemorrhage ; and the same is true in the 
matter under discussion-heart-failure in narcosis from 
anaesthesia. 
The strength of the salt-solution ♦ is that normal to the 
blood serum ; roughly, a heaped teaspoonful of chloride 
of sodium to the quart of sterilized water. It is fair to 
assume that every operating-room, even in a private 
house, has water ready at hand that has been boiled and 
is still hot. This, some table salt, a Davidson syringe, 
and a coarse hypodermatic needle or a cannula are all the 
equipment needed. Remove the tip from the syringe, 
replace it with the cannula-hilt, and tie the latter in place 
with a thread. Disinfect this apparatus by pumping 
boiling water through it.f 
As to the amount of the solution to be used, perhaps a 
pint may be called an average. In a case immediately 
threatening death I should inject still more, and hotter. 
The method is also of use in yet another way-by bring- 
ing added pressure to bear upon the heart-chambers, just 
as with the inversion plan (Nelaton's). 
In haemorrhage or in shock threatening imminent 
death, the writer has urged, in recent publications, the 
injection of the hot infusion directly into the femoral 
artery; the aspirating needle (not as yet attached to the 
syringe) finding it readily where, under Poupart's liga- 
ment, it is large enough in calibre to carry a lead-pencil, 
and a bright-red drop of blood welling up in the needle 
proving the latter to be in place ; upon which the syr- 
inge-end is tied on and the injection begun.j: 
But here, in anaesthesia-narcosis, there is not a moment 
to waste. The hot salt-water should reach the heart, in 
considerable amount, very quickly ; more quickly than 
the hypodermic needle would permit. It is better there- 
fore to use the cannula, and while the assistant is at- 
taching the base of this to the syringe-end, and filling 
both with the hot solution, the surgeon opens a vein at 
the bend of the elbow-or the internal saphenous over 
the inner malleolus, or any other vein of fair size ; 
perhaps one in the operation-wound. Now the cannula 
is tied within this vessel and the injection given. In a 
properly equipped room the injection may be begun 
within a minute or two of the time it is determined upon. 
Of course if the patient is able to swallow, hot drinks- 
for example, black coffee-or other hot stimulants (save 
alcoholic), are indicated. 
Cold.-Although in the writer's opinion not so efficient 
as heat, the application of a piece of ice over the heart 
will sometimes refiexly excite more vigorous contrac- 
tions ; and similarly, ice within the rectum aids respira- 
tory efforts. 
Use of Drugs.-Our syringe and cannula are still in 
* We must never omit the salt-it would be fatal to mix plain water 
with the blood, as this at once dissolves out the haemoglobin from the 
blood-disks; whereas even so small an amount of salt as that named- 
six parts per thousand-renders it safe. 
+ Of course well-equipped surgeons will not have to waste precious 
minutes by these steps, which may well be taken before the beginning of 
an operation requiring anaesthesia. 
* The only objection-a self-evident one-to this device, in haemor- 
rhage, is the hesitancy naturally felt to pierce so large an artery ; and 
this should vanish when one reflects that the most prominent plan now 
used bj' surgeons for aneurisms so placed as to be inoperable by ligation, 
and yet threatening rupture, is that of Macewen, of Glasgow, which is 
needling, and in which long needles are thrust-a dozen or so-into the 
sac. and left for many hours, to cause thicker deposits on the walls; and 
this with benefit, as a rule. 
If a diseased vessel can safely stand such treatment as this, it seems a 
mild inference that a sound artery can bear a single needle for a single 
half-hour. And such has been the writer's experience thus far. 
662 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Narcosis. 
Nasal Surgery. 
(SUPPLEMENT.) 
place-the latter tied within a vein. Either mingled with 
the hot salt-water, or preceding it, or following it, we 
may use properly diluted aqua ammonite, a remedy of un- 
questioned value. The latter, strychnine, and digitalis 
comprise all the drugs recommended as of real use in 
this condition by Dr. H. C. Wood in his Berlin Report in 
1890, who however did not experiment with strophanthus 
and many other heart-tonics. He says : " From fifteen 
to twenty-five minims of the aqua ammonite fortior, di- 
luted with four times its bulk of water, should be thrown 
directly into a vein of the arm, and repeated in fifteen 
minutes if necessary."6 
The same drug may be exhibited by inhalation, with 
some caution, as it is capable of causing violent local in- 
flammation where used in excess. The only hypodermic 
abscess for which the writer has ever been personally re- 
sponsible was caused by an injection of aqua ammonite- 
and not the fortior-in a case of opium narcosis; not 
injected into a vein but into the subcutaneous connective 
tissue of the thigh. A slough more than an inch across 
resulted. 
Regarding amyl nitrite, it is certain from Burrall's 
clinical cases that it must be of some value, although 
Wood found it inefficient on dogs. Paralyzing as it does 
unstriped muscle everywhere, and consequently com- 
pletely dilating the blood-vessels, it must inevitably dimin- 
ish the resistance caused by vascular tone against which 
the heart has to work in pumping blood. If that tone be 
lost from complete narcosis, then it is plain that in such 
case, at such time, this drug would be almost useless, 
since its direct stimulant effect on the heart is but slight, 
and the rapid action of this organ under amyl nitrite is 
due mainly to depressing the inhibitory centres ; to which, 
in complete narcosis, the heart could hardly be expected 
to respond vigorously. 
Strychnine lias already been discussed. Both as a heart 
tonic and as a respiratory stimulant it is of great value. 
Regarding digitalis, the testimony is equally strong, so 
far as the heart is concerned. The writer carries regu- 
larly to his operations a solution of strychnine sulphate 
in equal parts of the tinctures of digitalis and strophan- 
thus, and has repeatedly used this combination by hypo- 
dermatic needle with benefit. 
Strophanthus alone he has not employed. However, 
since it is more rapid in action than is digitalis, has less 
tendency to contract arterioles than has the latter drug, 
and stimulates the heart vigorously and very much like 
digitalis, it is obviously indicated. 
Two remaining devices the writer has never seen used ; 
but he cannot doubt their value in absolutely desperate 
cases. This has been repeatedly demonstrated on the 
lower animals. One of these is mechanical stimulation 
of the heart by a long, slender needle passed through the 
anterior chest-wall ;7 and the other, introduction of a 
finger through a cut in the prsecordium, thus permitting 
intermittent pressure on the heart; to be repeated some 
twenty times, at the rate of seventy to eighty times a 
minute. It is not necessary to empty the heart thereby; 
a slight pressure will drive on some blood.8 
In conclusion, it is perhaps needless to say that sur- 
geons employ not one but as many as are deemed wise, at 
once, from this list of weapons against an enemy that 
comes unexpectedly and kills quickly if at all. Every 
moment is golden, and indecision or unwise choice may, 
in a matter like this, cost a life. 
Robert II. M. Dawbarn. 
1 Berlin Report, 1890. 
a Anaesthetics : Mr. D. W. Buxton, 2d edition, 1892, p. 122. 
3 Kirke's Physiology, 11th edition, p. 846. 
4 Dalton's Physiology, 7th edition, p. 80. 
6 Medical Record, January 2, 1892 ; also November 12, 1892. 
6 Wood's Therapeutics, 7th edition, p. 330. 
7 D. W. Buxton (quoted), p. 125. 
8 Mr. George Rowell, F.R.C.S., British Medical Journal, October 29. 
1892. 
NASAL SURGERY, ASEPTIC AND ANTISEPTIC. 
The only reason why antiseptic methods have been em- 
ployed so little in nasal surgery is because surgical oper- 
ations in the nose have become frequent only within the 
last few years. It requires a few years for any line of 
surgery to develop antiseptic methods. In a very short 
time it is safe to predict that the rhinologist will be as 
particular in his methods of operating as is the abdom- 
inal surgeon of to-day. It would seem that either the 
general surgeon is over-careful in his attempts to secure 
perfect cleanliness, and over-zealous in the employment 
of aseptic and antiseptic agents, or nasal surgeons, so far 
as my knowledge extends, have paid too little attention 
to this matter of antisepsis in their operative work. If 
the germ theory of infection or of putrefactive fermenta- 
tion of Pasteur, Koch, Lister, and Watson Cheyne-a 
theory which is firmly believed in by nine-tenths of the 
leading American surgeons to-day-if this germ theory 
is proven, nasal surgeons need to be as particular as 
other surgeons in their methods of operating. 
In a discussion of a paper by the writer, entitled " An- 
tiseptic Nasal Surgery," by the American Laryngological 
Association, at its Tenth Annual Congress, 1888, various 
opinions were expressed as to the necessity of employing 
antiseptic measures when doing nasal surgery. The dis- 
cussion became very general. Several of the gentlemen 
said they did but little nasal surgery, because in their 
opinion there were but few cases that required surgical 
interference. A small number employed only the gal- 
vano-cautery in removing tissue, and were not favorably 
disposed toward cutting and drilling operations upon the 
bony and cartilaginous structures of the nose, so that, 
aside from the observance of strict cleanliness in treating 
nasal disease, they had had but little occasion to employ 
antiseptic solutions. I would like to add, in parentheses, 
here-and I shall refer to it again-that the application 
of the galvano- (that is, the actual) cautery to open 
wounds affords one of the most effective means of pre- 
venting the absorption of septic material. Gerster 1 says 
"the actual cautery is the most effective sterilizer." 
It may be true, therefore, that if only the galvano-cautery 
is used in removing nasal obstructions there is little 
need to employ other antiseptic precautions. Strict 
cleanliness before operations, and application of the ac- 
tual cautery to the wound would perhaps satisfy most 
aseptic operators. While it is true, however, that the 
majority of rhinologists do make use of the saw, scis- 
sors, and trephine, so short a time has elapsed since these 
instruments were perfected, and also, indeed, since nasal 
surgery has assumed its present large proportions, that 
it is perhaps still too early to pass judgment upon the 
question whether perfect asepsis and antisepsis are attain- 
able in nasal surgery. 
A second reason for the lack of attention paid to the use 
of antiseptics in nasal surgery is that the wounds inflicted 
by operations are very small as compared with those 
which the general surgeon has to treat; but the advan- 
tage the nasal operator possesses in the loss of a smaller 
extent of surface tissue is more than equalized by the 
peculiar conditions of nasal wounds, and these conditions 
furnish the third reason why antiseptics have been held 
at so low a value by nasal surgeons. It is far more diffi- 
cult to employ antiseptic methods effectively in the nasal 
cavities than upon the surface of the body or in the ab- 
dominal or pelvic cavities. Not only is it wellnigh im- 
possible to obtain an aseptic condition before operations, 
as can be done on the surface of the body, by thoroughly 
scrubbing with soap and water, and sponging with a 
solution of carbolic acid or bichloride of mercury, but 
the nasal wound is subjected to all the conditions which 
are deemed most favorable to the generation and propa- 
gation of micro-organisms, viz., heat and an abundance 
of moisture and oxygen. 
Watson Cheyne 2 says: "The ideal result of wound 
treatment is seen in the repair of subcutaneous injuries." 
He might have cited nasal wounds as the most unfavor- 
able illustration of wound healing. The decomposing 
nasal secretions add to the fertility of the soil which is 
most favorable to the development of pathogenetic mi- 
crobes. The swelling of the tissues within the bony 
nasal walls prevents effective drainage, one of the safe- 
guards against septic absorption, and the pent-up secre- 
tions furnish ample septic material until the absorbents 
are satisfied. We find, therefore, in nasal wounds 
663 Nasal Surgery. 
Nasal Surgery. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
caused by operation both varieties of the "obstacles to 
repair " which are recognized by writers-the mechani- 
cal and the chemical. The mechanical are present in 
the particles of bone, cartilage, or soft tissue, or in the 
atoms of dirt which remain in the nasal cavities unless 
great care is taken to wash them out, while all the usual 
conditions of nasal wounds favor putrefactive fermenta- 
tion, which is the basis of the chemical obstacle to heal- 
ing. 
In endeavoring to mention all the difficulties lying in 
the way Of the practice of aseptic nasal surgery, we must 
not forget that the peculiar anatomical structure of the 
nasal tissues and the peculiar physiological function they 
perform, furnish additional hindrances to the proper 
treatment of wounds. If an attempt is made to exclude 
all air from an ulceration on the septum, by covering it 
with a protective and sealing the nasal orifice, we have 
the evil results which are caused by the irritation of these 
packings in the nostril. The erectile tissues will not 
bear the contact of a foreign body with impunity, the 
dressings disturb the vaso-motor reflexes, and the nostrils 
are filled with mucus and serum, which wet the dressings 
and render them less effective. 
In view of these difficulties the question may be asked, 
Is it possible to obtain an absolutely aseptic condition 
for the healing of nasal wounds? We think not. If 
this is true, is it the duty of the nasal surgeon to use all 
antiseptic methods possible ? Are we depriving our pa- 
tients of any degree of safety or comfort by treating 
nasal wounds as the general surgeons treated all wounds 
before antiseptics were known ? To make the question 
still more tangible : Do we see symptoms of septicaemia 
more frequently following those nasal operations where 
no antiseptic precautions are observed, than those which 
are protected by every effort to exclude disease-bearing 
germs ? Our experience would say, yes, emphatically. 
We believe that few patients would die if nasal wounds 
were made with unclean instruments ; but everyone is en- 
titled to every safeguard which protects his life, and 
which adds to his comfort. Our patient must not be 
put to bed because of a small nasal operation. It is 
possible to do nasal surgery in such a manner that his 
business will not be interfered with. I shall not at this 
time discuss the point whether there is more surgical 
work performed in the nose than is requisite or judi- 
cious. There should be no debatable ground as to how 
it should be performed. 
In 1888, before antiseptics were generally employed, 
when investigating the value of antiseptic methods in 
nasal surgery, I found that it was almost the universal 
testimony of those who used the knife, the saw, the 
scissors, and the trephine, that constitutional disturbance, 
more or less marked in character according to the amount 
of tissue removed or the extent of surface denuded, fol- 
lowed a certain percentage of these operations. These 
symptoms may be stated as commencing in from twelve 
to forty-eight hours, with slight chilly feelings, occa- 
sionally with a chill, and followed by a rise of tem- 
perature ranging from 99.5° F. in mild cases, to 103° F. 
in severe ones, headache, pains through the eyes, nose, 
and forehead, and in the back and limbs. The patient 
feels too ill to engage in any business. Men of nervous 
temperament remain at home for a day or two, and 
women stay in bed. These patients seem to be extremely 
nervous and irritable, and they do not thoroughly regain 
their equilibrium for some time. Some of the above 
symptoms occurred in some degree after, perhaps, twen- 
ty-five per cent, of the cutting, sawing, or drilling oper- 
ations on the nose. Of the severe cases I have seen but 
one in my practice, and that was not in any sense grave. 
I may describe it. 
In the spring of 1887 a young man came to me with 
his left nostril almost entirely stopped with cartilaginous 
deflection. I remember him as one of the most nervous 
patients I ever saw. The trephine driven by the electric 
motor was used. The operation lasted but a few mo- 
ments. Haemorrhage was not severe, but it was persist- 
ent, and I placed an ordinary cotton tampon against the 
wound. The patient came to the office the next day. I 
(SUPPLEMENT.) 
removed the plug and washed the nostril with a carbo- 
lized solution, but, as the bleeding continued, I put in a 
second tampon. I saw the patient at his house the next 
day. The tissues over the left nostril and cheek were 
swollen and red, the left eye was almost closed by oedema 
of the lids. The patient had had chilly feelings the 
night before, and 1 found his temperature 102.5° F. 
He exhibited the nervous irritability spoken of. I re- 
moved the plug and washed the nasal cavities with car- 
bolized solutions. He began to improve the next day, 
and was about in four days. In another case, operated 
upon in 1886, after the use of the galvano-cautery on the 
septum, the patient suffered from constitutional symp- 
toms ; temperature, 101.5° F. ; and on the second day after 
the operation an erysipelatous blush showed itself on the 
nose and for a short distance on the cheeks. This lasted 
only twenty-four hours and the patient quickly recov- 
ered. 
I formerly saw numbers of cases where the patient felt 
uncomfortable the second day after an operation on the 
septum. There was probably some slight rise in tempera- 
ture in all these cases. It used to be common enough in 
dispensary practice to have patients return a few days 
after a cautery or drilling operation on the nasal septum, 
and say that they had felt quite ill for some time after 
the operation. 
My attention was most forcibly called to the serious 
results which may follow nasal operations by the un- 
comfortable experience of a prominent surgeon of New 
York. He was operated on by a physician of experience 
in nasal work. A cartilaginous and bony convexity of 
the septum was removed by a revolving drill The 
work was done under chloroform. The second day after 
the operation the nostril was closed by inflammatory 
swelling. The patient had a chill on the evening of the 
second day, and for seven days afterward the tempera- 
ture ranged from 103° to 104° F. ; slight chills were 
frequent, perspiration abundant, albumin in the urine. 
The nose, eyes, and face were considerably swollen. The 
patient lost flesh so rapidly and was so depressed men- 
tally that fears were entertained at one time that he 
would not recover. He convalesced slowly, and was un- 
fit for work for six weeks. In conversation with me 
about his case he criticised in strong language the lack 
of antiseptic methods employed by nasal surgeons. He 
himself, a strong advocate of all antiseptic precautions, 
and most particular in his practice as a general surgeon, 
styled the old-time methods by the more expressive than 
elegant term of " rotten surgery." There was no doubt 
but that he had suffered from a severe attack of blood- 
poisoning, the "septic intoxication" of Cheyne, the 
" traumatic infectious " disease of Koch. Absorption of 
putrid matter had taken place through the denuded carti- 
lage and bone of the nose, and, as a consequence, he had 
almost lost his life. I have heard of other serious cases, 
but have no authentic history of them. But this all oc- 
curred from 1886 to 1888. 
The constitutional symptoms which follow operations 
in the nasal cavities, even where no antiseptic precau- 
tions are resorted to, may not be severe nor long contin- 
ued. The patient's life is rarely endangered, but his 
comfort may be seriously interfered with. There are a 
number of rhinologists who do not perform cutting or 
drilling operations upon the nose because they fear the 
constitutional disturbance that may follow such opera- 
tions. As one physician expresses himself in regard to 
these operations, he " prefers to be on the safe side." Is 
it not possible to operate freely in any nasal case where 
good judgment advises, and, by employing strict antisep- 
tic precautions, always be on the safe side ? 
General symptoms, which appear during the first 
twenty-four hours after a nasal operation, may properly 
be attributed to shock and the reaction after shock. The 
amount of shock will depend upon the temperament and 
general health of the patient. Sex seems to have little 
significance. Shock will be in proportion to the amount 
of tissue removed, the extent of surface laid bare, the 
amount of pain inflicted, and the quantity of blood lost. 
The degree of shock is also in direct ratio with the length 
664 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Nasal Surgery, 
Nasal Surgery. 
of time consumed in operation. Shock seems to be 
greater when the nasal septum is wounded than when 
the soft tissues are injured, but this perhaps is because 
the saw, scissors, or trephine are rarely used on soft tis- 
sues. All the symptoms which may be fairly attributable 
to shock following the small operations upon the nose 
should be over in twenty-four hours. For example, a 
cutting operation is performed upon the septum, and in 
a few hours the patient may feel generally shaken up- 
with headache, neuralgic pains about the eyes, nose, and 
teeth ; he may feel weak and perhaps even faint; re- 
action declares itself in a slight rise of temperature, not 
more than 99.5° F., which subsides in twenty-four hours. 
We should not confound such constitutional disturbance 
with symptoms which begin later, last longer, and are more 
pronounced-symptoms which surgical writers formerly 
grouped under the names of "traumatic" or " surgical" 
fever. 
The transitory disturbance called shock subsides as 
soon as the nervous system has had time to recover its 
equilibrium. But neither shock to the nervous reflexes 
nor mechanical disturbance of the nasal circulation is 
considered any longer competent to explain the systemic 
disturbance which was called "surgical fever" by the 
operators of twenty years ago. Thanks to the investiga- 
tions of Pasteur and Koch, and to the antiseptic surgical 
procedures elaborated by Lister, traumatic fever is no 
longer a legitimate disease which follows all surgical 
operations. The presence of marked constitutional dis- 
turbance, chills, and high temperature after the severest 
operation now reflects unfavorably upon the methods 
employed by the operator, and the old "laudable" pus, 
teeming with germs of suppuration, has been proven to 
be an evidence of wound infection. 
The belief that symptoms such as we have described 
were caused by the action of micro-organisms, and w7ere 
not, as Billroth 3 has it, "the general accidental diseases 
which may accompany wounds," had been suggested at 
the beginning of this century; but, in 1831 Braconnet 
stated the opinion that micro-organisms produced virulent 
principles which acted as ferments. In 1836 Donne dis- 
covered microscopic organisms in the pus of chancres. 
In 1848 Fuchs spoke of the presence of bacteria in some 
of the septic diseases of animals, and Pollender, in 1850, 
discovered bacteria in the blood of cattle dying of char- 
bon. 
In 1861 Pasteur began his remarkable demonstrations, 
proving first that butyric fermentation was effected by 
an organism, and in the next year that there existed in 
the air countless organized corpuscles which were the 
germs of fermentation. In 1863 he stated that putrefac- 
tion was determined by ferments of the vibrio species. 
This theory of the relation of putrefaction to fermenta- 
tion was quickly and naturally applied to pathological 
conditions, and the germ origin of splenic fever was soon 
demonstrated. 
Pasteur was first to maintain that septicaemia. was of 
germ origin. Koch has demonstrated, by inoculation in 
animals, that a number of diseases similar to those in 
men are caused by a specific microbe. Pathogenetic mi- 
crobes have been demonstrated in erysipelas, gonor- 
rhoea, anthrax, empyema, tuberculosis, osteomyelitis, 
etc. Rosenbach,4 of Gottingen, after painstaking experi- 
mentation, denies the possibility of the formation of pus 
by mechanical, physical, or chemical means if microbes 
are excluded, and Ogston5 has also quite clearly shown 
that all suppurative processes are caused by micro- 
organisms. Gottstein/ of Berlin, says that the microbes 
found in pus probably exist in a latent way on the skin, 
and in the mouth and nose, and become active only when 
a wound is produced which gives them access to the blood- 
tissues, or rather furnish an opportunity for the absorp- 
tion of the products of the micro-organisms-the so-called 
ptomaines, or the sepsin of Bergmann, or the " putrefac- 
tive alkaloids," or the excrementitous products of the mi- 
crobes mentioned by other writers. Gottstein further 
says that this absorption continues until an aggregation 
of leucocytes furnishes a barrier which prevents its fur- 
ther progress. This dam of leucocytes is the granulation 
tissue which is present in old ulcerations, and its pres- 
ence explains why we have no symptoms of blood- 
poisoning in ulcerous coryza and other long-continued 
ulcerations of the nose. Gottstein asserts that these 
micro-organisms are the cause of traumatic infectious 
diseases. Cheyne7 remarks: "The antiseptic method 
is based on the germ theory of fermentation and putre- 
faction, and not necessarily of infectious disease." Ros- 
well Park 8 says : "The lowest forms of vegetable life 
are the cause of all forms of fermentation, only a certain 
number of which are putrefactive." This latter fact 
granted, antiseptic surgery has given its reason without 
discussing in detail the origin of surgical diseases. Some 
one has said that " antiseptics should be used to supple- 
ment cleanliness." Gerster1 says in his text-book that 
" modern wound treatment is based entirely on the old 
and well-known principles of the preservation of organic 
substances." I cannot do better than to quote once more 
from Cheyne,2 whose very intelligent writings make the 
subject of antiseptics a very attractive one. He says: 
" When a wound is large, and no antiseptics are used, 
absorption takes place, and we have in a few days trau- 
matic fever, and that the symptoms of septic intoxication 
are due to the absorption from the wound is proved in 
that the symptoms subside when granulation takes 
place." 
The bacteria which are found in the nostril may be 
harmful or harmless. Nature may or may not be able to 
prevent the entrance of septic germs through surgical 
w'ounds of the nose, or render them innocuous after their 
entrance. These considerations remain to be settled by 
bacteriological study, but the experience of some years 
in nasal surgery has fully satisfied us that our patients 
suffer far less after operation from constitutional dis- 
turbance, and the wounds heal more quickly, when they 
are somewhat protected from external influences. Dr. 
Jonathan Wright, of Brooklyn,11 has made a careful study 
of the various kinds of bacteria which he found in the 
healthy nose, and if space allowed it would be of inter- 
est to cpiote largely from his article, " Nasal Bacteria in 
Health," but a few results must suffice. He found that 
the bacterial forms varied very much according to the 
dry or moist condition of the streets, and the amount of 
wind existing. The staphylococcus pyogenes was by far 
the most frequent variety found. The investigations of 
many workers in this field have demonstrated that this 
form of bacterial life is found upon all the mucous sur- 
faces and upon different portions of the human body. 
Whether this particular germ is the one which is to be 
feared after nasal operations remains to be decided. The 
many conditions which are necessary to the growth of 
this, as well as to that of the many other forms of micro- 
organisms, leaves us in doubt as to the influence they exert 
upon a nasal wound. They must be in sufficiently large 
numbers to overcome Nature's resistance. Although the 
staphylococcus pyogenes is found in abundance in the 
mouth, it is a significant fact pointed out by Wright,11 
that infection never follows excision of the tonsils or 
uvula. 
Nasal wounds, however, are apparently much more ex- 
posed to pathogenic organisms than are injuries of other 
mucous surfaces, for the nostrils filter them out of the 
inspired current of air, as has been proven by Aschen- 
brandt13and others. Wright conducted a series of ex- 
periments which showed that while ten litres of labora- 
tory air contained four moulds and one hundred and 
twenty-five bacteria, it contained only one mould and 
twenty-four bacteria after its passage through the nose, 
This is not the place to give the various opinions held 
by ardent students as to the manner in which nature 
renders the septic germs harmless, whenever they have 
obtained entrance into the circulation. It is enough for 
our purpose to state that the larger number of investiga- 
tors believe that pathogenic germs are killed by the 
chemical action of the blood serum, while the minority, 
represented perhaps by Metschnikoff,14 hold that the real 
enemy of disease-bearing bacteria are the leucocytes. 
Those who argue against the value of using antiseptics 
in nasal surgery maintain that since it is impossible to 
665 Nasal Surgery. 
Nephrorrliapliy. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
obtain anything like an aseptic condition of the nose, 
antiseptic precautions are almost valueless. They might 
as well say that since the nose cannot be made perfectly 
clean it is useless to employ any cleansing sprays what- 
soever. 
Were we ever so indifferent as to the importance of 
treating nasal wounds antiseptically, we cannot ignore 
the greatly improved results which surgeons have been 
able to obtain since they have employed antiseptic meth- 
ods. The largest operations are so scientifically per- 
formed in our hospitals to-day that we have ceased to 
wonder when we observe that there is less constitutional 
disturbance after an exsection of the knee, an amputation 
of the thigh, or an abdominal section, than formerly fol- 
lowed the loss of a finger or toe. A most interesting 
paper was read at the New York Academy some years 
ago, which brought out an earnest discussion. The 
writer advocated external operation for deep urethral 
stricture on the ground that in performing internal ure- 
throtomy proper drainage was obtained with great diffi- 
culty, and that urethral fever, the great bugbear of oper- 
ators, was due to sepsis and not to nervous causes. The 
discussion was as to the causation of urethral fever. I 
believe only one surgeon who discussed the paper indorsed 
the older theory, that urethral fever was due to reflex 
nervous causes. In extirpation of the tongue it is found 
that there is much less danger of septicaemia where pre- 
liminary tracheotomy is done, and it is thus rendered 
possible to employ antiseptic solutions and to partially 
exclude air from the mouth. 
There are two general methods of treating nasal wounds 
after operation, viz., the open and the closed methods. 
Among nasal surgeons of large experience there are 
strong advocates of each. Some operators believe that 
nasal wounds do well enough if left entirely alone. They 
do not fear infection, either from the germs which are 
habitually found in the healthy nostril, nor from those 
special micro-organisms characteristic of erysipelas, scar- 
let fever, etc. We should consider it unsafe to ad- 
vocate such indifference to antiseptic methods. They 
claim that the blood-coagulum is ample protection against 
wound infection. There seems to us to be many disad- 
vantages attending the "open" method of wound treat- 
ment, and 1st, the danger of haemorrhage. Strong solu- 
tions of cocaine are always used in cutting operations in 
the nose, so that haemorrhage immediately after the opera- 
tion may be slight, for the reason that the cocaine has 
expelled the peripheral circulation. The bleeding ceases 
and the patient is allowed to go on the street. The cir- 
culation in the nose is restored after a little, and profuse 
bleeding from the uncovered nasal wound may take place, 
if not to the danger, at least to the discomfort, of the 
patient. 2d. If it is granted that there is no danger of 
infection from the ordinary germs that are commonly 
found in the nose and in the atmosphere, should we leave 
nasal wounds exposed to the germs of erysipelas, scarlet 
fever, diphtheria, etc. ? To dispensary patients such ex- 
posure must be common enough. 3d. We have found 
that nasal wounds heal more quickly when covered by 
some antiseptic protective. 
We believe the majority of writers advocate some 
modification of the closed method of treatment after 
operation. We repeat what we have said before, that we 
think it is impossible to hermetically seal a nostril either 
by the method proposed by Kitchen15 or the very similar 
one proposed by Roe.16 This plan is to cover nasal 
wounds with flexible metal, such as tin, copper, or alu- 
minium, the metal shield to be fitted accurately to the 
wound, after it has been covered with antiseptic cotton 
or gauze. Our experience with all such appliances is 
that they are very difficult to adjust, and that most people 
cannot, or will not, wear them, because of the pain and 
discomfort they produce. Dr. Roe calls this the "asep- 
tic method as applied to intra-nasal surgery," because he 
claims that the metal covering entirely prevents the ac- 
cess of pathogenic germs to the wound. 
A method advocated by Dr. L. Freudenthal, in a paper 
read before the Academy of Medicine, in November, 1892, 
seems to us to promise more encouraging results. He 
(SUPPLEMENT.) 
covers the wound with a specially thick collodion, and 
he expresses the hope that this obtains for the wounded 
surface an aseptic condition. We have had no experience 
with this method. 
It is wise, we think, to follow some routine method in 
our attempts to secure as nearly as possible an aseptic 
condition of the nostrils and wound. The success of all 
antiseptic methods depends upon methodical detail. The 
methods which are advocated both before and after the 
operation are in no sense new, but I state them, because, 
as I have said, it is well to have a detailed routine. 
Something may be accomplished in the right direction if 
the patient is instructed to ■wash out his nostrils twice 
daily for some days before the operation, with a tepid 
saline or alkaline spray, such as a modification of Dobell's 
or Seiler's antiseptic tablets. I like a prescription of per- 
oxide of hydrogen, twenty per cent., containing one per 
cent, of cocaine muriate in solution. The peroxide of 
hydrogen cleanses to better advantage after the swellings 
have been partially effaced by the cocaine. A solution 
of salt and water, generously and carefully used, does 
more than cleanse-it acts as an antiseptic. A solution of 
mercuric bichloride, 1 to 4,000, sprayed with an atomizer 
is beneficial, but is apt to be irritating. Freudenthal 
sprays with sterilized water. Tavel's fluid, composed of 
salt, seven and a half per cent., and natr. calc., two and 
a half per cent., is recommended on the ground that it is 
a physiological fluid. The operator can wash out the 
nose with some one of these solutions just before operat- 
ing. A sterilized ten per cent, solution of cocaine may 
be applied to the portion of the nose to be operated upon. 
All instruments should be sterilized or placed in the usual 
carbolic surgical solution, and the hands of the operator 
made aseptic. 
I am in the habit of covering the portion of the nostril 
to be operated upon with clean absorbent cotton, wet 
with a solution of mercuric bichloride, 1 to 2,000, after the 
cocaine has been applied, and just before operating. 
This cotton is only left in position for a moment or two. 
After operating, whether with knife, saw, scissors, or 
trephine, care should be taken to remove all loose pieces 
of tissue, cartilage, or bone, with forceps ; the patient can 
assist by blowing the nose thoroughly. A layer of cotton 
wet with a solution of mercuric bichloride, 1 to 2,000, may 
then be loosely placed over the wound, not packed into 
the nostril. Such a loose layer of cotton becomes a suf- 
ficiently tight plug to check bleeding when the effect of 
the cocaine has disappeared, and the tissues of the nostril 
have become somewhat swollen. Plugging the nostril 
tightly for the purpose of stopping haemorrhage is usually 
unnecessary, and it causes painful irritation. We are in 
the habit of keeping patients at our office for ten or fifteen 
minutes after the operation. At the end of that time 
the loose cotton layer is removed, and if the bleeding has 
ceased, iodoform, iodol, or aristol may be dusted over 
the wound, and the wound again covered with a layer 
of iodoform gauze, or antiseptic cotton. Usually there 
is bleeding enough, to render the application of any 
powder impracticable, and the first layer of bichloride 
cotton is simply replaced by a second one, or by iodo- 
form gauze, which is left in position for thirty-six or 
forty-eight hours. We have not been in the habit of 
washing out the nose with any antiseptic solution after 
operation, but have been satisfied to allow the patient to 
blow it thoroughly. We believe somewhat in the protec- 
tion afforded by the blood coagulum. Roe advocates ir- 
rigation of the nostrils after operation with a hot solution 
of salt and bichloride, 1 to 4,000. It may be wise to check 
all bleeding by hot antiseptic irrigation, so that an anti- 
septic powder can be placed upon a fairly dry surface. 
Dr. O. B. Douglas, of New York, recommends the 
use of the solution of aluminium acetotartrate, 3 j- to 
5 iv., as a substitute for other antiseptics. Cotton may 
be saturated with this solution and placed upon the 
wound, and left in position for several days, it is claimed, 
without danger of wound infection. 
After all covering has been removed from the wound 
at the end of forty-eight hours, the nostrils may with 
advantage be thoroughly cleansed with some one of the 
666 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Nasal Surgery. 
Neplirorrliaphy. 
(SUPPLEMENT.) 
antiseptic solutions already referred to, and the patient 
can accomplish all that is necessary by spraying the 
nostrils twice daily with a proper cleansing prescription. 
While there is little danger of infection through nasal 
wounds after the lapse of forty-eight hours, they require 
considerable attention for many days, to hasten healing 
and to prevent the outgrowth of granulation tissue, which 
will again block the nostrils. 
Our belief may be stated briefly, in conclusion, that 
while it is impossible with our present knowledge and 
present methods to obtain a perfectly aseptic condition 
for nasal wounds, yet experience has demonstrated that 
patients suffer far less from constitutional disturbance 
after nasal operation, that bleeding is more surely con- 
trolled, and that nasal wounds heal much more quickly, 
when all reasonable antiseptic precautions are employed. 
Clarence C. Rice. 
the various viscera. In such cases the displacement is so 
general that the symptoms complained of should not be 
attributed to the mobility of the kidney alone. I have 
seen two such patients on whom the operation of neph- 
rorrhaphy had been performed by skilful operators with- 
out the slightest benefit. 
It is only just to state that a few careful observers, 
both physicians and surgeons, are still rather sceptical as 
to the existence of movable or floating kidney, and a cer- 
tain number of others who doubt the significance of this 
abnormality as a cause of severe symptoms, and who are 
still more doubtful as to the necessity or efficiency of any 
operation for relief of this condition. There is scarcely 
a man, however, who has devoted special attention to 
abdominal diseases, who questions the occasional occur- 
rence of movable kidney, and while a few of such spe- 
cialists do not look with favor upon nephrorrhaphy, yet 
this number is rapidly diminishing, 
The existence of both movable and floating kidney has 
been proven by thousands of observations on the examin- 
ing, operating, and autopsy tables. It is equally certain 
that such mobility is frequently the cause of painful, and 
in a few cases of grave, symptoms. It has been fre- 
quently proven that it is possible to secure fixation of the 
kidney by operation, and as a result of such fixation 
the patients have been entirely relieved of their suffer- 
ings. It certainly seems reasonable to conclude that 
with the methods now at our disposal we ought to be 
able to fasten the kidney so securely that it cannot break 
loose from its new attachments. If the sutures are 
passed directly through the substance of the kidney, 
and then through the muscles of the loin, it seems most 
rational to believe that such anchorage will, in the 
majority of cases, be permanent. The numerous cases 
where relief from all distressing symptoms has directly 
followed the operation, and where after a lapse of years 
there has been no return of the symptoms, would cer- 
tainly seem to prove, almost beyond a doubt, that the 
permanent fixation of the movable organ has been ac- 
complished. Still further proofs of the satisfactory re- 
sults obtained are afforded by the patients with thin and 
lax abdominal and lumbar muscles, through which the 
kidney can be distinctly felt so firmly anchored in place 
that strong manipulation fails to move it from its bed. 
In one of my own patients this condition is very mani- 
fest, and on examination three years after operation the 
kidney can be felt firmly anchored in a situation which, it 
is true, is rather lower than is normal, but which is suffi- 
ciently correct to free her from all pain, which formerly 
had entirely incapacitated her from work. More than 
this, several cases have been reported where the firm an- 
chorage of the kidney has been demonstrated both by 
autopsy and at secondary operations. Langenbuch re- 
ports a case where, several months after the original oper- 
ation, he reopened the lumbar wound on account of a 
fall which the patient had received, and he found the 
kidney firmly anchored. Tillman has observed at au- 
topsy, two months after operation, the kidney, which for- 
merly had an extensive range of motion, firmly fastened 
by newly formed connective tissue permeated by numer- 
ous blood-vessels, and intermingled with masses of cica- 
tricial tissue. 
Nephrorrhaphy is a justifiable operation in any patient 
whose life is made miserable by the distress caused by 
the movable kidney. Indeed in such cases operation 
should be urged. In other cases where moderate dis- 
comfort only is experienced the nature and dangers of the 
procedure, and its chances for relief or complete cure, 
should be explained to the patient, and she should then 
be allowed to decide whether or not she prefers to under- 
go the operation. In all cases it is a good rule to insist 
on the trial of some form of bandage or support before 
nephorrhaphy is undertaken. In comparatively few 
of the severe cases will a bandage be of benefit, but it is 
worthy of a trial. In no case, if the kidney is otherwise 
healthy, should nephrectomy be advised until nephror- 
rhaphy has failed. 
Mortality.-The operation is a comparatively safe one. 
In more than two hundred reported cases only three 
1 Gerster : Aseptic and Antiseptic Surgery, p. 3. 
2 Cheyne : Antiseptic Treatment of Wounds, p. 7. 
3 Billroth's Surgical Pathology, p. 396. 
4 Bosenbach : Mikroorganismen bei der Wund-Infection. 
6 Ogston: Report upon Micro-organisms in Surgical Disease, Brit- 
ish Medical Journal, March 12, 1881. 
9 Gottstein : Die Verwerthung der Bacteriologie in der klinischen 
Diagnostik. 
7 Cheyne : Antiseptic Surgery, p: 359. 
8 Park : Antiseptics in Surgery, Wood's Reference Handbook, etc., 
Vol. I., pp. 257, 258. 
9 Gerster : Aseptic and Antiseptic Surgery, p. 5. 
10 Cheyne : Antiseptic Treatment of Wounds, pp. 15,16. 
11 Wright: Journal American Medical Association, September 21, 
1889. 
12 Wright, loc cit. 
13 Aschenbrandt: Die Bedeutung der Nase fur die Athmung. Wurz- 
burg, 1886. 
14 Metschnikoff, Elias ; Ueber eine spross pilskrankheit der Daphnien, 
Virchow's Archiv, Bd. cvii., S. 209. 
15 Kitchen : Medical Record, January 7, 1888. 
19 Roe : Medical News, March 28, 1891. 
NEPHRORRHAPHY. During the past ten years two 
hundred and fifty cases of nephrorrhaphy have been re- 
ported. The operation may now be said to rest upon a 
secure basis. The number of cases reported has been suffi- 
cient to enable us to determine what danger attends the 
operation, and what benefits result from this procedure. 
The details of the operation have been perfected, and ex- 
perience has proved that certain methods may be rejected 
as unsatisfactory. Several new methods for the firmer 
anchorage of the movable organ have also been intro- 
duced. Considerable light has been thrown on many of 
these procedures by experimentation on animals, which 
in recent years has been pursued, especially in France, 
with extreme care. 
A movable kidney is no longer looked upon as a rare 
condition. It is difficult to determine exactly in what 
proportion of cases this abnormality occurs. A marked 
difference exists in statistics on this point. Thus Lindner 
claims that one woman in every six has a movable kidney, 
while most other observers estimate the proportion among 
females as one in two hundred or three hundred. In 
males it is a much more uncommon occurrence. I feel 
sure, however, that it is a condition which is often over- 
looked, as, unless especially sought for, it will rarely 
thrust itself upon the examiner's attention. I feel sure 
also that often symptoms are attributed to other causes 
which in reality are due to the mobility of the kidney. 
It is certain that in many cases no symptoms will be 
caused by this condition. It may be asserted, I think, 
that in the great majority of cases it is the cause of but 
little discomfort. In other cases it may cause considera- 
ble discomfort, but yet the suffering is not severe enough 
to demand resort to operative procedures for its relief. 
It is only in exceptional cases that the pain experienced 
by the patient is so severe that operation is demanded. 
There are a few cases where the symptoms produced are 
of considerable gravity, but which are not suitable for 
operation, because of the probability that the nephror- 
rhaphy will fail to relieve these symptoms. In such pa- 
tients the mobility and displacement of the kidney is de- 
pendent on the general laxity of all the abdominal tissues, 
where an enormously pendulous abdomen has, by stretch- 
ing the various ligaments, dragged down and displaced 
667 Nephrorrhapliy. 
Nervous System. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT ) 
deaths can be attributed to the operation. One of these 
occurred in the practice of a surgeon who does not be- 
lieve in antiseptic surgery, and another occurred in con- 
sequence of a dangerous method used in the fixation of 
the kidney. The mortality can be estimated as about 
one to two per cent. 
In what proportion of cases may we expect to effect a 
radical cure ? This is a difficult question to answer cate- 
gorically. The majority of cases cannot be watched for 
a sufficient length of time to be of much aid in this cal- 
culation. Certainly eighteen months or two years should 
elapse before we can decide that a permanent cure has 
been effected. The proportion of permanent recoveries 
ranges from fifty to seventy-five per cent., and of the cases 
operated on during the last four or live years it certainly 
will reach this latter figure and perhaps exceed it. By 
permanent cure I mean fixation of the kidney and per- 
manent relief from all bad symptoms. A certain pro- 
portion of cases are improved, while in others the kidney 
appears to be fixed and yet the symptoms persist. In 
this latter class of cases the diagnosis has probably been 
incorrect. Out of my own 11 cases of nephrorrhaphy 2 
have been complete failures, 6 have resulted in complete 
cure, 1 has been improved, and 1 has disappeared from 
view. 
Operation.-The object is to firmly anchor the kidney 
in as near its normal situation as is possible. A number 
of different methods have been and are employed, but all 
procedures are alike in one point, that they aim to fasten 
the kidney to the lumbar muscles by means of sutures. 
They differ in two points, the nature of the suture mate- 
rial and the tissues which the sutures penetrate. The pa- 
tient should be placed in such a position as will make the 
space between the last rib and crest of the ilium as long 
as possible. This can best be accomplished by placing 
the patient partly on the side opposite to that on which 
the operation is to be done, and partly prone. Pads 
should be placed under the abdomen, and crowding up 
under the opposite ileo-costal space so as to make as 
prominent and large as possible this space on the side on 
which the operation is to be performed. The usual anti- 
septic precautions should be carefully carried out, thor- 
ough scrubbing with green soap, washing off with alco- 
hol or ether, followed by the antiseptic or aseptic solution 
favored by the operator. The incision down to the 
adipose capsule of the kidney is made as in other opera- 
tions. It may be either oblique, an inch below and parallel 
to the last rib, or vertical, along the outer edge of the 
erector spinae muscle. The latter incision is the one I 
very much prefer, and is the one generally adopted in 
nephrorrhaphy. The oblique incision, while perhaps 
equally as serviceable in other operations on the kidney, 
is, for the purposes of this operation, inferior to the verti- 
cal. The skin incision is made from the last rib to the 
upper border of the crest of the ilium, along the outer 
border of the erector spinae muscle. After division of the 
skin and cellular tissue and lower fibres of the latissimus 
dorsi muscle, the sheath of the erector spinae is opened 
and this muscle is crowded inward by retractors toward 
the spinal column. The division of the middle layer of 
the lumbar fascia follows and the exposure of the quad- 
ratus lumborum muscle, which is easily recognized by the 
direction of the coarse fibres from above downward. This 
is also crowded inward and the anterior layer of the 
lumbar fascia divided and the perirenal fat (adipose cap- 
sule of the kidney) exposed. During the operation it 
should be remembered that the pleura extends down to 
the twelfth rib, and sometimes a little below it, and care 
should be exercised to avoid opening it. This accident 
happened to me in one case, where the pleural cavity 
was punctured at a point one-eighth inch below the last 
rib ; no bad consequences followed. The kidney can by 
pressure from the abdomen be pushed into the wound, 
and it then remains to fasten it in place in its normal 
situation behind the twelfth rib. 
The following different plans have been adopted: 
1. The adipose capsule, opened or unopened, is united by 
sutures to the edges of the incision. This was Hahn's 
original operation, but it is now nearly abandoned. 
2. After freely opening the adipose capsule the sutures 
are passed through the fibrous or true capsule of the kid- 
ney. This is a method which has been often successful, 
but is gradually being susperseded by one of the follow- 
ing methods, which seems to promise better results. 
3. After free exposure of the kidney the sutures are 
passed directly through its parenchyma. They are 
passed through a considerable portion of the substance 
of the kidney, and at such a depth that they completely 
control its movements. Two or three such sutures are 
used, and they penetrate the kidney for a distance of 
about an inch and a half, and at a depth of one-fourth 
to one-half inch below its surface. 4. The fibrous cap- 
sule is divided vertically for a distance of. two to three 
inches, and peeled off the kidney on each side till a raw 
surface of considerable extent is made, which is then 
brought into contact with the cut tissues in the loin. 
The sutures are then passed as in the last method, enter- 
ing and emerging through the capsule just outside the 
raw margin. It has been found from experimentation 
on animals that, when the kidney, deprived of its cap- 
sule, is brought into contact with the cut muscles of 
the loin, the union resulting is far firmer than when the 
unbroken capsule is brought into apposition with the 
same structures. The results of operation seem to be in 
accord with these experiments. The division of the 
capsule is supposed also to serve another useful purpose 
in the relief of tension from the kidney itself. The 
last-mentioned method appears to me to be the secur- 
est. 
I have operated according to the latter in four cases, and 
in none of them has there been any sign of relapse. The 
method does not seem to be attended with any special dan- 
gers. As far as we know at present the passage of sutures 
through the parenchyma of the kidney does not appear 
to cause any disturbance, either immediate or remote. 
It is even the exception to find red blood-corpuscles in 
the urine after these operations. Care should be taken, 
however, that the sutures are not tied too tightly, as 
otherwise they might cut the kidney tissue. I prefer to 
pass them threaded on a common round sewing-needle 
through the kidney itself. They can then be drawn 
through the muscles on each side of the incision by 
means of a handled needle. My own plan before tying 
these sutures is to unite the cut muscles carefully by 
means of buried sutures, thus shutting off the kidney 
from view, and then to tie the kidney sutures over the 
united muscles. In this way no tension is placed upon 
the kidney sutures. The skin is then united, and if 
deemed best a drainage-tube placed at the lower angle 
of the wound. In my later cases no drainage has been 
employed ; but if there be any doubt about the absolute 
sterility of the wound, sponges, instruments, or dressing, 
then by all means a drain should be inserted. Formerly 
it was the custom not to close the external wound by 
sutures but to leave it entirely open, packed with gauze, 
so that it might fill up with granulation tissue. It was 
considered that the adhesions so formed by means of 
granulation tissue were firmer than those obtained by a 
primary union. 
Various materials have been employed for sutures- 
silk, catgut, kangaroo tendon, silkworm-gut, and silver 
wire. The important point is that the material be thor- 
oughly aseptic. Probably chromicized catgut and silk 
are the best materials. The former will hold for several 
weeks and will then disappear. The latter will become 
encapsulated, as a rule, and cause no disturbance, but oc- 
casionally the system will not tolerate its presence, and it 
will be eventually discharged through a sinus. Silkworm- 
gut and wire, while easily made aseptic, and while very 
unirritating and durable, may be apt to cut the kidney 
tissue. A number of operators, principally of the Italian 
school, consider it wise to fasten the upper end of the kid- 
ney at a higher point than can be reached by the ordinary 
incision. To accomplish this they have resected the 
twelfth rib in whole or in part, and sometimes the elev- 
enth as well. To the periosteum of these ribs the sutures 
are fastened. In a few cases they have been attached to the 
periosteum without removal of the rib. This appears to 
668 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Nephorrliapy. 
Nervous System. 
be an unnecessary procedure. It must certainly add to 
the dangers of the operation, and in one case it was 
to some extent responsible for a fatal result. Schachner 
has performed a number of experiments upon animals in 
the endeavor to replace the sutures " by natural stays 
in the shape of a pocket formed between the transversalis 
and internal oblique muscles." The method was success- 
ful in animals, but it remains to be proved whether or 
not it will be of advantage in the human subject. 
The subsequent treatment of the case is of importance. 
Considerable neuralgic pain is felt for the first week, or 
longer, shooting down toward the groin. This can be 
quieted in the usual way by opiates. It is of great ad- 
vantage to keep the patient fiat on the back for two or 
three weeks at least after the operation, and rest in bed 
should be maintained for another two weeks. This will 
necessitate confinement to bed for about five weeks, and 
another two weeks should elapse before the patient can 
resume business of any kind. No violent exercise should 
be attempted for at least four months. In a few cases 
lumbar hernia (of the kidney through the cicatrix) has 
followed nephrorrhaphy, but it is an accident of very 
rare occurrence. Andrew J. Me Cosh. 
NERVES, REGENERATION OF. A reunion by first 
intention of the severed ends of a nerve can no longer be 
doubted, although such instances are rare. This desira- 
ble result is owing largely to the adoption of the most 
rigid antiseptic precautions, and when obtained the re- 
turn of sensation begins within about twenty-four hours, 
soon to be followed by a return of motility. 
The most valuable contribution yet offered on this sub- 
ject has recently been published by Howell and Huber 
{Journal of Physiology, xiii., No. 5, 1892). Their investi- 
gations were partly physiological and partly histological. 
With a single exception dogs were used. The nerves 
experimented upon were the ulnar of the two sides, and 
in case of cross-sutures, the median and ulnar. An- 
tiseptic precautions were observed. Carbolized catgut, 
or catgut in juniper, was used for sutures. The cut ends 
of the nerves were in almost every case brought together 
by one suture on each side which passed through the epi- 
neurium, wounding the nerve-fibres as little as possible. 
In most cases the nerve was lifted with a thread and cut 
with sharp scissors. After a certain time the nerve was 
laid bare and irritability tested in various ways, and sub- 
sequently histological examinations were made. 
The chief results of this research are as follows : 
In none of the experiments was there union of the cut 
ends by first intention. In all cases the peripheral end 
degenerated completely throughout its entire length. 
During the first four days there gradually occurred a 
complete loss of irritability and conductivity in both 
sensory and motor fibres, which lasted until regenerative 
changes, as shown by histological investigation, set in. 
Irritability in all cases appeared first, after union was 
made, inthe neighborhood of the wound, and from that 
part spread centrifugally, apparently with great slowness. 
The gradual increase in irritability at any one level 
seemed to go hand in hand with the increase in the num- 
ber of newly-formed fibres, and not with a progressive 
regeneration in the single fibres. The return of irrita- 
bility to the sensory fibres was in advance of that to the 
motor fibres. With the beginning of the return of irri- 
tability mechanical stimulus was more efficient than elec- 
trical stimulus. This, the authors believe, is due to the 
fact that the nerve-fibres in the process of regeneration 
are in the embryonic stage, possessing but a low degree 
of irritability, and that the more violent mechanical stim- 
ulation is necessary to arouse them. 
Conductivity appeared before irritability. In other 
words, the nerve conducted impulses before it became 
excitable to direct stimulus. 
The return of function, which began to appear at the 
end of three weeks, was not perfect at the end of seven 
weeks, although nearly so at the end of eleven weeks. 
Although functional activity returns first to the fibres 
near the wound and spreads centrifugally, it does not fol- 
low from this that the fibres which first branch off from 
the trunk and have the shortest route to travel are the 
first to regenerate. 
The possibility of the functional union of two spinal 
nerves is proven, but indicates that the time required for 
the regeneration of the nerve-fibres is longer than in the 
union of the two ends of the same nerve. 
After complete severance from the nerve-centres of 
the peripheral end of the nerve, degeneration occurs 
throughout its entire extent. 
The degenerative changes and the subsequent regener- 
ation take place as follows : (a) Segmentation of the 
myeline and axis at the intersegmental lines ; (6) prolifera- 
tion and migration of the internodal nuclei ; (c) secondary 
fragmentation and absorption of the myeline (and con- 
tained debris of the axis), most active in the neighborhood 
of the nuclei; (d) increase of protoplasm round the nu- 
clei, forming finally a continuous sheath band of proto- 
plasm lying in the old sheath ; (e) formation of a new 
sheath on the periphery of this band, thus making an 
" embryonic fibre ; " (/') union of the embryonic fibres of 
the peripheral end with those similarly formed in the 
central end, the union taking place in the intervening 
cicatricial tissue ; (#) formation of myeline in the periph- 
eral end as isolated drops, usually seen first near the 
nuclei. These afterward unite to form a continuous 
tube. The formation of the myeline proceeds centrifu- 
gally, starting from the wound ; (h) the outgrowth of 
new axes from the old axes of the intact fibres of the cen- 
tral end, the outgrowth following quickly upon the de- 
velopment of the myeline : (i) in the central end, and espe- 
cially when connection with the periphery is not made, 
several new fibres may form within the sheath of an old 
fibre to take the place of the portion degenerated. Each 
of these may develop myeline and receive a branch from 
the axis cylinder above. Edward T. Reichert. 
NERVOUS SYSTEM, COMPARATIVE ANATOMY 
OF THE. Recent Progress.-The field is so large 
and the accumulated literature of the last few years so 
enormous, that it has seemed best to select typical or rep- 
resentative episodes, and to present data from various 
sources without attempting to edit them compactly or to 
assimilate them fully into a complete and orderly whole. 
This procedure is in harmony with the existing state of 
the science, which hurries from one discovery to another 
without intermission, and it will only be profitable to 
make a complete summary after the possibilities of the 
modern technique have been measurably exhausted. 
While it is not claimed that the selection has been as 
discriminating as could be desired, and many valuable 
additions to our knowledge are unwillingly passed over 
in silence, we trust that sufficient material has been col- 
lated to indicate the tendencies of modern research. The 
classes of vertebrates are taken up in succession and 
afterward a few special topics are discussed. 
Amphioxus.-Hatschek 1 has added valuable points to 
our knowledge of this simplest vertebrate. The results 
seem to warrant the hope that the perplexing problems 
of cerebrogenesis may yet be solved by comparative 
methods. 
The spinal cord of Amphioxus contains.a circular canal 
which extends dorsad 
in a delicate cleft near- 
ly to the dorsal surface 
of the cord. The 
canalis centralis is sur- 
rounded by gray mat- 
ter, which extends to 
the dorsal surface, but 
on all other aspects is 
clothed with white 
fibres. 
In the young the 
brain consists of a cephalic enlargement of the medul- 
lary tube, which subsequently is obscured. In a later 
stage, three vesicles are indicated corresponding to the 
primary embryonic vesicles. 
The first of these sections (primary prosencephalic 
vesicle) contains a distinct ventricle. From the cephalic 
Fig. 431.-Longitudinal Section through 
the Brain of Amphioxus when young. 
/, II, III. vesicles ; N, Sensory pit, 
which is homologous with the pitui- 
tary ; ch, chorda. 
669 Nervous System. 
Nervous System. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
extremity of this cavity, the infundibulum is formed. 
It is an expansion of the brain-wall which comes into 
direct communication with the ciliated pit of the dor- 
sal surface of the head. The communication is subse- 
quently closed. The cavity of the sec- 
ond vesicle is a mere tube, which has 
been compared (with doubtful propri- 
ety) with the aqueduct. The third ves- 
icle has a dorsally located fossa rhom- 
boidea with membranous dorsal roof. 
The brain in the young is in the 
region of the first and second seg- 
ments. The ciliated frontal pit is 
connected by an olfactory nerve with 
the front of the brain. The pit is 
homologous with the hypophysis and 
nasal sac of craniates. A comparison with Ammocoetes 
and higher vertebrates shows that, in the latter, the in- 
fundibulum (and with it the whole brain axis) has been 
flexed ventrad. 
The spinal nerves have the usual divisions. The 
dorsal root does not communicate with the ventral, but 
passes toward the periphery, where 
it divides into a dorsal and ventral 
ramus. The ganglion is repre- 
sented by numerous cells scattered 
in the nerve near its point of 
division, and thus near their 
origin. This is very suggestive as 
to the origin of the spinal gang- 
lion. 
The dorsal ramus gives off a cu- 
taneous dorsalis and lateralis dor- 
salis nerve, and the ramus ventralis 
similarly divides into a cutaneous 
ventralis and lateralis ventralis. In 
addition to these, the ventral ramus 
affords a special visceral branch. 
There is a tendency to the forma- 
tion of plexi, and it is thought that 
many of the fibres may be sensory. 
It has been compared with the 
vagus, but a similar branch is found 
in the dorsal regions. The ven- 
tral root is the special nerve to the 
trunk muscles, and is purely mo- 
tor. The sensory (dorsal) branch is intersegmental, the 
ventral segmental. 
The first pair of nerves lies along the dorsal side of the 
cord (and the rostral muscles of the larva), and supplies 
the epithelium of the cephalic end of the rostrum. Some 
of the branches are supplied with Quatrefages' ganglion 
cells. 
The second nerve consists of an anterior portion, dis- 
tinct nearly to the root, which gives off a strong lateralis 
dorsalis and ventralis ; these supply the remainder of the 
rostrum. The second portion divides into two cutanei 
dorsales, a cutaneous ventralis and a cutaneous visceralis, 
which latter innervates the buccal muscles. 
The third to fifth nerves have the normal form (as 
above). All the viscerales unite in a plexus to which 
the fourth and fifth supply especially strong contingents. 
The separate descending branches pass to the muscles of 
the mouth and velum, while a strong branch, which 
fuses with a branch from the sixth anti seventh, passes 
to the plexus of the branchial apparatus. 
The fifth nerve gives off an especially large visceral 
branch which supplies a strong branch to the sensory 
organ of the right side (derived from the ectoderm of left 
side). 
It is regarded as probable that the first nerve is homo- 
logous with the ophthalmicus profundus, and the ventral 
nerve of the rostrum with the maxillaris. 
Ammomtes.-The additions to our knowledge in the 
Cyclostomata have related chiefly to the homologies of 
the nerves. Hatschek1 shows that there is a great 
similarity, in general, with the distribution prevailing 
in fishes and the embryological data discovered by 
Kupffer.3 The cranial nerves also show the same fun- 
damental parts as already reported in Amphioxus. 
The dorsal root produces (a) a ramus dorsalis, which di- 
vides into a cutaneous dorsalis and a lateralis dorsalis, and 
(b) a ramus ventralis, 
which represents a 
cutaneous and prae- 
trematicus, and also 
gives off strong rami 
viscerales and the 
cutaneous ventralis, 
which together form 
the ' ' post -1 r e m a - 
ticus." 
The visceral 
branches carry 
motor fibres to supply the muscles of the mouth and 
gills, as well as sensory fibres to the mucous membrane. 
There is a longitudinal set of connecting fibres uniting 
all nervi laterales dorsales, the continuation of which 
forms the recurrens lateralis of the vagus, extending the 
whole length of the animal. This longitudinal system is 
related with the sensory organs of the lateral line. This 
system embraces (dorsad and ventrad) the eye. The im- 
portant morphological deduction from the above fact is 
that the nervus lateralis vagi is phylogenetically formed 
of the nervi laterales of all the spinal nerves, the direct 
connection with which has been subsequently lost. 
Another longitudinal set of connecting fibres brings all 
the ganglia of the rami ventrales into communication (this 
arrangement is complete only in the young). The epibran- 
chial sensory organs (organs of the ventral lateral line) are 
supplied by nervi laterales ventrales which branch from 
each of the rami praetrematici. It appears from a compar- 
ison of these types that there is essential similarity be- 
tween the cranial and spinal nerves, but it is the latter 
and not the former which have been altered. 
The trigeminus is now generally recognized as com- 
bining two nerves. Hatschek distributes the cranial 
nerves and head organs as indicated in the table on 
page 671. 
In a subsequent paper6 Hatschek announces the dis- 
covery that the dorsal roots, in all higher vertebrates, 
connect with the ventral root next caudad, and their 
branches follow the myoseptum. Thus the ventral roots 
are segmental, and the dorsal intersegmental. The arches 
are intersegmental, and the clefts are segmental. This 
simplifies the above scheme without invalidating the facts. 
Edinger0 describes the olfactory nerves of Ammoccetes, 
in which he recognizes a commissure and a chiasm which 
are in direct connection with the interlobular (anterior) 
commissure. Unfortunately no one has yet studied the 
olfactory in the light of our present morphological 
knowledge, and the existence of a radix lateralis and hip- 
pocampal rudiment is still only conjectural. 
Selachii*-Edinger concludes, from a study of the em- 
bryology as well as from a comparison of the adult brain, 
that the fore- 
brain of sharks 
and rays differs 
from that of all 
other (higher) 
vertebrates i n 
that no true 
hemispheres are 
formed, but the 
primary proSen- 
cephalic vesicle 
persists, and the thickened walls contain the elements 
which in other groups constitute the hemispheres. The 
sharks are somewhat in advance of the rays and have 
slight indications of the subdivision. 
The same author gives a detailed description of the 
diencephalon. The latter is divided into a cephalic and 
a caudal portion into which the pedunculi cerebri enter 
from the prosencephalon. The habenulae of the two sides 
differ greatly in size and are connected by a commissura 
habenaria. The caudal or infundibular part of the dien- 
cephalon has two lateral lobes and a posterior (caudal) 
lobe, and bears a large hypophysis, saccus vasculosus, and 
Fig. 434.-Longitudinal Perpendicular Sec- 
tion of the Brain of Ammoccetes, for com- 
parison with the similar view of the brain 
of Amphioxus (Fig. 431). eh, chorda; 
olf, olfactory sac; inf. infundibulum. 
Fig. 432.-Cross Sec- 
tion in the Region 
of the Third Ves- 
icle. 
Fig. 433.-Cross Section 
of Body (diagram- 
matic). N, nerve tube ; 
eh, chorda ; if, muscu- 
lar segment ; G, dorsal 
branch, with ganglion 
cells passing through 
the muscles and divid- 
ing into a dorsal ramus 
(d) and ventral ramus 
(v), the latter again di- 
viding into a cutaneous 
and a visceral branch; 
v.b, motor root. 
Fig. 435.-Lateral View of the Brain of Adult 
Petromyzon. Epiph, epiphysis; hem, hemi- 
sphere ; opt. I, optic lobes. 
670 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Nervous System. 
Nervous System. 
Seg- 
ment. 
Myotom. Ventral roots. 
Dorsal roots. 
Visceral arches. 
Epibranchial sense organs. 
■ 
(a) " Medullary " region. 
Olfactory and nose (the first a " medullary " nerve related to a " neuroporus " sense organ). 
Optic and retina (the first an " intra-medullary " nerve related to a " medullary " sense epithelium). 
(b) Dorsal nerve roots situated cephalad of the first myotom. 
Probtic metamers. 
■ Fore-head. 
I. 
II. 
L 
Myotom ab- Absent 
sent. 
Myotom re- Reduced 
duced. 
Musculus N. abducens .... 
lateralis. 
Trigeminus A*, situated cephalad of the first 
(reduced) myotom, later : 
Oculomotor, as derivative of the visceral branch 
of the above. 
(c) Normal metameric portion. 
Trigeminus B,+ situated caudad of first (re- 
duced) myotom, later: 
Trochlearis, as derivative of the visceral branch 
of the above. 
Facial, including auditory (as nerve of a dorso- 
lateral sense organ). 
Visceral cleft absent. 
Anterior organ of the ventral lateral- 
line (?). 
Mandibular visceral cleft (rudimentary). 
Mandibular arch. 
First epibranchial sense organ. 
Pseudobranchial border (= hyoid cleft). 
Hyoid arch (behind auditory capsule). 
Second epibranchial sense organ. 
£ 
• 
E 
r 
Primitive 
in. 
First meta- Ventral root of 
otic myo- glossopharyn- 
tom. geal. 
Glossopharyngeal 
First true visceral cleft. 
First visceral arch. 
Second epibranchial sense organ. 
£ 
O 
region. 
IV. 
Second me- Ventral root of 
taotic my- vagus, 
otom. 
Third meta- Ventral roots of 
Vagus and the dorsal ganglionic portion, includ- 
ing the first ventral (epibranchial) ganglionic 
mass with its peripheral nerves. 
Spinal-like vagus branch and the following 
Second true visceral cleft. 
Second visceral arch. 
Fourth epibranchial sense organ. 
Third to seventh true visceral clefts. 
5 
Hind gill 
V. to 
otic myo- the spinal-like 
spinal-like nerves. 
Visceral arches. 
* 
region. 
IX. 
tom, etc. (spinal artigen) 
nerves. 
Second to sixth ventral (epibranchial) ganglia of 
vagus. 
[Segmentation of back follows.] 
Epibranchial sense organs. 
* Trigeminus A includes : N. frontalis primus; portio profundus of ophthalmic ; N. mandibularis. 
t Trigeminus B includes: N. frontalis primus; portio superficialis of ophthalmic ; N. mandibularis. 
recessi laterales infundibuli (mammillaria.) In adults 
the hypophysis consists of coiled and branching pouches. 
The histological structure is much as in bony fishes. 
fibres pass to the deeper layers of the tectum opticum. 
The commissura transversa is identified with von Glid- 
den's commissure. A tract is described from the habeme 
to the roof of the mesencephalon, also a tract to the pros- 
encephalon comparable with the taenia thalami. The 
ventricular cinerea gives rise to decussating fibres. Most 
of the fibres of the diencephalon spring from the pars in- 
fundibularis, among them the fasciculus longitudinalis 
dorsalis. This bundle seems to receive a contingent from 
the region of the oculomotor and passes into the ventral 
columns of the cord. The prepedunculi of the cerebellum 
arise from the region where the ventral peduncles disap- 
pear. 
The Brain of Dipnoids.-The lung-fishes have long 
been recognized as of great morphological interest by rea- 
son of their primitive and intermediate position. The 
combination of embryonic characters in the skeleton and 
limbs with amphibian peculiarities of the circulatory and 
respiratory systems makes them very instructive in indi- 
cating the possible primitive condition of the vertebrate 
phylum. The neurology of the African lung-fish, Pro- 
topterus, has recently been carefully investigated by Dr. 
R. Burckhardt.* The relations of the brain of different 
groups of vertebrates may be expressed somewhat as in 
the following diagram, which, however, differs in sev- 
eral points from that given by Burckhardt: 
Fig. 436.-Longitudinal Section of Selachian Brain, according to 
Edinger. The brain is supposed to be transparent, and the various 
fibre systems are projected upon one plane. 
Nerve-fibres are said to arise in the infundibulum, but 
the writer has found only gelatinous fibres in the corre- 
sponding organ of fishes. 
The pedunculi divide into a dorsal and ventral tract, 
the latter terminates in the infundibular portion, the 
Primitive 
vertebrate. 
( Lamprey. 
Sharks. 
Rays. 
Dipnoids. 
■ Ganoids-Bony Fishes. 
Ichthyophis-Amphibia. 
Mammals. 
Reptiles Birds. 
The resemblances to lampreys (Petromyzon) is very 
great, in spite of certain reductions in the latter, due to 
retrograde metamorphosis. 
Ganoid' Fishes*-Professor Kupffer has studied the de- 
velopment and discusses the morphological results. He 
states that at a period of forty-five hours after fertiliza- 
tion the brain is not yet separated fully from the epider- 
mis. It is of great morphological importance to deter- 
mine at what point the attachment is effected. 
Only two vesicles are clearly distinguishable, the ce- 
phalic being the smaller. Growth is at first more rapid 
in the ventral part of the tube and this gives rise to a 
Fig. -137.-Diagrammatic Representation of a Section of the Brain of 
Scyllum. - 
former passes beyond the diencephalon. A tract which 
requires further study is the so-called " mantle tract," 
which is said to originate from the dorsal part of the pros- 
encephalon and decussate caudad of the chiasm and ven- 
trad of the commissura transversa. After decussation the 
* Das Centralnervensystem von Protopterus annectens. R. Fried- 
laender, Berlin, 1892. 
671 Nervous System. 
Nervous System. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Fig. 438.-The Brain of Protopterus annectens. 1. Longitudinal median section. Con., conarium or dorsal sac: Z., pineal gland ; Z.p.," pineal 
pillow;" Mes., mesencephalon; Ep., epencephalon ; Pl. vent, iv., plexus of fourth ventricle; Vel., velum; Com. ant., precommissure ; Opt., 
optic nerve ; Hyp., hypophysis ; Met., metencephalon. 2. Ventral view of the same brain. Tr. ol., olfactory tract; Pros., prosencephalon ; Di., 
diencephalon ; L. inf., hypoaria : Met., metencephalon ; II. to XII., cranial nerves. 3. Lateral view of same object. Tub. ol., olfactory tuber ; 
Lob. hip., hippocampal lobe ; M. sp., medulla spinalis , S. e., saccus endolymphaticus. 4. Dorsal view of the same brain. 
"plica encephali tentralii" (pl. tent.). This is the 
floor of the mesencephalon and is the first indication 
of what in mammals is called the saddle-cleft. The 
roof, like the floor of the brain, consists of simple 
epithelium. The first indication of the pineal appears 
near the middle of the roof (ep^, Fig. 443), nearly mid- 
way between mesencephalon and prosencephalon. 
Just caudad of the plica is the pons flexure. The 
slight curvature of the floor in front of the plica is 
constant in all vertebrates and is called by Kupffer 
"tuberculum posterior" in spite of the previous use 
of nearly the same term for the obscure 
corpora quadrigemina posteriora of Sau- 
ropsida, etc. The cephalo-dorsal part of 
the brain tube isopen, and communicates by 
a tubular conduit with a space beneath the 
outer layer of the epidermis, while the brain- 
walls are continuous with the inner epider- 
mal layer (at r, Fig. 443). Just below (ven- 
trad of) this communication is the recessus 
opticus, on the caudal aspect of which the 
optic chiasm will develop, and on the ce- 
phalic aspect the anterior commissure. The 
hypophysis is at this stage of unexpected 
size and shape (hy), and it impinges on the 
front of the brain-tube. The organ is 
developed from the layer of cells where 
the entoderm and inner ectoderm layer 
meet in front of the head. It is in im- 
mediate connection with a thickened part 
of the inner ectoderm layer which is to 
Fig. 439. 
Fig. 440. 
Figs. 439 and 410.-Longitudinal Sections of the Brain of Protopterus. Cal., callosum ; 
Vh. b., prosencephalic bundle; C.a., precommissnre; L.t., lamina terminalis ; Inf., in- 
fundibulum ; Sac. vas., saccus vasculosus ; Hgp.. hypophysis ; Tr. o., optic tract; Dec. 
po., decussatio post-optica; Ba., cephalic peduncles of cerebellum; Hl.b., dorsal longi- 
tudinal bundle; Dec. M. F., decussation of Mauthner's fibres. ; N. vag., vagus nidnlus; 
Cb., cerebellum ; Mes., mesencephalon ; Post. C., postcommissure ; .V. b., Meynert's bun- 
dle; Sup. C., supracommissure; Tub. ol„ olfactory tuber; Fiss. pr., fissura post-olfac- 
toria ; Hr., cortex: Olf. b., olfactory fibres; Tr. gh.. tract from superior commissure to 
cerebrum ; Tr. d. and Tr. pro., tracts from superior commissure to diencephalon and 
cerebrum (tsenia). 
672 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Nervous System. 
Nervous System. 
form the sucking disk (A/, Fig. 443), immediately above 
the mouth. 
When the age of fifty-seven hours is reached (Fig. 
444), the brain has elongated, the connection of brain 
and epidermis is now a solid cord of cells. The epiphysis 
has become more distinct. 
From this time on the 
hypophysis begins to sepa- 
rate from the skin, with 
which it is for a long time 
connected by a stalk. The 
brain communication with 
the ectoderm is severed, 
and a slight protuberance 
at this point remains, 
which the author calls the 
tuber olfactorius impar. 
The region of the future 
infundibulum (Fig. 446) 
becomes greatly expanded 
and several sinuses are de- 
veloped. The inferior 
commissure system ap- 
pears earlier than the 
chiasm fibres. 
The tuber olfactorius 
impar, which Kupffer con- 
siders the morphological 
front of the head, and 
which was originally in juxtaposition with the hypoph- 
ysis, becomes more and more widely separated from it 
and ceases to grow, and even becomes reduced. At the 
end of larval life (Fig. 446) the paraphysis ep' is derived 
from the prosencephalon in front of the dorsal sac. 
The velum transversum (vt.), 
which immediately precedes, be- 
gins to assume a plexiform ap- 
pearance. The commissures are 
well developed. The star in Fig. 
446 indicates what the author and 
Burckhardt regard as the caudal 
limit of the base of the mesen- 
cephalon. Two commissures of 
the infundibulum are called com. 
debelis(tZe) and com. terminalis (/), 
though it is hard to see what ex- 
cuse can exist for these new terms. 
The author identifies the com. 
debelis with Edinger's decussatio 
infundibuli. The dorsal sinus of 
the infundibulum becomes the 
hypoaria, and the ventral becomes 
the saccus vasculosus, though also 
producing two lateral vesicles 
which are probably the homo- 
logues of the similar sacs of Tele- 
osts which Herrick has homo- 
logized with the mammillaria. 
Kupffer concludes that his re- 
searches settle the question as to 
the morphological front of the 
brain. Baer, His, and the writer 
have contended that the region of 
the infundibulum is the front, 
while Reichert and Kblliker lo- 
cate it in the terma in front of the 
chiasm. Mihalkovics locates the 
theoretical front in the middle of 
the terma and denies the existence 
of a " hook - curvature " of the 
axis. Von Wijhe shows that the 
point of attachment of the brain 
with the skin is independent of the hypophysis. Kupffer 
completes this argument by discovering a median olfac- 
tory fundament. 
The Ganoids have a much greater development of the 
roof of the diencephalon than is characteristic of the 
Teleosts and Selachii. The greatly distended base of the 
diencephalon Kupffer designates as hypencephalon. The 
most caudal part of this segment gives rise to the hy- 
poaria, which the present writer, on embryological 
grounds, has been tempted to relegate to the base of the 
mesencephalon. 
Regarding the whole cavity cephalad of the mesen- 
cephalon as a single vesicle, Kupffer arranges the sec- 
ondary modifications of its walls as follows: 1. From 
the cephalic wall, the optic vesicles and stalks. 2. From 
the dorsal wall, the epencephalon (= cerebrum), the pa- 
raphysis or anterior epiphysis, the parencephalon (dien- 
cephalon), the epiphysis proper. 3. From the floor, the 
hypencephalon with the saccus dorsalis, hypoaria and 
saccus vasculosus. 
The author makes much of the fact that there is in 
Amphibia a large postpineal part of the roof which is ab- 
sent in the Ganoids. 
The adult brain has been recently examined by Go- 
Fig. 441.-Section through the Pre- 
commissure of Brain of Protop- 
terns. Con., conarinm ; A. hip., 
hippocampal lobe ; Cal., callosum ; 
Amh., cornu ammonia ; Rec. po., 
recessus preopticus; Prec., pre- 
commissure. 
Fig. 443.-Median Section of Embryo of Acipenser Sturio, Forty-five 
Hours after Fertilization. 
ronowitsch10 in Acipenser, and by Herrick11 in Scaphi- 
rhynchus and Lepidosteus. The following extracts from 
the paper of Goronowitsch will be useful: 
" Cerebrum.-The roof of the prosencephalon is mem- 
branous, and consists of a variously folded epithelial 
lamina. The roof of the olfactory lobes, however, con- 
sists of thick medullary walls. Between the roof of the 
prosencephalon and the epiphysis there is a broad mem- 
branous sac, the cavity of which is distally in wide con- 
nection with the cavity of the prosencephalon. The 
blind end of the sac is directed proximally (cephalad !). 
The sac, therefore, must be considered as a broad diver- 
ticle of the roof of the prosencephalon, springing from a 
point cephalad to the origin of the epiphysis. This may 
be called, for the sake of brevity, simply the dorsal sac. 
" At the anterior margin of the left ganglion habenula 
(the left is much the smaller) a lateral induplication of 
the membranous roof of the prosencephalon enters the 
ventricle. This fold is somewhat complicated. The 
epithelial layer of which it consists forms numerous 
folds and sacs, into which projections of the membranes 
and blood-vessels enter. The structure is, in other 
words, that of a plexus choroideus. 
"Careful study of continuous series of sections indi- 
cates that there is nowhere a discontinuity in the epithe- 
Fig. 442.-Longitudinal 
Horizontal Section 
through the Cerebral 
Hemispheres, etc., of 
Protopterus. L. po., 
lobus post-olfactorius; 
Pp., preplexus; C. str., 
striatum; II., habena; 
Z. st., stipe of pineal 
gland; Aq. £., aque- 
duct; Cgr.. axial gray 
matter; Cb., cerebel- 
lum. 
Fig. 444.-Similar Section of Embryo, Sixty-four Hours after Fertiliza- 
tion. 
lial layer. The cavity of the prosencephalon is there- 
fore completely closed. The dorsal lamina of the fold 
forms the ventral wall of the dorsal sac, and the ventral 
lamina forms the membranous wall of the prosenceph- 
alon. It thus appears that the opening of the dorsal 
sac is asymmetrical. Cephalad from this point the two 
chambers are separate. The ventral portion of the neural 
tube at this region consists of thick paired masses, the 
basal ganglia. The membranous roof bears a system of 
673 Nervous System. 
Nervous System. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
folds which becomes more complicated. The middle 
portion projects into the ventricle and forms a sort of 
falx cerebri. The dorsal wall also circumscribes the 
dorsal sac laterad and encloses it in a plexiform struct- 
ure derived from the roof the prosencephalon. 
" Somewhat cephalad of the base of the olfactory lobes 
a groove appears upon the dorso-median aspect of the 
basal ganglia, which passes mesad and can be traced di- 
rectly into the cavity of the olfactory lobe. The median 
falx of the roof dips deeply into the ventricle of the 
prosencephalon. The falx extends to the epithelial 
lamina which connects the two olfactory lobes. Ceph- 
alad of this point the membranous roof of the prosen- 
cephalon is continued to form paired sacs dorsad of the 
olfactory lobes. 
" In this structure of the prosencephalon of A. ru- 
thenus I detect the paired nature of the prosencephalon, 
which consists in the strongly developed falx as well as 
the membranous sacs of its cephalad portion. 
' ' At the cephalic level of the chiasm two prominences 
appear upon the dorsal portion of the encephalon wall 
which have the structure of the basal ganglia. This 
structure extends soon to embrace the entire lateral 
walls of the prosencephalon. These ganglia consist of a 
very compact, finely granular stroma, with peculiarly ar- 
ranged ganglion cells, and of a system of exceedingly 
fine, non-medullated fibres. Beneath the epithelium, in 
the dorsal region of the ganglia, is a layer of small cells 
whose fibres extend ventrad and radially. Such cells 
are not found in the ventral portions, but instead irreg- 
ularly scattered small cells. In the midst of the gan- 
glion are large cells with large round nuclei and pale 
body. The processes are also radially disposed to the 
ventricular surface, producing in cross-sections a very 
characteristic habitus. The transition in structure in 
passing into the olfactory lobes is gradual. 
" The cephalic ventrally arched end of the embryonic 
nerve-tube, which, according to Gotte, forms the primi- 
tive prosencephalon, is to be regarded as the most primi- 
tive phyletic condition of the prosencephalon which on- 
togony suggests. The primitive prosencephalon is ho- 
modynomous with a segment of the spinal cord. By the 
growth of the dorsal surface of the primitive prosen- 
cephalon arose the discrete central organ of smell, while 
the lobus infundibuli is the result of a protrusion from 
its base. The formation of the olfactory centre led to 
the development of the prechordal portion of the skull. 
The architecture of the cranium of the most primitive 
of the Gnathostomata, the Notidaidse, corresponds to 
that of the brain. The gradual development of the or- 
gan of smell gave rise to the rhinencephalon of recent 
Selachii. This still indifferent organ exhibits no special 
homologies with the diencephalon and prosencephalon 
of higher vertebrates. It is closely connected with the 
lobus infundibuli, which is reduced in higher verte- 
brates. 
" On one hand, the reduced form of rhinencephalon 
of Ganoids and Teleosts is derived from the rhinen- 
cephalon of Selachii, which, on the other hand, give rise 
to the structure of the prosencephalon in Dipnoii, Am- 
phibia, and Reptilia. It is among these forms that the 
first indications of the origin of the prosencephalon of 
higher vertebrates may be sought. The first step toward 
the higher organization consists in the reduction of the 
lobus infundibuli and a transformation of the tracts con- 
necting with the caudal parts of the nervous system. 
The development of the thalami and the reduction of 
the lobus infundibuli alters the development process of 
the neural tube in higher vertebrates from the earliest 
stages on. There appears a diencephalic and a second- 
ary fore-brain, the former having an 
entirely different significance from 
the posterior part of the prosenceph- 
alon of fishes, for it is the result of 
accelerated development of a certain 
dorsal portion of the neural tube 
which remains undeveloped in fishes. 
With the gradual development of the 
thalami and alteration of the rhin- 
encephalon of Selachii, there grad- 
ually arise the tegmentum cruris and 
the pes pedunculi of higher verte- 
brates. 
" The Thalamus.-The lateral walls 
of the lobus infundibuli form two 
round, lateral projections, the lobi in- 
feriores, containing a considerable cav- 
ity. The posterior part of the lobe 
extends into a membranous sac, the 
so-called saccus vasculosus. Ventrad, 
the lobe connects with the bilobed 
hypophysis. 
" The walls of the lobus infundi- 
buli consist of finely granular stroma, 
staining pink with carmine, resem- 
bling that of the peripheral portion 
of the cerebellum. In the peripheral 
portion this stroma is compact, and it 
requires high powers to make out a 
fine fibrous structure parallel to the 
surface. Two fibre systems are more 
obvious entad. The fibres of the first 
run parallel to the surface, those of 
Fig. 445.-Similar Section of Larva, Three Days Old. 
Description of Figures 445 and 446.-c, Cerebellum; ca, precommissura ; cc, commissura cere- 
belli; cd, chorda dorsalis ; ch, chiasm and commissura post-opticae ; cp, post-commissura ; cs, 
supra-commissura : de, commissura debilis; e, cerebum; en, entoderm: ep1, paraphysis; ep2. 
epiphysis ; h, hypencephalon = infundibular region ; hf, sucking disk, hy. hypophysis ; hz, heart; 
hi, cartilage ; lo, lobus olfactorius impar. ; JT, mesencephalon ; m, mouth ; N, metencephalon ; 
p„ praepineal roof of diencephalon (parencephalon); pd, plica dorsalis ; pv, plica ventralis ; r, 
median olfactory plate ; ro, recessus opticus ; si, sinus post-opticus ; t, commissura terminalis ; 
tp, tuberculum posterius ; v, prosencephalon ; vt, velum transversum of the fore-brain. 
Fig. 446.-Similar Section of Larva, Four Weeks Old. 
674 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Nervous System. 
Nervous System. 
(SUPPLEMENT.) 
the second radial to the surface. The latter spring from 
a layer of tissue clothing the inner surface. This layer 
is composed of a few series of round cells, much resem- 
bling those of the granular layer of the cerebellum. 
They are, however, somewhat larger than the latter, 
and the dark protoplasm mass surrounding the round 
nucleus of these cells is more highly developed. It is 
possible to trace the processes of these cells into the 
fibres of the radial system. In the fibrous zone round 
cells are scattered, as well as rod-like cells of the neu- 
roglia. 
" In the ventral portion of the cleft-like canal connect- 
ing the lobus infundibuli with the mesencephalic ven- 
tricle a ganglionic body composed of large cells occupies 
either side. Out of these ganglia springs a tract of non- 
medullated fibres which, passing caudad, subdivides, part 
of the fibres, passing to the caudal part of the lobus in- 
fundibuli, and part to the dorsal portion of the sacculus 
vasculosus. Associated with this system is a rather large 
bundle of non-medullated fibres derived from a small 
cluster of nerve-cells lying dorsad to the above-mentioned 
ganglion and ventrad to Meynert's bundle, immediately 
beneath the epithelium. The ventral portion of the 
caudal wall of the lobus passes into the thin epithelial 
wall of the saccus vasculosus, a part of the fibrous layer 
entering it. The saccus itself is a broad, very vascular, 
folded sac, clothed within by a peculiarly modified epi- 
thelium. 
"'The discoidal hypophysis consists of two completely 
distinct parts. The caudal portion is composed of three 
or four lobes, into each of which passes a thick bundle 
of non-medullated fibres, which passes to the ventral por- 
tion and subdivide in the several sacculi. The sacculi of 
the cephalic portion are covered, like the former, with 
multilamellate epithelium with fusiform cells, but no 
nerve-fibres are present. The interstitial substance is con- 
nective tissue only. A thin layer of epithelium connects 
the two portions. 
" The Ganglion Habenulae.-Cephalad of the ganglion 
interpedunculare and ventrad of the transverse fibres of 
the commissura ansulatse, there are two longitudinal 
bundles, which could be followed caudad only to the in- 
terpeduncular ganglia. These are Meynert's bundles, the 
right being much stronger than the left. The bundles 
pass cephalad and mesad of the fibres of the oculo-motor, 
and gradually pass dorsad, and at the point of communi- 
cation of the ventricle of the lobus infundibuli with the 
mesencephalic ventricle they lie adjacent to the epithe- 
lium. These bundles terminate cephalad of the anterior 
commissure in the ganglion habenulae." 
Herrick, in speaking of Lepidosteus and Scaphi- 
rhynchus adds: "The lateral ventricles are not absent, 
nor are they merged in the olfactory ventricles, as stated 
by others. A section taken at a point in front of the fora- 
men of Monro in the sturgeon brain shows that a cavity 
clothed by tela choridea (or pallium) extends cephalad 
along the dorso-mesal surface of each olfactory lobe. 
This cavity is of great morphological importance; part 
of its walls are modified to form a plexus, and it comes 
into direct communication with the aula. The surface 
of the lobe bordering is, like other ventricular surfaces, 
covered with epithelium. The cellular structure is also 
unlike that of the remainder of the lobe. It seems un- 
questionable that this space is homologous with the cavity 
of the lateral ventricle, which is not roofed over with 
nervous matter, but has merely the tela or pallium. 
These two ventricles become confluent cephalad to the 
Fig. 447. 
Fig. 448. 
Fig. 449. 
Fig. 450. 
Fig. 451. 
Fig. 452. 
Fig. 453. 
Fig. 454. 
Figs. 447-454.-Transections through the Brain of the Gar-Pike (Lepidosteus). Fig. 447.-Olfactory lobe, v.l., cephalad projection of the lateral 
ventricle, roofed over by the velum. Fig. 448.-Transection at the callosum, c.c. v.l., lateral ventricle; tn., membranous roof of the ventricle corre- 
sponding to the mantle ; a. I., axial lobe of the cerebrum : f. M., foramen of Monro ; gl.. remnant of the glomerular layer of the olfactory ; nl, olfactory 
nidulus beneath the aqueduct of the olfactory. Fig. 449.-Transection back of the chiasm. A mesad protuberance of the axial lobe corresponding to 
a part of the striatum is separated by projections of the ventricle. The aula is partly confluent with the ventricles, v.l., spur of the posterior cornu 
passing cephalad. In the connecting portion uniting the thalamus and hemispheres some evidence of the taenia thalami was detected. Fig. 450.- 
Transection at the level of the habenae. The lateral ventricles have completely circumscribed the axial lobe, c.g.e., corpus geniculatum externum; 
n, lateral nidulus of the thalamus; Hy.. hypophysis; n.M., nidulus Meynerti ; f.M., foramen of Monro. Fig. 451.-Transection through the pos- 
terior commissure. A portion of the epiphysis is seen above, ep. S.c., commissura Sylvii; Pc., post-commissura ; M.b., Meynert's bundle ; Ha., Hypo- 
ariutn. Fig. 452.-Transection at the middle of the optic lobes. Ill, third nerve in a groove between the hypoaria and lateral lobe of the thalamus. 
The tori project medianly into the ventricle. Fig. 453.-Transection through the posterior part of the optic lobes. IP, fourth nerve ; vol., volvulus, 
or portion of the cerebellum thrust into the optic ventricle. Fig. 454.-Transection through the medulla and cerebellum at the opening of the reces- 
sus lateralis. 
675 Nervous System, 
Nervous System. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
openings of the olfactory lobes, but a partial division, by 
a depending loop corresponding to the dorso-mesal walls 
of the mantle, may be traced back of that point. From 
the ventral extension of these median walls two arms, 
forming with them an irregular inverted Y, pass laterad 
nearly to the ectal thickened walls of the hemisphere, 
shutting off a median aula from the lateral ventricles, 
with which the former is connected by a large portie. It 
is from the ventricles thus bounded, and not from the 
median chamber, that the olfactory aqueduct springs. 
" The development of nervous matter in the cerebrum 
is greater relatively in the gars, therefore the membranous 
portion of the mantle is greater in Scaphirhynchus. In 
Lepidosteus the ventricle gives off two spurs in the median 
portion delimiting a body somewhat resembling the cor- 
pus lenticulare of the striatum. The posterior cornu 
sweeps back of the crura and then circumscribes the ven- 
tral and ectal portions of the cerebrum, finally meeting 
the dorsal extension of the ventricle, enclosing a large 
occipito-basal lobe much as in reptilia. The extent of 
the ventricle may be most easily recognized by the epi- 
thelial covering of the axial lobe where it is present. . 
" The cerebrum is more highly developed in Lepidos- 
teus. Cephalad, it projects beyond the olfactory, and ap- 
(SUPPLEMENT.) 
" The epiphysis springs from the most caudal portion of 
the recessus pinealis, which is clothed, as usual, with very 
large and dense epithelium, very different from that of 
the adjacent parts of the third ventricle. There seems to 
be a perforation passing obliquely dorso-caudad, forming 
the communication between the cavity of the epiphysis 
and the recessus. The epiphysis itself is tubular, and 
arches rapidly caudad to a point over the tectum, then 
curving more rapidly cephalad, between the hemispheres, 
is slung, as it were, in the membrane connecting them. 
The structure is like that of reptiles, varying much in 
different localities by the greater or less development of 
certain elements. In characteristic portions there is, 
first, the wall of connective tissue ; seated upon this are 
slender cells, fibrous in character, which support small 
granular nuclei in several series, and centrally a larger 
nucleus beyond which the cell extends as a long narrow 
flagellum projecting into the cavity. The appearance is 
as though the single stalk supports nuclei of both sorts, 
though this may be an illusion. Nerve-fibres may be 
followed in the spaces between the cell-bases, extending 
in the direction of the axis of the organ, and passing into 
the larger nuclei. There can be no noubt of the nervous 
character of the organ. 
" A blood-sinus closely invests the epiphysis, outside of 
which is a second investment from the dorsal sac which 
projects caudad to ensheath it. The walls of the dorsal 
sac consist of a single-layered epithelium with long cilia 
or flagella projecting into the lumen. Numerous plexi- 
form diverticles also project into the cavity. The fibres 
from the epiphysis were traced, with apparent certainty, 
to the supra-commissura. 
" Cephalad of the habenulae, as well as immediately 
above them, the dorsal sac communicates with the third 
ventricle, the lateral ventricles being entirely distinct. 
Slightly farther cephalad the dorsal sac is shut off from 
a median portion which must be considered as homolo- 
gous with the aula. Into this median portion the cavities, 
of the lateral ventricles open, as usual, the only differ- 
ence being that the aula is more elongated than usual, 
and the portae are correspondingly enlarged. It has suf- 
ficiently appeared from the above that the dorsal sac is 
not a portion of the cavity of the prosencephalon, but of 
the diencephalon. It is not a new structure, but one 
found in reptilia as well, and pertains to the epiphysis." 
In this connection was identified, apparently for the 
first time in fishes, a homologue of the hippocampus. 
" The habena is imperfectly divided into two parts, a 
ventro-median portion, with smaller cells, giving rise to 
Meynert's bundle, and a cephalo-dorsal and ectal portion, 
of larger cells, giving rise to the taenia. The right ha- 
bena is somewhat larger and is apparently chiefly asso- 
ciated with the fibres of the epiphysis." 
The hypoaria, or caudo-lateral lobes of the cinereum, 
are less highly developed in Lepidosteus than in the 
sturgeon. They arise caudad of the chiasm as tuberosi- 
ties of the lateral wall of the infundibulum dorsad of the 
ventral nidulus of large cells above mentioned. A di- 
verticle of the infundibulum enters them, and this cav- 
ity expands to a spheroidal cavity. The cell structure is 
similar to that of the tuber. In Lepidosteus they extend 
much farther caudad, so as to reach the exit of the third 
nerve. A rather strong tract enters the caudo-mesad 
portion where it is becoming separated from the thala- 
mus and passes toward the tract of the third nerve, pass- 
ing Meynert's bundle, and apparently unites with fibres- 
passing toward the cerebrum. If these fibres be compared 
with the fornix tract, they might seem to warrant the sug- 
gested homology of the diverticles of the third ventricle 
between the hypoaria with the mammillaria. This seems 
the more reasonable, inasmuch as there seems to be a 
homologue of the corpus geniculatum dorsad of them. 
The lobi optici are very large and resemble those of 
reptiles in nearly every respect. Very large ventricles 
occupy their centres, and where these are confluent (Fig. 
25) there is a curious pendant body on either side of the 
median line due to a lateral diversion of the median walls 
of the tecta, below their union with each other. This 
body, originally called fornix by Carus, may perhaps 
Fig. 455. 
Fig. 456. 
Figs. 455 and 456.-Dorsal and Ventral Views of the Entire Brain of 
the Gar. The bi-lobed mass lying behind the cerebellum is not of a ner- 
vous character. 
pears in transection as two independent bodies dorsad to 
the olfactory lobes. Fig. 447 illustrates a section through 
the olfactory and extreme cephalic part of the lateral ven- 
tricle, which is bounded only by the pallium. The rela- 
tions are essentially the same in all Ganoids. Fig. 448, 
which passes through the callosum, shows the relation 
between the olfactory aqueducts and lateral ventricle. 
The real homologues of the foramina of Monro are con- 
siderable slits. In the sturgeon the relations are similar, 
but the partial eversion of the hemispheres laterally 
brings the openings of the aqueduct of the olfactory 
lobes farther laterad. 
" Respecting the dorsal sac, Lepidosteus affords much 
clearer information than the sturgeon, and renders neces- 
sary a considerable change in the interpretation of this 
structure offered by Goronowitsch. Morphologically it 
is a dorsal pouch of the diatela, such as may be detected 
in all reptiles in which the epiphysis is strongly devel- 
oped. The asymmetry upon which Goronow'itch lays so 
much stress is slight, and more apparent than real. The 
fact that it extends so far cephalad between the hemi- 
spheres is an incident to the cephalad projection of the 
epiphysis. It may be useful to first study the structure 
of the latter. 
676 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Nervous System. 
Nervous System. 
retain the name suggested by Fritsch, torus longitudina- 
Us, since it is free from the false homology involved in 
the other. The structure of this body is very simple, 
consisting of dense clusters of small cells like Deiter's 
corpuscles. 
From the base of each optic ventricle there is a projec- 
tion which has been called torus semicircularis. These 
lobes must be regarded as an inherent part of the mesen- 
cephalon, being provided with a slightly modified ventral 
accumulation of the cell-layer constituting the fourth of 
the above-mentioned layers of the tectum. The struct- 
ures are those already familiar in reptiles, and called 
(rather unfortunately) by Rabl-Riickhard the colliculi. 
The roof of the aqueduct is thickened and thrust far 
forward under the optic lobes, or better, the optic lobes 
are thrust so far caudad that they over-arch the valve of 
Vieussens or valvula cerebelli. The presence in this body 
of the decussation of the fourth nerve is sufficient proof 
of the correctness of the homology. 
In Lepidosteus the adhesion of the valve dorsally upon 
a forward tongue of cerebellum ventrad is considerable, 
but in Acipenser the ventral (cerebellar) portion is 
pushed forward and rolls cephalo-dorsad, fairly filling 
the cavity. The structure of this body, which may be 
called volvula cerebelli or volvula, is identical with that of 
the cerebellum proper. 
The Cerebellum.-In the development of the cerebellum 
we have the most characteristic feature in the brain of the 
ganoid fishes and, at the same time, the peculiar modifi- 
cations of the theme express the generic variations most 
distinctly. In the gars, where the whole brain is quite 
reptilian, the cerebellum is highly developed superficially, 
while in the sturgeon only a relatively small part is ex- 
posed, the remainder being packed in the cavity of the 
mesencephalon and the laterally enlarged fourth ventri- 
cle. In Lepidosteus the cerebellum may be divided into 
the following parts: first, a cephalic invasion of the 
mesencephalic cavity, more or less closely associated 
with the valve, constituting the wlvula as above de- 
scribed ; second, the median lobe or vermiform lobe, 
third, two lateral lobes ; fourth, a posterior pouch or 
bursa. 
In Scaphirhynchus the volvula is enormously devel- 
oped and thrust far forward, completely obscuring the 
valve. Appearing first as a pentagonal projection from 
the inner (dorsal) surface of the (inverted) valve, it goes 
on increasing cephalad, till, rolling ventrad, it folds upon 
itself, turns caudad, carrying its median protuberance 
upon its (now ventral) surface, and passing somewhat 
dorsad to connect with the vermiform lobe. The central 
portion consists of white matter filled with enormous 
and beautiful branching Purkinje's cells, the lateral por- 
tions containing the Deiter's corpuscles. There is no 
bursa nor distinct cephalad diverticle, as in Lepidosteus, 
but the vermiform lobe remains a solid mass with its 
white matter mesad and dorsad and its granular layer 
laterad and ventrad to the end. 
The Bony Fishes (Teleostei).-The discovery of Rabl- 
Riickhard12 that the cortex cerebri is functionally absent 
and simply morphologically represented by a membra- 
nous pallium of fishes has opened the way for new stud- 
ies in this neglected group. Great progress has been 
made in identifying homologies between the fish brain 
and that of higher vertebrates. The olfactory region is 
best studied in fishes because of the variability of the 
tuber and clues afforded by the manner in which the 
identical morphological relations are expressed under the 
varying conditions. Here, as in all other groups so far 
investigated, there are two distinct roots of the tuber. 
The radix lateralis is derived from the pero or external 
part of the tuber (that part composed of the glomerules 
and specific olfactory cells). This root passes along the 
ventro-lateral aspects of the cerebrum, at the line of 
union of the pallium with the axial lobe, and enters a 
special cluster of cells which has been homologized with 
a part of the hippocampus (" hippocampal nidulus "). 
The radix mesalis passes from the pes olfactorii and, 
even in the numerous cases where the tuber is removed 
by a long interval from the cerebrum, is always distinct 
(SUPPLEMENT.) 
from the preceding. It passes through the praecommis- 
sura. It has been shown that there are somewhat con- 
stant fissures upon the surface of the axial lobe and that 
the lobe is topographically subdivisible into subordinate 
lobes which differ in histological structure and fibrous 
connections. Thus the cephalic portion gives rise to 
the ventral peduncles which end in the hypoaria, while 
the dorsal part originates the dorsal peduncular bundles 
which pass to the midthalamus and there come into rela- 
tions with the sensory niduli. The commissures of the 
cerebrum are difficult of interpretation. The great cen- 
tral bundle which connects the two axial lobes consists 
of three distinct portions, as described by Edinger and 
Bellonci; first, the praecommissura ; second, decussation 
of olfactory radices ; third, axial commissure (commis- 
sure of basal cerebral fasciculus, Edinger). In some 
cases feeble indications of a callosum have been recog- 
nized, as well as fibres from the " hippocampal nidulus," 
forming a M fornix" (Herrick).14 The diencephalon is 
much modified in fishes and has received exceedingly 
divergent interpretations. The dorsal wall is frequently 
greatly reduced by the cephalic growth of the tectum op- 
ticum while its ventral aspect is increased by numerous 
expansions of a nervous or non-nervous nature. The 
non-nervous portions are essentially parts of the same 
system. The hypophysis and saccus vasculosus are both 
parts of a system of expansions of the ventral walls which 
are so thinned that only the thin, fibrous walls of the 
spongioblasts remain. These fibres have been described 
as nervous, but are undoubtedly remnants of the epithe- 
lium cells dragged out of the original position by disten- 
tion of the walls. The saccus receives numerous vessels 
and is essentially a sort of plexus, while the axial part of 
the hypophysis is almost precisely similar and is in more 
or less direct communication with the former. 
The hypophysis consists, in addition, of a mass of 
tubular vessels derived from the pharynx as in other 
groups. There are possibly nerve-fibres in the axial por- 
tion of the hypophysis, but most of the fibres which pass 
dorsad from it may be spongioblastic (gelatinous.) The 
epithelium of the saccus is ciliated. Caudad of the sac- 
cus are two small pouches which have been homologized 
by Herrick with the mammillaria. The great expansions 
back of the tuber cinereum known as the hypoaria or 
lobi inferiores are regarded by most authors as expan- 
sions of the base of the thalamus, but recently the view 
has been advanced that they represent (in part at least) 
the base of the mesencephalon which in other vertebrates 
is largely lost in the " saddle cleft." 
In the base of the diencephalon of fishes the several 
decussations and commissures are unusually distinct. 
The commissura ventralis is the most ventral member of 
the system. The fibres arise in the tuber cinereum and 
form a true commissure. The commissura transversa is 
closely associated with the chiasm. Its fibres seem to 
spring from cells near the entrance of the cephalic branch 
of the optic tract into the tectum and may be associated 
with the anterior brachium opticum. A small but dis- 
tinct bundle with similar course forms the commissura 
minor. 
The commissura horizontalis, after forming a sharp 
loop across the median line, passes by a reverse curve 
through the nidulus ruber to the nidulus "corticalis" 
near the habena. 
Meynert's bundle pursues the same course in fishes as 
in higher animals and serves as a valuable landmark. A 
possible taenia thalami connecting the diencephalon and 
prosencephalon was noted. 
The dorsal surface of the thalamus gives rise (over the 
aula) to a remarkable pouch or dorsal sac which may 
extend far cephalad and is intimately associated with the 
epiphysis. It seems probable that the same structure 
exists in all vertebrates and forms the plexiform body, 
sometimes called paraphysis and in some cases mistaken 
for the epiphysis itself. 
The habena is frequently well-developed and contains 
numerous small cells. It sends numerous spongioblast 
fibres into the tectum. The most remarkable external 
structure on the lateral surface of the diencephalon is 
677 Nervous System. 
Nervous System. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
thegeniculatum, which in its internal structure is peculiar. 
The ectal surface has numerous large cells like the pe- 
ripheral cells of the hypoaria. These give rise to two 
fork-like processes which form a switch-station for the 
tracts. The interior is composed of similar cells in a great 
mesh-work of fibres. The ventral commissure enters it 
and thus suggests a connection with the brachia optica, 
while a contingent of fibres passes to the dorsal pe- 
duncle. 
Although the optic nerves pass over the walls of the 
thalamus there is no connection directly with the cells of 
that region. The tracts divide at once into a cephalic and 
a caudal portion which pass severally to the cephalic and 
caudo-lateral portions of the tectum. The gray matter of 
the diencephalon will be further treated in connection 
with the mesencephalon. 
The roof of the mesencephalon is composed of a greatly 
distended tectum opticum, while much of the central 
cinerea is crowded into the interior of the ventricle in the 
form of the torus. The latter is derived from the me- 
dian part of the tectum and contains granules and cells. 
Its spongioblasts are connected with the tectum and are 
obviously simply the elongated walls of the displaced 
epithelium cells whose ventral ends have been crowded 
into the ventricular space. These slender remnants of 
the cell-walls (" gelatinous tracts ") are among the most 
important indices of the structural relations of the 
modified brain-walls. The tectum opticum is so com- 
plicated and difficult that no apology is necessary for 
giving in full the suggestions derived from a study 
of this organ in fishes. 
The fibre-tracts are : 1. The optic fibres, entering 
from the cephalo-mesal and caudo-lateral aspects 
respectively. These tracts are part of the same 
continuous sweep of fibres from the optic nerve, 
which have been separated by the architectural 
necessities of the brain; their internal course is 
morphologically identical. 2. The fibres of the 
cephalic and caudal brachia which, after effect- 
ing cellular connections at their exit from the 
tectum (?), connect with a double commissural sys- 
tem (transverse and ventral commissures) as above 
described. 3. The radiation to the lemniscus de- 
rived from the ventral ganglionic series of the 
tectum and passing to the lateral aspects of the 
medulla. 4. Associated with the latter the fibres 
of the middle peduncles of the cerebellum (decus- 
satio tegmenti) and probably also fibres to the third, 
fourth, and perhaps the sixth nerve niduli. There 
may also be among them commissural fibres. 5. 
The Sylvian commissure system whose fibres pass 
in a more or less complicated course from one side 
to the other, originating in the ectal reticulum of 
either side. 6. A system of fibres belonging to the 
category of gelatinous tracts, i.e., connective fibres 
springing from the epithelium of the ventricular 
portion of the torus and passing to the ectal surface of 
the tectum. 
The connective framework of the tectum is constructed 
on the same plan'as that of the rest of the brain, and con- 
sists of a continuous epithelium with the base of each 
cell upon the ventricle and its summit at the periphery. 
The integrity of the series is greatly disturbed by the de- 
velopment of neuroblasts and their migration and the in- 
vasion of fibre-tracts, as w'ell as by the great changes in 
position suffered as a consequence of the development 
of the cerebellum and volvula. The primitive simplicity 
is retained more perfectly in Amphibia (Menopoma, etc.). 
To all appearances, the nucleus of the epithelium cell 
divides without causing division of the cell, yet this is 
not certain. After passing the inner ganglion layer the 
walls collapse and form a thread which may enclose one 
or more nuclei and terminate at the periphery in a cell. 
These are conspicious in the young, but practically 
shrivel up with age. Between these cylindrical connective 
cells the neuroglia stroma, nerve-cells and fibres develop. 
The cells develop from the neuroblasts of the ventricular 
region and accumulate between the connective cells up 
to the level of the first fibre belt, forming a basal cellu- 
(SUPPLEMENT.) 
lar zone. The upper portion becomes functional and 
some cells migrate toward the periphery. By the grad- 
ual thickening of the tectum the ganglionic layer is sep- 
arated from the ventricular surface by an interval. It 
seems probable that only the outer portion of the dense 
zone of nerve-cells is functional, and it is only with these 
that a fibrous connection has been observed. The first 
layer of the tectum, beginning from the ventricle, there- 
fore, consists of columnar epithelium cells whose proto- 
plasm in the adult is more or less shrunken and whose 
nucleus may still remain distinct or may become im- 
bedded in a thin layer of protoplasm adjoining the walls. 
The walls may collapse beneath the ganglion layer and 
there is frequently an intricate folding which produces a 
peculiar appearance in section, but Fusari has completely 
misinterpreted this appearance in Plate III. of his work.* 
The appearance of a brush-like radiation of fine process- 
es is illusory and in perfectly prepared specimens, not 
too much dragged in cutting, the walls of the cylindrical 
epithelium cells can still be followed. Above this level 
the whole tectum becomes charged with a dense mass of 
gelatinous matter, giving it a homogeneous appearance. 
The (generally collapsed) walls of the connective cells 
pass directly toward the periphery and in some cases en- 
close nuclei with surrounding protoplasm. Whether 
these nuclei have simply retreated from the ventricular 
surface, or whether a single epithelium cell may have 
more than one nucleus is uncertain, but at the peripheral 
terminus there is always a small fusiform cell-like body. 
Fig. 457.-Diagrammatic Longitudinal Section of Fish-brain illustrating the 
Course of the Most Important Tract and Commissure. (From Anatom incher 
Ameiger, vli., 13-14.) 
These were apparently figured by Fusari as terminal 
expansions of ganglion-cell fibres in the plate above re- 
ferred to. 
It is only in well-preserved material that the distinction 
between the nuclei of the ventricular epithelium and the 
internal ganglion layer is obvious. A comparison with 
Amphibia shows that the same arrangement prevails 
there also. Each ganglion cell has its peripheral process, 
which passes into the ectal layer of the tectum and there 
divides dichotomously, mingling with the optic fibres to 
form a fine reticulum. This zone is perforated at inter- 
vals by the lemniscus and decussating cerebellar tracts, 
whose fibres collect ectad. In many cases actual com- 
munication between fibre and cell could be seen. But 
there is also a partial commingling of fibres of the next 
layer at some levels. 
The fifth layer is a dense band filled with a homoge- 
neous gelatinous substance, through which pass the fibres 
from the apical processes of the ental ganglion layer. It 
also contains sporadic cells of that layer as well as pos- 
* Atti de Lincei Mem. cl. sc. fis. ecc. Ser. 4, Vol. IV. Intorna alia fina 
anatomia dell' Encefalo dei Teleostei. 
678 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Nervous System. 
Nervous System. 
sibly those forming the termini of the anterior bran- 
chium fibres ; the sixth and seventh layers cannot be 
topographically distinguished with precision ; the sixth 
is chiefly composed of transverse (sylvian commissure) 
fibres, while the seventh is the layer of optic fibres 
passing more or less obliquely caudad. Within these 
two layers is contained the ectal layer of ganglion 
cells of large size and with elongate processes. The 
apex process terminates in a strong fibre which divides 
dichotomously and gives off its ultimate branches to the 
reticulum. Careful study with high powers showed that 
these fibrils actually unite with or come into contact with 
the reticulum. The appearance of free termination, seen 
in Golgi preparations, seems to be unconvincing, espec- 
ially in view of the imperfect conservation implied by 
that procedure. The basal processes 
of these cells turn cephalad and seem 
to enter the optic tract. 
Amphibia.- The most, notable re- 
cent additions to our knowledge of 
the amphibian brain are due to the 
efforts of Osborn, Burckhardt,15 and 
Edinger.6 The Gymniophona (sub- 
terranean amphibia) have been in- 
structively compared with the sala- 
manders, etc. Those amphibia 
which, like Ichthyophis, are mero- 
blastic in development agree in the 
method of formation of the head with 
the Amniota in several aspects. We 
may conveniently refer to Dr. Burck- 
hardt's figures of Ichthyophis. Fig. 
458 is a lateral view of the youngest embryo. The infundi- 
bulum (/) is the front of the brain, which is somewhat 
curved ventrad. Comparing with this figure a nearly cor- 
responding stage of the human embryo, as reconstructed 
from sections by Professor His, a marked similarity is 
obvious, Fig. 459. The greater elongation and differen- 
tiation of the hu- 
man embryo is ap- 
parent and the in- 
fundibulum is less 
obviously the front 
by reason of the 
protrusion of the 
future optic recess. 
Fig. 460 is a later 
stage of Ichthy- 
ophis, in which the 
origin of the hypo- 
physis is visible and 
the true nature of 
the cerebral vesi- 
cles as dorsal pro- 
jections is very well 
exhibited. The 
saddle - cleft sepa- 
rating the metencephalon from the rest of the brain 
is greatly developed and still unclosed. In Fig. 461 
the subsequent combinations are shown, and Figs. 462 
and 463 give illustrations of the adult brain. The 
special development of a "temporal lobe" which may 
be compared with the "hippocam- 
pal rudiment " discovered by Her- 
rick in fishes, is noticeable, though 
the connection of the praecommis- 
sure with the olfactory tubes 
described by Burckhardt must re- 
ceive a new interpretation. 
The embryology of Ichthyophis 
shows that the nasal epithelium, 
Jacobson's organs, and other sen- 
sory patches of the roof of the 
mouth have a common origin, and 
it is but a step farther to identify 
them with the pituitary fundament 
as parts of a frontal sensory plate 
of the primitive vertebrate. Edin- 
ger recognized the existence of an 
occipital lobe in amphibia and observed the corpus cal- 
losum as described by Osborn. 
Among the most stimulating papers of the last few 
years is Professor Osborn's18 on the callosum. Re- 
specting the Amphibia he says : " The cerebral commis- 
sures lie behind the foramina of Monro. 
They consist of an upper and a lower 
bundle. The former is much the 
larger. It passes upward and forward 
behind and above the foramen and 
gives the commissural supply to the 
dorso-medial portion of the hemi- 
spheres. It is the corpus callosum. 
The lower part is the anterior com- 
missure. Its main division is the pars 
olfactoria, which supplies a part of the 
brain stem, the ventro-lateral portion of 
the hemispheres, and probably the 
olfactory lobes. Its lesser division, 
supplying the lower posterior part of 
the hemispheres, is the pars temporalis. 
The. inner olfactory tracts arise near 
the anterior commissure, cross each 
other, and pass to the olfactory lobes." 
The upper bundle of the callosum was found to de- 
velop at an early stage in the frog. The fibres of the an- 
terior commissure appear somewhat later as a delicate 
thread beneath the callosum. A mechanical explana- 
tion of the fact that this order is the reverse of what oc • 
curs in mammals was suggested in what is called the 
primary and secondary positions of the callosum. In 
the primary position, Amphibia (and Fishes ?), this com- 
missure lies in the floor of the primary fore-brain, a part 
Fig. 461.-Embryo 
of a Still Later 
Stage. 
Fig. 458. - Youngest 
stage of Ichthy- 
ophis. I, infundi- 
bulum ; Abi, optic 
vesicle; Zh, dien- 
cephalon ; Afh, mes- 
encephalon ; Uh, 
metencephalon. 
riG. 459. - Figure of Hu- 
man Embryonic Brain. 
(From His.) A, optic ves- 
icle : II, prosencephalon; 
Z, diencephalon ; M, mes- 
encephalon : I, isthmus; 
Tr, infundibulum; Pm, 
maininillare : Br, Pons ; ZM, cerebellum ; 
Bf, roof of fourth ventricle ; Gb, auditory 
vesicle ; -V, medulla ; Nk, cervical flexure. 
Fig. 462. 
Fig. 463. 
Figs. 462 and 463.-Adult Brain of Ichthyophis. 
of the brain-wall which is early developed, hence its de- 
velopment is as rapid as that of the anterior commissure. 
In the secondary position, mammalia, the callosum lies 
in the middle portion of the terminal plate, which is a 
later growth than the floor of the ventriculus communis, 
hence its late development. The existence of a fornix 
commissure was regarded as doubtful in amphibia, 
though certainly present in reptiles. 
A considerable dispute has grown up as to the pro- 
priety of applying the term callosum to the fibre-strands 
connecting the dorso-median portion of the mantle. 
With the ditferentiation of a mantle from an axial por- 
tion of the cerebrum the dorsal system becomes more 
distinct and complicated, attention needs to be called to 
the fact that morphologically the precommissure, cal- 
losum, and hippocampal commissure are all parts of a 
Fig. 460.-An Older Em- 
bryo of Ichthyophis. 
Ep, epiphysis; Ast, 
optic peduncle; Sb, 
mesencephalic flexure ; 
B b, pons flexure. 
679 Nervous System. 
Nervous System. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
single system connecting homologous parts of segment^ 
of the dorsal part of the neuraxis. One may increase 
at the expense of another, or nearly supersede it, as is the 
case in the marsupials. 
In 1888 Professor Osborn 16 devoted an extended paper 
to the amphibian brain. Some of bis results are the follow- 
ing : There is a direct motor tract 
to the prosencephalon and dien- 
cephalon. A portion of the de- 
scending trigeminal tract passes 
through the cerebellum. The 
posterior (dorsal) longitudinal fas- 
ciculus sustains relations to the 
eighth, sixth, fourth, and third 
tracts. The nidulus of the oculo- 
motor is connected with the post- 
commissure. A new sensory tract 
and nidulus common to the ninth, 
tenth, and seventh pairs of nerves 
was noticed. The size of the 
roof of the mesencephalon is in 
proportion to the functional per- 
fection of the eyes. The cerebel- 
lum was regarded as interseg- 
mental, and secondarily acquires 
a functional importance equiva- 
lent to that of other segments. 
The early constriction of the brain 
roof, which gives rise to the four 
vesicles, is for the accommodation 
of three nerve-fibre tracts decussat- 
ing dorsally, viz., the supra- and 
post-commissures and the cere- 
bellum, which in their primitive 
condition have a serial homology. 
In Proteus and Menobranchus the primitive epiblastic 
stalk of the optic vesicles is persistent. 
The nerves of the third, fourth, and sixth pairs form a 
special system with no apparent homology or connection 
with the motor elements of the vagus or trigeminal sys- 
tems. 
The attempt to employ the cerebral commissures as 
landmarks of the chief morphological segments of the 
brain (Osborn ") has not been generally accepted, but 
has served to call out much useful discussion. Kupf- 
fer 18 attempts to show that the Amphibia 
have segments of the dorsal roof which are 
not developed in other classes, at least not to 
the same extent. 
In Amphibia, Edinger identified the basal 
prosencephalic tract (ventral peduncle) which 
arises in the lateral and basal parts of the 
prosencephalon and passes to the dienceph- 
alon dorsad of the infundibulum, evidently 
forming anastomoses with cerebellar and 
other tracts. He also describes a homologue 
of the taenia thahuni and an olfactory tract 
which, after crossing in the praecommissure, 
enters the diencephalon (?) and, doubtfully, 
a mantle bundle which decussates caudad of 
the chiasm. Two tracts (equivalent to Os- 
born's direct diencephalic tract) pass into 
the lateral aspects of the cord. The connec- 
tion of the diencephalon with the cerebellum 
through prepeduncles is described, and it is 
apparent that the relations are the same as 
describe 1 by Herrick for Fishes. 
The Brain of Ueptiles.-The authors who 
have contributed most extensively to our 
knowledge of the reptilian brain are Stieda, 
Rabi-Riickhard, Edinger, Herrick, and 
Meyer. The prosencephalon was carefully 
described by Edinger19 (1888), who discusses 
Lacerta agilis, Anguis fragilis, Emys lutaria, and Tropi- 
donotus natrix. He divides the axial portion into a 
cephalic portion containing scattered cells and a caudal 
spheroidal portion which is called nucleus sphaericus. 
The origin of the peduncle tracts is in the axial lobe, 
and they divide in the thalamus, one to enter the nidulus 
of the thalamus, while the ventral portion passes on into 
the medulla. The figures, however, leave open the pos- 
sibility that the ventral peduncle communicates in this 
case, as the writer has shown in Fishes, with the middle 
peduncle of the cerebellum. 
The dorsal cortex of the median wall of the hemi- 
sphere is considered homologous with the cortex of the 
cornu ammonis, and a portion of the median wall devoid 
of cortex is said to represent the fornix ridge. Edinger 
says explicitly that the cortex first appears in Reptilia, 
though we now know that it is represented in Dipnoi 
and Amphibia. 
A callosum and fornix bundle are recognized much as 
they were by the writer. Aside from the fornix region 
an occipital region and a dorsal region are distinguished, 
which latter is supposed to communicate with the olfac- 
tory. An intermediate cell layer is also mentioned. 
The writer20 published one year later a brief account 
of the alligator, in which many of the above points were 
independently observed. The mistake of Wiedersheim 
and Riickhard in supposing the olfactory bulb to be ab- 
sent is corrected by reference to the young brain, in 
which the tuber still adheres to the brain. 
Distinct callosum, fornix, and taenia thalami were ob- 
served, and also a bundle corresponding to that called 
by Edinger "Bundel der sagittalen Scheidewand." The 
several commissures are found to occupy the same rela- 
tive position as in other Vertebrates. The remarkable 
olfactory fossa, a depression found in all Reptiles and in 
the Opossum, is noticed for the first time. 
" Three distinct kinds of cells can be detected in the 
mantle, one characteristic of the superior and anterior 
regions, a second of the occipital, median, and posterior- 
lateral regions, and a third about the ventro-basal region 
or hippocampus. 
" The natural division of the cerebrum into an axillary 
and mantle portion is very convenient for the purpose of 
description of the nervous elements. Attention is again 
called to the reason for regarding these two regions more 
closely related than either is with the diencephalon. The 
corpus striatum, as such, does not exist in the alligator, 
but the major part of the cerebrum consists of what 
Rabl-Riickhard called axillary lobes (Stammlappen). 
The axillary lobes consist of a rather homogeneous mass 
of cells, and has a contour similar to that of the entire 
Fig. 464.-Median Longi- 
tudinal Section of Brain 
shown in Fig. 30. Cc, 
callosum; Com. a., pne- 
commissura; Com. sup., 
supracommissura; PZ. 
■chor. sup., prasplexus; 
Gf/A^habena; Sp^epiph- 
ysis; Com. p., post- 
commissura; Cbl, cere- 
bellum ; Z, infundibu- 
lum ; Cho, chiasm ; Lt, 
terma ; Hy.. hypophysis ; 
Ssp, "saddle-cleft;" B, 
pons. 
FIG. 465.- A, B, C, Three Views of the Brain of a Young Alligator. 
hemispheres, but is covered by a mantle which embraces 
it on all sides except behind, and is separated from it on 
all sides except antero-inferiorly by the ventricle, which 
is exceedingly narrow. The axillary lobes are, there- 
fore, the immediate cellular envelopes of the direct ex- 
tension of the peduncles. The mantle portion is exceed- 
680 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Nervous System. 
Nervous System. 
(SUPPLEMENT.) 
ingly thin, and presents little opportunity for variety in 
structure. There is, however, a marked diversity in the 
cellular elements entering it. 
" From analogy these varieties of cells may be assigned 
to motor, psycho-sensory, and special olfactory functions 
respectively. The axial lobes likewise have two sorts. 
" The pyramidal cells which were first above men- 
tioned stain deeply, have small nuclei, and have a long 
apex-process, generally directed obliquely toward the pe- 
riphery, and several basi-lateral processes. No central 
basal process such as described by Meynert was seen. 
These motor-cells can be traced into connection with the 
basal prosencephalic tract (continuations of the pe- 
duncles). Indeed, similar cells can be followed to the 
diencephalon. The second variety of cells is flask- 
shaped or balloon-shaped, and has a slight power of pre- 
cipitating stains; and is further characterized by the 
large, clear nucleus, or perinuclear space. Such cells are 
distinctive elements over the posterior and median parts 
of the cortex. Especially constant are they in the me- 
dian wall. 
" The great bulk of the axial lobes-that portion which 
protrudes into the ventricle-is filled with similar flask 
cells, but these are curiously clustered in groups of two 
or multiples of two. The evidence that these cells are 
undergoing rapid increase by fission in this young animal 
is very conclusive. All stages of the process may be ob- 
The above indicates that the writer identifies the homo- 
logue of the hippocampus differently from Edinger, and 
relies on the course of the olfactory fibres as a guide, as 
Burckhardt has since done. 
The existence of communicating tracts between the 
tectum opticum and the oculo-motor roots was noted. 
See Fig. 466. 
In 188121 the writer published several contributions to 
the neurology of Reptiles. The free caudo-ventral portion 
of the cortex is definitely homologized with the hippo- 
campus and two distinct portions are distinguished. The 
axial lobe is divided into two portions. The caudal one 
(n. sphsericus of Edinger) is coiled upon itself by the 
backward revolution of the hemisphere and is called the 
occipito-basal lobe, while the cephalic portion, receiving 
the pedunclar tracts and probably representing the stria- 
tum, is known as the central lobe. 
The cortex is aggregated in specialized regions, called 
the frontal, parietal, fronto-median, and intra-ventricular 
respectively. 
The pre-commissure consists of three parts, one of 
which passes to the pes of the olfactory, another to the 
lateral regions of the hemisphere, and the third to the oc- 
cipito-basal lobe. The callosum and taenia thalami are 
also described. 
The existence of two commissures in the region of the 
epiphysis is noted, one being the pre-commissure, the 
other the commissure of the habena. Attention is called 
to the fact that the projecting plexus (conarium of Eu- 
ropean authors) has been frequently mistaken for the 
epiphysis (Zirbel). 
Meyer23 devotes an extended paper to the reptilian 
brain, but finds it necessary to rename many of the or- 
gans. He describes the radix lateralis as extending from 
the olfactory pero to the occipito-basal lobe (his "nu- 
cleus sphericus"). Much difficulty in construing the 
olfactory region would be removed if the pes olfactorii 
were recognized as a part of the hemisphere. The sub- 
division of the mantle into a number of distinct cell- 
groups is recognized. The median wall is called septum 
pellucidum, but the author finds no commissural fibres 
connecting the pallium of the two sides. 
If it were present it could not represent the callosum, 
which, he claims, must arise in a late stage of develop- 
ment and form a secondary connection between the hemi- 
spheres. The writer has abundantly demonstrated the 
existence of a callosum in the sense employed by Osborn 
in other reptiles, and sees no reason why the period 
at which the fibres appear should influence the homology, 
especially as we know almost nothing of the period when 
they appear in Reptiles. Nothing is more probable than 
that a strongly developed mass of commissural fibres 
should create a place for themselves apparently outside 
the septum in which they originate. 
The Brain of Birds.-The most important contribution 
which has yet appeared in this department is that pre- 
pared by Mr. C. H. Turner,22 under the direction of the 
writer, in 1891. 
Compared with other Sauropsida the avian brain is 
quite large and is remarkably compact. The large pros- 
encephalon entirely covers the diencephalon, and may 
cover rhinencephalon and mesencephalon. Although the 
compactness of the brain, the highly developed cerebel- 
lum and ventrally and laterally revolved optic lobes 
give to the bird-brain a habitus peculiarly its own, yet it 
is, after all, but a modified reptilian organ. Mr. Turner 
shows that a careful use of brain measurements and pro- 
portions offers valuable aid in classification. 
The avian prosencephalon is large, but unconvoluted. 
The epencephalon is well developed and transversely 
convoluted. From the introduction of the class Aves 
until now there has been a gradual retrograde evolution 
of the avian rhinencephalon. In the lowest type of 
birds the rhinencephalon is double, and projects be- 
yond the cephalic extremity of the prosencephalon ; in 
the highest type it is single and does not project. In the 
lower types of bird-brains the optic lobes are only par- 
tially covered by the prosencephalon. During the evo- 
lution of the class Aves and the differentiation of the 
Fig. 466.-Cross-section of Optic Lobes of Alligator at Exit of Third 
Nerves, col., Colliculus; tec., tectum; g.c., large cells of mesence- 
phalic root of the fifth nerve ; n. III., nidulus of the oculo-motor; 
d.t., tract from tectum passing adjacent to the nidulus. 
served. It may be suggested that, if in the case of young 
animals this part of the brain is most actively multiply- 
ing cells, it is possible that the growth of the mantle (in 
which there is little material for rapid growth) may be 
in some way associated with this proliferation of cells, 
resulting in the increase of the mantle from its margins, 
as though the material were pushed up around the mar- 
gins of the ventricle by rapid growth within. 
" The connection of this portion of the axial lobes of 
the cerebrum seems to be with the superior or sensory 
longitudinal tracts of the peduncles. In addition to the 
tracts above mentioned, the taenia thalami, springing 
from the basal region and passing to the habenulae, form a 
sensory link between the thalamus and the cortex. It is 
noticeable that the cells associated with this tract, even 
in the thalamus, are of the flask variety." 
Four areas of the mantle were distinguished, and the 
variety of cells contained in each seemed to substan- 
tiate the theory that the pyramidal cells are motor and 
the flask cells sensory. "One cell-cluster, which occu- 
pies a relatively small area anteriorly, but increases cau- 
dad, occupies the lower median portion of the mantle. 
It consists of flask-like or sensory cells with fibres, which 
can be traced to the tract leading directly ventrad to the 
ventral median portion of the posterior part of the brain, 
i.e., the hippocampal region, and seems to embrace the 
continuation of the olfactory tract." 
681 Nervous System. 
Nervous System. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
families in it the dorsal and lateral portions of the avian 
prosencephalon have grown caudad much more rapidly 
than the ventral and mesal portions. This has caused the 
caudal portion of each cerebral hemisphere to revolve 
toward the meson, and, at the same time, to cover the optic 
lobes. The avian brain has great toxonomic importance. 
So far, at least, as major groups are concerned, aclassifica- 
cells only. The striatum contains cells of both types. 
There is a proliferating area in the axial lobe where small 
cells are produced. There is an involution of cortex in 
the occipital region of which there is no external indica- 
tion. Birds are pre eminently seeing animals, and all 
parts that appertain to vision are developed to a great de- 
gree. The optic nerve is the largest of the cranial nerves, 
and the optic lobes are complexly differentiated bodies. 
Even the third, fourth, and sixth nerves are relatively 
larger than the corresponding nerves of the mammalian 
brain. 
Mammalia. Minute Anatomy of the Spinal Cord.- 
Professor Golgi, of Pavia, by means of the method which 
bears his name, made out the following points, upon 
which recent investigations have been founded : 
1. All the nervous cells of the cord have but one ner- 
vous process. (That is,only one process which gives ori- 
gin directly to a nerve-fibre. Opinion differs greatly as 
to whether the other (protoplasmic) processes convey or 
receive nervous stimuli or act simply as nutrient roots.) 
2. The protoplasmic (shorter, branching) processes do 
not give rise to nerves but are distributed to blood-vessels 
and glia-cells. 
3. Nerve-cells differ greatly in size and form and 
method of branching of the protoplasmic processes, but 
these variations are not especially significant. 
4. More essential characters are furnished by the be- 
havior of the nervous branch, in accordance with which 
we may distinguish two types of nerve-cells: (a) Such 
as have an axis-cylinder which soon subdivides and pro- 
duces a reticulum ; (6) such cells as send out an axis- 
cylinder which maintains its integrity in spite of pro- 
ducing a few lateral branches. Cells (a) are found in the 
dorsal cornua and substantia gelatinosa, cells (b) in the 
region of the motor-root (ventral cornua). 
5. In the cinerea of the cord there is a diffuse reticulum 
of fibres which is continued into the medulla and forms 
a communication between all parts of the gray matter. 
In the cord this reticulum is formed of the fibres of the 
dorsal roots and nervous processes of the sensory cells, as 
well as of branches of fibres from the motor-cells, and 
similar cells of the dorsal cornu and from small branches 
from the fibres of the various tracts. 
6. In the cord nerve-cells of very different value are 
promiscuously scattered. 
7. The second type of cells (sensory), with divided axis- 
cylinders, is found in the cells of the substantia gelatinosa, 
a considerable number of the cells of the dorsal cornu 
proper, a few irregularly arranged cells of the marginal 
layer between the two cornua, and a few which are scat- 
tered in the ventral cornu. 
The motor type of cells is found represented by the 
majority of the cells of the ventral cornu, a few cells of 
the dorsal cornu, and cells of the intermediary zone, es- 
pecially those adjacent to the lateral bundles. 
The majority of the cells of the ventral cornu send 
their axis-cylinders into the ventral column or the ventral 
root, while a considerable number pass through the ven- 
tral commissure into the white bundles of the opposite 
side. A few cells send their processes into the lateral and 
ventro-lateral columns. 
In the ventral commissure three kinds of fibres cross 
to the opposite side : those of the cells of the dorsal cor- 
nua, those from cells in the ventral cornua, those from 
the zone between the central canal and the lateral col- 
umns. There seems to be a doubt in the mind of Golgi 
whether the cells actually pass into the columns of the 
opposite side or simply divide to form a reticulum. The 
fibres of the sensory nerves, after entering the spinal cord, 
subdivide like the axis-cylinders of cells of the second 
type. 
To these important statements the following were added 
by Ramon y Cajal, who used the same methodsand came 
to similar conclusions as Golgi, quite independently of 
the latter : 
(1) The nerve-fibres of the sensory roots divide after 
entering the cord into an ascending and descending 
branch, associated with the fibres of the dorsal cornua. 
(2) Cajal believes that the free tips of the nerve-fibres 
Fig. 467.-Brain of a Young Turtle (Aepidonectes spinifer). A, Entire 
brain from above, ol., Olfactory nerves ; Pn., epiphysis with dorsal 
sac ; Tr, fifth nerve. B, Longitudinal section of the same brain, o.t.r., 
Radix lateralis olfactorius: ac., precommissure ; tec., tectum opticum ; 
cp., corpus posterior or testes. C, Similar section, nearly median. 
Cp.g., corpus geniculatum ; gl., gif, glomerular layer of olfactory lobe ; 
inf., infundibulum : PP, post-plexus : med., medulla ; Pn., epiphysis. 
D, the epiphysis. V. Ep., ventricle of epiphysis ; P. ep., peduncle of 
epiphysis : Plex., plexiform part of dorsal sac ; pc., post-commissure : 
Aq. S, Sylvian aqueduct; s.v., venous sinus above epiphysis. E, Cells 
of the two sorts m mixed cortical area of the cortex. (All the figures 
from Journal Comp. Neurology, March, 1891.) 
tion based upon it agrees in all essentials with those based 
upon a careful study of all the structural elements. There 
is a distinct callosum in addition to the precommissure. 
There is a fibre-tract connecting the mesal division of the 
mantle with the optic lobe of the same side. There is a 
correspondence throughout the class in the distribution of 
cell-types. The mesal division of the mantle contains fusi- 
form cells only. The lateral division contains pyramidal 
682 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Nervous System. 
Nervous System.. 
(SUPPLEMENT.) 
and their branches end free instead of forming a reticu- 
lum. 
(3) In accordance with the above, nervous influence is 
transmitted by contiguity or contact and not by continu- 
ity of the paths. 
Professor Kolliker, in an admirable monograph pub- 
lished in 1891, reports the following results : 
(1) The sensory root-fibres divide, as described by Ca- 
jal, the branches lying in the dorsal columns are superfi- 
cially in the substantia gelatinosa in the' marginal zone. 
Some of these branches may be followed four to six cen- 
timetres, while others turn entad and end in free tips. 
(2) No instance of direct connection between the fibres 
of the dorsal roots and the cells of the cord has been ob- 
served. 
(3) All sensory longitudinal fibres of the columns give 
off collaterals, which subdivide and end free in the gray 
matter. These are particularly numerous in Clark's col- 
umn and the marginal region of the gelatinosa. 
(4) The motor root-fibres spring from large and small 
plasmic processes of a part of the cells of the ventral cor- 
nua. 
(8) The dorsal commissure is composed of (a) crossing 
collaterals of sensory root-fibres, (5) possibly the crossing 
of collaterals of the dorsal part of the lateral columns. 
(9) Nerve-cells of three sorts, (a) motor, (J) cells of the 
columns, and (c) other cells whose nervous processes do 
not extend beyond the gray matter but simply subdivide 
within it (dorsal cornu). 
(10) Protoplasmic processes subdivide minutely and 
ramify in various parts of the gray and white matter, but 
do not give rise to nerve-fibres or anastomoses. 
(11) The glia-cells are formed from the elements of 
the medullary plate, and are either primary or second- 
ary, the former remaining as the ventricular epithelium. 
Professor Kblliker, accordingly, agrees with Golgi that 
the protoplasmic processes are solely nutritive, never ex- 
erting a nervous influence over adjacent structures. The 
influence exerted by one neuron upon another is purely 
by contact, not by continuity. Voluntary motion is- 
produced by the effect produced by pyramidal fibres 
upon the motor cells of the ventral cornua, a process 
which is facilitated by the collaterals and terminal 
brushes of the former forming a net-work around the 
latter and thus coming in contact with the cell. 
Sensory impressions are conveyed through the dorsal 
root-fibres, which ascend to the medulla and thence by 
undiscovered paths to the brain. Reflex reactions are 
explained by the passage of collaterals of the dorsal root- 
fibres to the cells of the ventral cornu. 
Minute Anatomy of the Cerebellum.-The most 
important recent additions to our knowledge of the his- 
tology of the cerebellum are derived from applications 
of the Golgi method to embryos of various groups of 
Vertebrates. The most significant papers are those of 
Golgi, Cajal, and Kblliker. It will be remembered that 
the cerebellum contains four layers, which, beginning at 
the periphery are (1) the molecular layer, containing 
superficial fibres ; (2) the layer of Purkinje cells ; (3) the 
granular layer ; (4) the white matter or axis-cylinder 
layer. 
(1) Golgi was the first to clearly prove the existence in 
the molecular layer of small ganglion cells. These cells 
are of variable form and give off " axis-cylinder " pro- 
cesses, which lie chiefly transverse to the convolutions, 
and which, in the deeper cells, give off perpendicular 
fibres which, according to Cajal, form a basket-like en- 
velope for the Purkinje cells. The peripheral cells are 
smaller, and are similar to other bipolar cells. Gierke had 
observed what he called neuroglia envelopes of the Pur- 
kinje cells, and it is not impossible that these " basket 
cells" may be of this nature, but the unanimous opin- 
ion of those who have studied them by the new methods 
is that they are nervous, and that the processes which 
envelop the Purkinje cells do not actually unite with the 
latter but simply are contiguous to them. 
(2) Purkinje's cells are shown by this method to have 
an extraordinarily abundant supply of processes similar- 
in structure to the protoplasmic processes. These pro- 
cesses ramify in the molecular layer, and, although they 
may reach the surface, do not anastomose or connect 
with the pia, the blood-vessels, or other fibres. These 
fibres are chiefly confined to one plane, i.e., transverse to 
the convolutions. The axis-cylinder process may give 
off a few lateral processes, but continues into the white 
zone. 
(3) The granular layer contains two kinds of cells : {a} 
The small nerve-cells are scattered throughout the layer 
and give rise to a number of short, much-branched proto- 
plasmic processes and to one long-axis cylinder. The 
latter passes between the Purkinje cells, and, after pene- 
trating the molecular layer, divides into two branches, 
which extend parallel to the surface and in the plane of 
the gyri for some distance. It would seem that these 
cells are the ones which migrate from the surface at a 
late period of embryonic life, as described by Herrick 
(see next article). (6) The larger cells of the granular 
layer are not numerous and are irregularly distributed. 
The " axis cylinder " branches very profusely. 
Fig. 468.-Diagrams of the Tracts and Centres in the'Cord. A, Longi- 
tudinal »ection. po, Ventral pyramidal tract; ps, lateral pyramidal 
tract; in,motor cells ; m w, motor roots. B, Cross-section to show the 
same elements. C, Diagram of the elements concerned in reflex ac- 
tion. s, Sensory root-fibre: sa, ascending, sa', descending branch ; 
se, sensory collaterals. D, Diagrams of the decussating fibres in the 
ventral commissure, sz, Cells of the fasciculi; sf. fibre of lateral bun- 
dle : vsf, fibre of ventral bundle : sc, sensory collateral ; sw, sensory 
root; sth, point of bifurcation. E, Diagram of short tracts. 
cells of all parts of the ventral cornua in the form of a 
simple axis-cylinder. (There may be small branches.) 
(5) The ventral and lateral columns of the cord are com- 
posed in part of fibres which arise in all regions of the 
cord. These cells frequently give off from their fibres 
more or fewer lateral branches, which end free in the 
gray matter. 
(6) All, or nearly all, the conducting fibres of the ven- 
tral and lateral columns give off collaterals which enter 
the gray matter of the ventral cornu and the ventral part 
of the dorsal cornu and terminate free, and many of the 
fibres themselves bend at a right angle and end in the 
same way. 
(7) The ventral commissure consists of (a) nervous 
processes from cells of the cinerea of all regions, which, 
after crossing, are continued as longitudinal fibres of the 
ventral and ventro-lateral columns, (b) crossed collaterals 
of the ventral and lateral columns, and (c) crossed proto- 
683 Nervous System. 
Nervous System. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
The medullated fibres form a dense layer beneath the 
Purkinje cells, while others pass into the molecular layer 
(SUPPLEMENT.) 
ham,* in the " Memoirs of the Irish Academy of Science " 
bearing his name, gives an extended account of the com- 
parative development of the surface anatomy of the cere- 
bral hemispheres. We condense from this work the 
following statements : 
Complete Fissures (" Total Falten ").-The transitory 
fissures which appear in an early period of the develop- 
ment of the hemispheres are distinguished by the fact 
that they are a result of a series of deep infoldings of the 
thin cerebral wall and form shelf-like projections into 
the ventricles. 
Under normal conditions none of the fissures which 
appear on the lateral aspects of the hemispheres persist 
in the adult, though in the ape two at least are persist- 
ent. Upon the mesal aspect, on the contrary, the cho- 
roid, a portion of the arcuate, and sometimes the parieto- 
occipital with part of the calcarine fissures persist. The 
choroid and arcuate appear gs early as the fifth week. 
The choroid fissure occupies the lowest limit of the mesal 
wall, reaching the porta, cephalad, and extending caudad 
nearly to the extremity of the temporal lobe. Though 
not at first occupied by blood-vessels, and therefore not 
formed by them, its walls do not develop into nervous 
tissue but remain epithelial and are occupied by this pre- 
plexus. The fissura arcuata (Ammonsjurche of Mihalko- 
vics) makes its appearance on the mesal face of the hemi- 
sphere at a higher level than the choroid fissure, and 
while it extends, like the preceding, into the temporal 
lobe, it also passes cephalad into the 
frontal region. That portion of the 
hemisphere lying between the two fis- 
sures mentioned is termed the arcus 
marginalis, in connection with which 
are formed the callosum, the gyrus 
dentatus, and the fornix. 
The caudal part of the fissura arcu- 
ata is retained in adults as the hippo- 
campal fissure, and gives rise to the 
elevation in the floor of the descend- 
ing cornu known as the hippocampus 
major. 
Dr. Cunningham does not agree with 
Mihalkovics and other writers that the 
cephalic part of this fissure produces 
the callosal fissure, but regards this 
portion as transitory. 
The remainder of the complete fis- 
Fig. 469.-A Single Purkinje Cell (by Golgi's Method), n, Axis-cylin- 
der process passing into the granular layer (G). 
and subdivide. Such fibres also occur in various parts of 
the molecular layer. The connections are as yet obscure. 
Types of Cortical Cells.-Various observers sub- 
stantiate Golgi's statements that 
sensory and motor (psycho-motor 
and psycho-sensory) cells differ 
in the nature of their axis-cylinder 
or nervous process. Martinotti 
■especially claims that the gan- 
glion cells communicate by a sin- 
gle nervous process with the axis- 
cylinder, while the protoplasmic 
processes do not connect directly 
or indirectly with the nervous 
fibres but tend to pass to the 
blood-vessels and surfaces. Two 
sorts of ganglion-cells are recog- 
nized : one in which the nervous 
process divides and forms a net- 
work or neuropilem, the other in 
which there is direct connection 
with a corona radiata fibre. Her- 
rick has attempted to distinguish 
sensory and motor cells by other 
methods. In those regions ven- 
trad of the rhinalis fissure the 
cortex is composed of cells whose 
processes subdivide to form a 
dense neuropilem or nerve-felting 
in the so-called neuroglia layer 
entad of olfactory fibres from 
the radix lateralis. This type of 
cell corresponds with the second type of Golgi (Fig. 472,«). 
The motor cells are pyramidal with a peripherad pro- 
cess much more conspicuous than the remainder. . Re- 
gions known to be sensory in function contain a 
large number of cells of a dif- 
ferent type ; the form is ra ther 
flask-shaped than pyramidal, and 
the nucleus is clear and spherical. 
The delimitation of areas is very 
incomplete, and both types of cell 
are to be found in nearly all parts 
of the dorsal cortex, though the 
second (sesthesodic) variety is most 
abundant over the occipital region. 
The same writer has shown that in 
r e n t i 1 e s and other vertebrates 
lower than mam- 
mals the distinc- 
tions between the 
two types of 
cells is very clearly 
seen. 
Fissures of 
the Cerebrum. 
Dr. J. I). Cunning- 
Fig. 470. - One of the 
Smaller Cells of the Gran- 
ular Layer. tA, Bifur- 
cation of axis cylinder 
(n); pr, protoplasmic 
process; M. molecular 
layer; P, layer of Pur- 
kinje cells ; G, granule 
layer. 
Figs. 472, 473. and 474.-Types of Cortical Cells (all from the Opossum). 
Fig. 472, m, motor (above), and s, sensory (?) cells (below). Fig. 473, 
sensory (?) cells. Fig. 474, pure motor cells. 
Fig. 472. 
Fig. 473. 
Fig. 474. 
sures are transitory. The niesal wall of the hemispheres 
being thicker than the outer the transitory fissures there 
first appear. They may appear as early as the eighth 
week, and reach a high degree of development only after 
Fig. 471.-Basket Cell from Molecular Layer. 
Pr, Protoplasmic processes: n, axis cylin- 
der : fk, basket-like envelope of the Pur- 
kinje cells. 
* Contribution to the Surface Anatomy of the Cerebral Hemispheres, 
J. D. Cunningham, Cunningham Memoirs of Royal Irish Academy, vii. 
684 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Nervous System. 
Nervous System. 
the tenth week. Their maximum development is reached 
between the periods when the fornix and callosum ap- 
pear, i.e., near the beginning of the fifth month. 
On the mesal aspect of the hemispheres the transitory 
fissures, which vary in number, radiate from the arcuate 
fissure toward the free border of the hemisphere, and 
others, lying between them, but not connecting with the 
arcuate fissure, appear near the margin. The usual num- 
ber on each hemisphere appears to be eight. 
The primitive fissures which bound the cuneus are the 
precursors of the calcarine and parieto-occipital fissures. 
As the wall of the cerebral vesicle thickens, and the 
hemisphere elongates, the stellate fissures become de- 
tached from the arcuate fissure and gradually disappear. 
Upon the outer aspect the arrangement of the fissures 
is also radial, with the Sylvian fossa as the centre, but 
these fissures usually do not reach the fossa. There is 
frequently an additional fissure occupying the place of 
the future Sylvian. In some cases the precursor of the 
calcarine is carried horizontally around the occipital 
pole, appearing on the lateral surface as an external cal- 
carine fissure. 
It is regarded probable that under abnormal conditions, 
as when the callosum fails to develop, the transitory 
fissures may persist to a certain extent. The fact em- 
phasized by Sir William Turner, that in Macropus, where 
the callosum is rudimentary, the radiating fissures re- 
semble those of an immature human brain, is at least 
suggestive that the development of the callosum has 
some effect on the disappearance of these fissures. 
Dr. Cunningham fully agrees with His and Kblliker 
that the occipital lobe is due to a general growth and not 
a local out-pouching of the hemisphere ; its peculiar form 
is due to the transformations produced by axial flexures 
-especially the pons flexure. This backward thrusting 
of the posterior part of the hemisphere is chiefly re- 
sponsible for the preservation of the precursory calcarine 
and parieto-occipital fissures. The temporary fissures 
are in all probability peculiar to primates, and appear 
prior to the appearance of a distinct occipital lobe. 
The parieto-occipital and calcarine fissures form upon 
the mesal aspect of a posterior part of the adult hemi- 
sphere a >- shaped figure. The stem is directed ob- 
liquely ventrad and intersects the gyrus fornicatus. The 
parieto occiptal fissure forms the more direct continua- 
tion of the stem, and continues on the ectal surface as the 
external parieto-occipital fissure. The calcarine branch 
passes toward the occipital pole. The stem is called the 
anterior calcarine fissure. The apex of the cuneus gives 
off two deep annectant gyri-the gyrus cunei and an- 
terior cuneo-lingual gyrus. The gyrus cunei forms a 
barrier between the parieto-occipital fissure and the 
stem, while the gyrus cuneo-lingualis anterior separates 
the stem and the posterior part of the calcarine fissure. 
The calcar (hippocampus minor) is formed wholly by 
the stem or anterior calcarine fissure. 
In apes the calcarine fissure is deep and much more 
stable than the parieto-occipital. In the chimpanzee the 
gyrus cuneus is on the surface (a condition found in 3.9 
per- cent, of human brains), while in the orang and gibbon 
the cunei may be on the surface or at the bottom of the 
fissure. The gyrus cunei is never absent. Cunningham 
believes that the whole calcarine fissure of anthropoids 
corresponds to the ' ' stem " of the human calcarine, or 
rather, the whole length of the precursor of the human 
calcarine is the equivalent of the ape calcarine. The 
posterior calcarine of man is of later origin and takes 
the place of an abolished portion of the original fissure. 
The cuneus of the ape does not have the same morpho- 
logical value as that of man. Only the cephalic part is 
present in the ape, the caudal part is absent or blended 
with the gyrus lingualis. In the ape the entire length 
of the calcarine fissure is on the tentorial face of the 
hemisphere. 
The posterior calcarine fissure is distinct from the 
" stem" in origin, the latter being a " complete fissure" 
and having unbroken continuity of existence with the 
fore-part precursor. 
The occipital and parietal indices are the distances 
along the mesal margin of the hemisphere intercepted 
by the intersection of tlie external parieto-occipital fis- 
sure and the fissure of Rolando respectively, in the first 
case measuring from the occipital pole, in the second 
from the parieto-occipital intersection, both these dis- 
tances in terms of hundredths of the entire length along 
the dorsal margin of the hemisphere. 
For the human brain the following averages are given : 
5| to 6| months. .0. index, 18.8 ; P. index, 28.5. 
6| to 7| months.. " 18.6; " 24.7. 
71 to 8| months.. " 20.7; " 24.1. 
Full time foetuses, " 20.8; " 25.7. 
First 12 months.. " 22.3; " 25.6. 
4 to 5 years " 23.2; " 24.2. 
11 to 15 years.... " 20.8; " 27.4. 
Adults " 21.2; 25.5. 
For apes the following table is given : 
Orang.... O. index, 23.2 ; P. index, 21.3. 
Chimpanzee " 24.2; " 19.9. 
Hamadryas " 29.5; " 20.5. 
Cynocephalus.... " 29.7; " 22.6. 
Mangaby " 30.5; " 24.1. 
Macaque " 31.0; " 19.0. 
Cercopithecus.." 32.9; " 19.0. 
Cebus " 33.1; " 20.6. 
The low parietal index and high occipital index are in- 
structive features. In low apes there is an enormous in- 
crease in the occipital portion of the border ; whereas, in 
the high apes, the amount of increase is smaller. The 
relative shortness of the parietal border in high apes is 
due to the relative increase of the occipital and frontal 
borders. In low apes the reduction of the parietal por- 
tion is entirely due to the great size of the occipital lobe. 
The following summary is reproduced verbatim : 
1. At an early period in the development of the cerebral 
hemisphere a series of deep infoldings of its thin walls 
make their appearance. On the exterior of each hemi- 
sphere these show in the form of sharply cut linear 
fissures. 
2. Certain of these fissures are permanent; the great 
majority are transitory. 
3. The transitory fissures, with two exceptions, have 
disappeared by the time the corpus callosum is fully 
formed. 
4. A deficiency of the corpus callosum is associated 
with a persistence of the temporary fissures. 
5. The temporary fissures indicate an important stage 
in the growth of the cerebrum, and are apparently asso- 
ciated with the mapping out of the occipital lobe. 
6. A quadrupedal pause in the growth of the cerebrum 
brings the skull capsule into antagonism with the growth 
of the hemispheres, and, in consequence, the wall of the 
cerebrum is thrown into folds. These folds disappear as 
the occipital lobe assumes shape, owing to the expansion 
of the cranial cavity, and a restoration of growth har- 
mony between skull and brain. 
7. Consequently it is only in Primates, which alone 
possess well-developed occipital lobes, that transitory in- 
foldings of the cerebral walls in all probability exist. 
8. The two transitory fissures which do not disappear 
before the full development of the corpus callosum are : 
-(a) the external calcarine, and (b) the external per- 
pendicular fissure of Bischoff. In point of fact the latter 
fissure does not appear until after the full development 
of the corpus callosum. 
9. The external calcarine fissure produces an infolding 
of the outer wall of the posterior horn of the lateral ven- 
tricle, which presents the same direction, and lies imme- 
diately opposite to the true calcarine infolding, or the 
calcar avis. 
10. The fissure corresponding to this in ape is, as a 
rule, permanent, and in some species its anterior end 
forms in "the adult a bulging on the outer wall of the 
ventricle. 
11. The external calcarine fissure disappears before the 
sixth month of foetal life in man. 
685 Nervous System. 
Nervous System. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
12. The external calcarine fissure is present on the outer 
surface of the foetal cerebrum from the beginning of the 
fifth month to the end of the sixth month. 
13. It is a complete fissure and corresponds to the 
" Affenspalte" on the ape's brain. 
14. The " Affenspalte " on the ape's brain is also a com- 
plete fissure, and presents a well-marked bulging on the 
outer wall of the posterior horn of the ventricle ; but, 
unlike the external perpendicular fissure of the human 
foetus, it is permanent. 
15. Certain fissures, therefore, which are complete and 
temporary in the human brain, are complete and perma- 
nent in the ape's brain. 
16. The complete permanent fissures in the human are : 
-(a) the fore part of the calcarine ; (b) the hinder part of 
the fissura arcuata; (c) in many cases the parieto-oc- 
cipital ; and (d) in some cases the mid-collateral. The 
Sylvian fissure is not a complete fissure. 
17. Of the fissura arcuata the hinder part alone is pre- 
served as the fissura hippocampi. The fore part, which 
is generally supposed to be retained as the callosal fissure, 
is in reality obliterated. 
18. Synchronous with the appearance of the radial 
transitory fissures on the mesal face of the hemisphere 
two fissures appear, which lie in series with the former 
and occupy the ground afterward held by the parieto- 
occipital and calcarine fissures. These may be termed 
the precursors of these fissures. 
19. The precursor of the parieto-occipital fissure some- 
times shows an unbroken continuity of existence with 
the parieto-occipital fissure of the adult brain. In other 
•cases it is obliterated, and its place is afterward taken by 
a secondary sulcus, which attains, however, a very great 
depth. 
20. In the adult brain the parieto-occipital fissure, even 
in its complete form, does not form any eminence on the 
inner wall of the posterior horn of the ventricle, because 
it does not extend downward as far as the cavity. Above 
its lower end the hemisphere is solid. 
21. The posterior end of the calcarine precursor is in 
every case obliterated, and the anterior part retained. 
The extent of the part obliterated varies considerably in 
different brains. 
22. The anterior preserved portion of the calcarine fis- 
sure forms the "stem" of the >- shaped fissural ar- 
rangement on this part of the hemisphere, and its hinder 
part corresponds to the calcar avis. 
23. In the place of the hinder portion of the calcarine 
precursor, which is obliterated, a secondary furrow ap- 
pears. This may be termed the posterior calcarine sul- 
cus. 
24. The posterior calcarine sulcus is formed in two 
pieces which run together and also form the "stem." 
In this way the entire length of what, in anatomical lan- 
guage, is called the calcarine fissure is formed. 
25. The posterior calcarine sulcus is not a complete 
fissure. 
26. In the ape the entire length of the calcarine fissure 
is represented by that portion of the fissure which in man 
is termed the " stem," and by that alone. The posterior 
calcarine sulcus does not exist in any form in the 
apes. 
27. The cuneus, therefore, has a different morphologi- 
cal value in the apes and in man. In connection with 
this compare the abnormal human hemispheres. These 
exhibit certain conditions which approximate to those 
present in the apes. 
The Fossa and Fissura Syleii.-The sign of the Sylvian 
depression appears at the end of the second month of 
■development. Dr. Cunningham summarizes his investi- 
gations as follows : 
"1. As growth proceeds the outline of the Sylvian fossa 
changes considerably. At first nearly circular, it elon- 
gates in a vertical direction and then backward on itself, 
and assumes a triangular outline. 
"2. The high prominent mantle-border or rim which 
surrounds the depression is divided by intervening angles 
into four sections, viz. : The temporal, or lower; the 
fronto-parietal, or upper ; the frontal, which is formed 
(SUPPLEMENT.) 
by an opening out and flattening of the primitive single 
anterior angle ; and an orbital, or front portion. 
"3. Each of these portions of the bounding rim acts 
as an independent line of growth, and consequently, in 
course of time, four opercula grow over the Sylvian area 
so as to enclose it. The temporal and fronto-parietal 
opercula appear first; the frontal and orbital do not de- 
velop until a much later period. 
" 4. The so-called three limbs of the fissure of Sylvius 
are formed by the meeting over the Sylvian area of the 
contiguous lips of the four opercula ; the posterior hori- 
zontal limb intervenes between the frontal-parietal and 
the temporal opercula ; the anterior ascending limb be- 
tween the frontal and fronto-parietal opercula ; the an- 
terior horizontal limb between the frontal and the orbital 
opercula. 
"5. The frontal operculum is therefore the same as 
the ' cap de Broca,' and it shows great variations in its 
length. It may be absent altogether, and then the two 
anterior limbs of the Sylvian fissure are fused into one. 
When the frontal operculum is reduced in length we 
have the Y-condition of the two anterior Sylvian rami. 
" 6. The Sylvian fossa once mapped out on the surface 
of the hemisphere, it extends very rapidly. The growth 
is not proportionate 'with that of the hemisphere, it is 
much more rapid. 
"7. During intra-uterine life the anterior end of the 
insula maintains a very nearly fixed position with refer- 
ence to the anterior end of the cerebrum, while the pos- 
terior end of the cerebrum moves rapidly toward the 
occipital pole. After birth the posterior end of the in- 
sula is fixed, while the anterior end, as growth advances, 
oscillates slightly-at first approaching and then retreat- 
ing from the anterior end of the cerebrum. 
"8. An anterior limb of the Sylvian fissures can only 
be determined by the following tests : (a) It must cut 
right through the entire thickness of the operculum and 
reach the furrow surrounding the island of Beil, (b) It 
must lie in front of the prsecentral sulcus. 
"9. A single anterior limb of the Sylvian was present 
in 30 per cent, of the hemispheres examined; the two 
anterior limbs, quite distinct and separate, w'ere present 
in 37.5 per cent. ; the Y-shaped condition of the two limbs 
was present in 31.5 per cent. 
" 10. The two orbital limbs of the Sylvian fissure can- 
not be regarded as belonging to the same category of the 
true anterior limbs. They are not developed as primitive 
deficiencies in the orbital operculum. 
" 11. The posterior insula is not connected with the ex- 
tremity of the temporal lobe, as Erbstaller has asserted, 
but with the limbic lobe. 
" 12. On the surface of the foetal insula there appear 
three radial furrows which correspond in every respect 
with the three " Primarfurchen " on the outer surface of 
the mantle (viz., the fissure of Rolando, the inferior pra?- 
central sulcus, and the vertical limb of the intra parietal 
sulcus). The radial furrows on the insula clearly belong 
to the same fissural system and intermediate links be- 
tween the three radial fissures on the outer surface of the 
hemisphere, and the three radial fissures on the insula 
may exist in the form of secondary sulci, cutting the 
margin of the fronto-parietal operculum. 
" 13. The fissure of Rolando is clearly the proper boun- 
dary of the frontal lobe. Above,*it is only separated 
from the calloso-marginal fissure, which bounds the lobe 
internally, by a narrow but superficial gyrus ; below, 
the inferior transverse furrow' of Erbstaller acts as an 
intermediate link betw'een it and the sulcus centralis 
insulie. The sulcus centralis insulae and the calloso- 
marginal sulcus are brought into close relationship at the 
anterior perforated spot on the base of the brain. An 
almost continuous fissural system, therefore, marks out 
the limits of the frontal portion of the cerebrum. 
" 14. The temporal pole is formed entirely by the for- 
ward growth of the fore part of the temporal operculum. 
" 15. In the adult brain the insula is proportionately 
longer in the male than in the female. At all periods of 
growth it would seem that the insula is relatively longer 
on the left side than on the right side. In the negro 
686 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Nervous System. 
Nervous System. 
brain it would appear that the insula is relatively shorter 
than in the European brain. 
" 16. In the anthropoid ape the so-called anterior limb 
of the Sylvian fissure is not homologous with either of 
the anterior limbs in man. 
" 17. In the chimpanzee and orang there are only two 
opercula, viz., the fronto-parietal and the temporal. 
The frontal and orbital opercula of the human brain are 
entirely absent in the anthropoid cerebrum. 
" 18. Restricting the term insula to that part of the 
hemisphere surface which is concealed from view by 
opercula, the extent of this area in the ape is very much 
less than in man. The central index is 18.2 in the chim- 
panzee and 21.5 in the orang ; in man the central index 
is 29.6. In the lower apes the central index is higher 
than in the anthropoids. 
"19. In man the field of the insula shows marked 
changes with reference to the cranial wall during intra- 
uterine life. More and more of its area comes to lie un- 
der cover of the parietal bone, and relatively less under 
cover of the frontal bone, as development proceeds. In 
the adult the coronal line cuts the insula in such a man- 
ner that thirteen per cent, of its length lies in front of it, 
and eighty-seven per cent, behind it. 
" 20. In the chimpanzee and the low apes no part of 
the insula lies in front of the coronal line ; in the orang 
the upper and anterior corner of the insula projects 
slightly in front of this line. 
" 21. In the human infant and young child, as well as 
in the ape, the point at which the stem of the Sylvian fis- 
(SUPPLEMENT.) 
and continuous in some of the lower apes {e.g., Cebus), 
becomes broken up in the human brain into a group of 
furrows which present different relations to each other 
in different cases. 
"2. Three of the elements of the sulcus in the human 
brain, viz., the sulcus post-centralis inferior, the ramus 
horizontalis, and the ramus 
occipitalis, are disrupted 
portions of the original fis- 
sure ; one, the sulcus post- 
centralis superior, is a super- 
added element. (Fig. 482.) 
" 3. In the development 
of the sulcus in the human 
foetal brain, all the four seg- 
ments of the sulcus have, as 
a rule, an independent ori- 
gin, although, as Pausch has 
shown, the sulcus post-cen- 
tralis inferior and the sulcus 
horizontalis very frequently 
appear as one continuous 
furrow. 
" 4. The sulcus post-cen- 
tralis inferior usually ap- 
pears first ; then the ramus 
horizontalis and ramus oc- 
cipitalis ; and last of all the 
sulcus post-centralis supe- 
rior. 
"5. In Cebus there is no 
sulcus post-centralis supe- 
rior, it is present, however, 
in most of the old wrnrld 
apes, e.g., the baboon, macaque, gibbon, chimpanzee, 
orang, and gorilla. (Fig. 476.) 
" 6. In the chimpanzee and orang there is reason to be- 
lieve that this segment of the post-central sulcus consists 
of two elements, one placed above the other. (Figs. 479 
and 480.) 
" 7. Eberstaller's third and lower segment of the post- 
central sulcus (viz., the sulcus post-centralis transversus) 
is not only present in man, but also in the majority of the 
old-world apes. 
" 8. In the apes the intra-parietal sulcus is deeper than 
the fissure of Rolando, the opposite is the case in man. 
This would seem to indicate that the morphological value 
of the sulci is different in man and the apes. The phy- 
logeny and ontogeny of these furrows are in apparent 
variance with each other. The fissure of Rolando ap- 
pears first on the developing cerebrum of the human foe- 
tus, yet it is the intra-parietal sulcus which first makes 
its appearance in the evolution of the primate cere- 
brum. . . . 
"11. In man there appears to be a general tendency 
toward a union of the two originally distinct post-central 
elements of the sulcus, and a divorce from the lower of 
those of the ramus 
horizontalis. . . . 
" 13. The ramus oc- 
cipitalis was connect- 
ed with the ramus 
horizontalis in 63.7 
per cent, of the adult 
human hemispheres 
examined. 
" 14. The union be- 
tween these two ele- 
ments of the sulcus, 
as Ecker and Wilder 
have shown, is much 
more common on the 
left side than on the 
right. 
" The sulcus transversus of Ecker is not the homologue 
of the Aftenspalter in the apes, but merely a terminal bi- 
furcation of the ramus occipitalis." 
The Sulcus Pracentralis.-" 1. The sulcus praecentralis 
inferior in the human brain is composed of a vertical and 
Fig. 476. - Cerebrum of Cebus 
Albifrons. /, Sulcus frontalis 
inferior ; p.c., sulcus post-cen- 
tralis inferior; r, fissure of 
Rolando; «, Sylvian fissure; p, 
intra-parietal sulcus; p3, ramus 
horizontalis ; p*, ramus occipi- 
talis ; st, furrow corresponding 
to sulcus transversus occipi- 
talis of Ecker ; p.o., parieto- 
occipital fissure; an., first an- 
nectant gyrus; a J., ape cleft. 
Fig. 475.-Left Cerebral Hemisphere of a Chacma Baboon, p, Various 
parts of the intra parietal system of furrows ; jo1, sulcus post-centralis 
inferior ; p2, two parts of the sulcus post-centralis superior ; p3, ramus 
horizontalis; f.p., sulcus post-centralis transversus ; o, occipital oper- 
culum. 
sure reaches the outer surface of the hemisphere is situ- 
ated relatively further back than in the human adult. 
"22. The Sylvian fissure is relatively longer in the left 
hemisphere than in the right, and in the ape than in 
man. . . . 
"28. In the cebus the Sylvian fissure lies above the 
level of the squamous suture ; in the macaque, homa- 
dryas, and orang, it lies immediately subjacent to the fore- 
part of the suture : in Cynocephalus anubis and the chim- 
panzee the fissure is situated in its fore-part below the 
level of the front part of the suture. 
" 29. The relative depth of the parietal and temporal 
lobes in the lower apes resembles that in the human 
child ; in the anthropoid ape the relative parietal depth 
of the hemisphere exceeds that in the human adult." 
The Fissure of Rolando.-Cunningham found that in 
sixty per cent, of the brains examined the upper end of 
the fissure of Rolando turned over the mesal border of 
the hemisphere ; in nineteen per cent, its ventral end was 
connected by a shallow transverse sulcus with the Syl- 
vian fissure. The fissure of Rolando appears in two 
parts, the lower two-thirds appears before, and indepen- 
dent of, the upper third. The relative position of the 
fissure of Rolando is remarkably constant. The upper 
fronto-Rolandic index is 53.3, the lower 43.3. In anthro- 
poid the upper end of the fissure of Rolando is placed 
relatively further back than in man. The average Ro- 
landic angle in the human brain is 71.7. The average 
relative length of the fissure of Rolando is 39.3. 
The Intro-parietal Sulcus.-" 1. The entire sulcus, single 
Fig. 477.-The Outer Surface of the Cere- 
brum of Cebus Albifrons. r, Fissure of 
Rolando ; p.c.i., sulcus praecentralis in- 
ferior : A, ramus horizontalis ; Z2, in- 
ferior frontal sulcus. 
687 Nervous System. 
Nervous System. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
a horizontal limb. The latter is carried forward into the 
middle of the frontal convolution. 
" 2. This furrow is the earliest to appear on the outer 
surface of the frontal lobe of the foetal brain. In some 
cases it is seen in the fifth-month cerebrum in the form 
of a long, deep, vertical sulcus, which subsequently un- 
dergoes*^, retrograde development before its adult condi- 
tion is reached. In 
many cases, in its early 
condition, it presents a 
form in every respect 
comparable with that 
observed in the cere- 
brum of the low ape 
(Cebus). Frequently 
it is developed in sev- 
eral pieces. 
"3. The sulcus 
praecentralis superior 
is closely connected 
with the basal part of 
the first frontal fur- 
row. It is usually developed along with it. It consists 
of two pieces-an uppei' and a lower-which may be 
partially or completely separated from each other, as 
well as from the basal part of the first frontal furrow by 
an annectant gyrus. 
"4. Two additional furrows belonging to the praecen- 
tral system are occasionally present, viz., the sulcus 
praecentralis medius and the sulcus praecentralis margi- 
nalis. 
"5. The sulcus praecentralis medius may arise in two 
different ways : (a) It may be formed by the ramus hori- 
zontalis of the inferior prae- 
central sulcus divorced from 
the vertical stem and assum- 
ing a very oblique or an 
almost vertical position ; (b) 
it may consist of a new ele- 
ment placed between the 
superior and inferior praecen- 
tral furrows, but showing a 
closer connection with the 
former. . . . 
"12. The superior frontal 
gyrus and the middle frontal 
gyrus are each partially sub- 
divided into two tiers or sub- 
divisions by furrows which 
may be respectively termed 
the sulcus frontalis mesialis 
and the sulcus frontalis me- 
dius. 
" 13. Both of these fur- 
rows have secured a firm 
footing in the human brain, 
but only one (viz., the fron- 
talis medius) lias established 
itself upon the brain of the 
chimpanzee." . . . 
"17. The sulcus frontalis 
mesialis is absent or poorly 
developed in the brain of the 
negro. . . . 
"20. The sulcus praecen- 
tralis inferior and the inferior 
frontal sulcus are the furrows 
which are most firmly im- 
pressed upon the brain of the 
apes. In Cebus they alone 
are present; in Calithrix 
there are also traces of the 
sulcus praecentralis superior and sulcus fronto-orbitalis ; 
in the baboon there are, in addition, a rudimentary sul- 
cus frontalis superior, and perhaps (?) traces of a sulcus 
frontalis medius. (Figs. 475 and 476.) 
" 21. In the chimpanzee and the gorilla the sulcus fron- 
talis medius is often present in a form precisely similar 
to that seen in the human brain ; in the orang the condi- 
(SUPPLEMENT.) 
tion of this sulcus is doubtful ; m the gibbon the sulcus 
frontalis medius is absent. 
" 22. In the chimpanzee, therefore, the same convolu- 
tion tiers may be seen as in man, with this exception : the 
superior frontalis is never 
split into two by a sulcus 
frontalis mesialis. 
"23. The inferior frontal 
convolution of apes is very 
different from that in man. 
"24. The frontal and orbi- 
tal Sylvian opercula are com- 
pletely absent in the apes. 
" 25. Consequently, a por- 
tion of the island of Reil is 
uncovered and exposed on 
the surface of the cerebrum. 
"26. The sulcus fronto- 
orbitalis of apes corresponds 
to the anterior limiting sul- 
cus of the island of Reil in 
man. 
' ' 27. There are no anterior 
limbs of the Sylvian fissure 
in the anthropoid apes. The 
so-called anterior limb of the 
Sylvian fissure corresponds 
to the anterior free border of 
the f r o n t o - parietal oper- 
culum. 
"28. About the seventh 
month of foetal life the in- 
ferior prsecentral sulcus of 
the human brain attains a 
position which it retains un- 
altered throughout all the 
subsequent changes of 
growth ; previous to this it is placed relatively further 
back on the surface of the hemisphere. 
" 29. At first it is placed in front of the coronal suture. 
The sutural line, howTever, moves forward so that the 
sulcus ultimately comes to lie behind it. 
" 30. In the ape cerebrum the inferior prsecentral sulcus 
lies relatively much further forward than in the cerebrum 
of man. It may be placed subjacent to, or in front of, 
the coronal line." 
Morphology of the Primitive Brain Tube.-Embryology 
and comparative anatomy are continually throwing new 
light on the problem of the archetypal structure of the 
neuraxis. 
The most obscure point and one of fundamental im- 
Fig. 478. - Another view of the same ; 
p.c.a., Sulcus pnecentralis inferior (?); 
e.o., a slight trace of the sulcus fronto- 
orbitalis. Other letters as in Fig. 477. 
Fig. 480.-Right Hemisphere of a 
Male Orang, Six Years Old. r, 
Fissure of Rolando ; p1, sulcus 
post-centralis inferior; p3, two 
parts of sulcus post-centralis 
superior; p3, ramus horizon- 
talis; p4,ramus occipitalis; a.n., 
first parieto-occipital annectant 
gyrus ; p.o., parieto-occipital fis- 
sure ; a.f., bottom of " ape- 
cleft ; " o, cut surface of occip- 
ital operculum ; s, fissure of Syl- 
vius ; t1, parallel sulcus. 
Fig. 479.-Cerebral Hemisphere 
of Young Female Chimpanzee, 
as seen from above. The oper- 
culum on each side has been 
removed, r, Fissure of Ro- 
lando ; pl, sulcus post-centralis 
inferior ; p2, two portions of 
sulcus post-centralis superior ; 
p3, ramus horizontalis; p*, 
ramus occipitalis ; b, terminal 
bifurcation of the intra-parie- 
tal sulcus : p.o., parieto-occip- 
ital fissure ; a.n., first parieto- 
occipital annectant gyrus; a, 
deep annectant gyrus in the 
course of the intra parietal sul- 
cus ; c, secondary sulcus in the 
superior parietal lobule; a.f., 
bottom of the " ape-cleft; " o, 
cut surface of occipital oper- 
culum ; f1, parallel sulcus. 
Fig. 481.-Right Cerebral Hemisphere of a Male Orang-outang, Six Years 
Old. p. Sulcus frontalis superior : f2, sulcus frontalis inferior : f.m., 
sulcus frontalis medius ; e.o., sulcus fronto-orbitalis; p.c., sulcus prae- 
centralis inferior : p.c.a., sulcus pnecentralis superior; p.c.i., sulcus 
praecentialis inferior : r, fissure of Rolando ; p1, sulcus post-centralis 
inferior ; p2, sulcus post-centralis superior ; p3, sulcus horizontalis in- 
tra-parietalis ; e.c., external calcarine fissure; t1, parallel sulcus; t2, 
second temporal sulcus; H1, ZZ2. H3, transverse temporal gyri of 
Heschl : Zf, insula ; A', first annectant gyrus ; S3, anterior free border 
of the fronto-parietal operculum ; O, anterior edge of the occipital 
operculum. 
688 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
(SUPPLEMENT.) 
Nervoug System. 
Nervous System. 
portance in the morphogenesis of the brain is the primi- 
tive cephalic end of the neuraxis. The two prevailing 
schools are represented by Professor His and Professor 
Kupffer, respectively. It* is quite possible that many of 
the contradictions grow out of the fact that the various 
authors have been employing different axes. 
Professor His uses an imaginary line lying in the base 
of the tube, and finds that its cephalic extremity coin- 
the tube closes, though it often remains open for a time, 
forming the neuropore. At the point where the frontal 
suture unites with the ventral is a transverse ridge-the 
basilary ridge-which marks the front of the brain base. 
Professor His distinguishes a basal plate and lateral alae, 
the former giving rise to the motor centres, including 
the bridge, peduncles, pars subthalamica, and at the 
cephalic extremity it gives rise to the optic vesicles. 
The tendency of the brain to fold sharply in the mes- 
encephalic region is common to all vertebrates. This 
fold, which gives rise to the saddle cleft, thrusts a part 
of tlie base into the cavity of the mesencephalon, produ- 
cing the tegmental tuberosity, behind which is the recess 
of the isthmus, and in front of which is the mammillary 
fossa. The former has been identified by Btirckhardt 
as a constant element, and the latter has been shown by 
Herrick to be represented by distinct paired vesicles even 
in fishes. 
The recess of Rathke penetrates more or less caudad 
of the basilary ridge, and the caudal wall of the recessus 
infundibuli gives rise to the infundibulum and the upper 
fundament of the hypophysis. The saccus vasculosus 
lies between the mammillary recess and the infundibu- 
lum. The formation of the hypoaria is due, in the opin- 
ion of the writer, to a reduction of the mesencephalic 
fold. In this case, instead of the formation of the teg- 
mental tuberosity, the excess of the base is thrust cephalo- 
laterad and appears to occupy the walls of the dienceph- 
alon. 
Respecting the roof of the diencephalon, Professor 
His24 has given a summary which is so useful that it is 
given somewhat at length : 
"With regard to the structures called epiphyses, re- 
cent times have begun to make sharper distinctions, 
since Goette has shown that the roof of the diencephalon 
in amphibia forms two projections, a cephalic (' ader- 
geflechtknoten ') and a caudal or true pineal. Since 
then, the presence of several rudiments has been repeat- 
edly noticed, most recently by Burckhardt in Protop- 
terus, and Eydeshymer in Amblystoma. The latter au- 
thor calls only the cephalic projection epiphysis, the 
caudal paraphysis, and very justly lays emphasis on the 
fact that the caudal structure appears later than the 
other. An examination of the profiles of various em- 
bryonic brains shows that epiphyses may arise at more 
than two places. 
" The choroidal node found by Goette at the cephalic 
margin of the diencephalon in amphibia, belongs to the 
category of cephalic epiphyses. Here it is easy to dis- 
tinguish them, as the distance between the two is very 
great. The epiphysis of Selachii also arises from the 
cephalic part of the roof of the diencephalon. Later, 
however, almost the w hole diencephalic roof is elevated, 
and there results the familiar projection included be- 
tween fore-brain and mid-brain, and whose base extends 
caudad nearly to the post-commissure. Similar condi- 
tions prevail in teleosts. An epiphysis of the cephalic 
roof of the diencephalon was encountered by me in a hu- 
man embryo 10.5 mm. in length. 
" The roof-plate forms at this stage a small median 
longitudinal ridge with two lateral angles. Cephalad 
this ridge is triangular, and the median angle separates 
for a short distance as an independent appendage. 
"When I first discovered this structure, some years 
since, I fancied I had solved the history of the pineal, 
and only a careful profile reconstruction revealed the 
fact that this body belongs to the very front of the roof 
of the diencephalon. The body seems later to disappear 
in the folds of the plexus. 
" The true epiphysis develops much later, after the 
post-commissure is already formed, by protrusion of 
the most caudal part of the diencephalic roof. In the bird 
brain, as even Remak noticed, the epiphysis arises from 
the middle of the diencephalic roof, and the same is true 
for the epiphysis of reptiles. 
" Thus we distinguish epiphyses of the front, middle, 
and posterior of the diencephalon roof. For the latter 
name pineal may be usefully retained. 
" Besides these special forms of outgrowth, we en- 
Fig. 482.-Outer Surface of a Cerebral Hemisphere in the Early Part of 
the Seventh Month : Z1, Parallel sulcus ; p.c.i., inferior frontal; f1, 
sulcus frontalis primus ; p.c.s., sulcus praacentralis superior ; r, fissure 
of Rolando ; p, intra parietal sulcus; p1, sulcus post-centralis inferior ; 
p3, ramus horlzontalls of the intra-parietal sulcus ; p4, ramus occipi- 
talis ; e.p., fissura perpendicularis externa. 
cides with the basilary ridge immediately above the re- 
cess of Sessel. Others employ a median axis which 
would terminate in front of the chiasm (Kiebel). Others 
seem to employ a dorsal axis which, according to His, 
would terminate in the upper extremity of the terma. 
To us it seems that the first of these is the most satis- 
factory reference line, since the diameter of the tube 
varies greatly, and the length from the termination of 
the ventral to that of the dorsal axis is by no means con- 
stant, while the point of the infundibulum is relatively 
constant. This selection has another advantage in mak- 
Fig. 483.-Hinder Portion of Cerebral Hemisphere of Full-term Fcetus, 
showing Conditions Approximating to those of Anthropoid Apes, r, 
Upper end of fissure of Rolando; c.m., calloso-marginal sulcus; p.o., 
parieto-occipital fissure ; cun., cuneus ; c, gyrus cunei; p.c., praecu- 
neus; g.f., gyrus fornicatus; c.c., callosum; c.f., collateral fissure; 
C, posterior secondary calcarine fissure ; S, " stem " of calcarine fis- 
sure. 
ing the chorda coextensive with the neural axis, and ob- 
viating the necessity for a distinction between chordal 
and prechordal brain segments. 
When the medullary tube closes it has three lines of 
union or sutures ; the ventral suture marks the line 
where the chorda was separated, the dorsal suture is the 
line where the medullary tube has separated from the 
ectoderm, the frontal suture is the line where the front of 
689 Nervous System. 
Nervous System. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
counter an elevation of the whole roof, as in Selachii and 
Teleostei. Goette's " Adergeflechtknoten" certainly per- 
tains exclusively to the group of anterior projections, 
while the so-called parietal eye of reptiles belong to the 
middle group." [Later investigations proved it to belong 
to the posterior group.] 
Burckhardt gives the following arrangement of the 
parts of the diencephalic roof : 1, Prseplexus ; 2, velum ; 
3, " Zirbelpolster " (paraphysis); 4, supra-commissura ; 
5, pineal ; 6, intercalary segment; 7, post-commissura. 
This seems to be a satisfactory arrangement, except that 
it fails to take into account the development of the pro- 
jections from the region of the pneplexus which are 
mentioned by His. There is a remarkable constancy in 
arrangement of these parts. The writer has shown that 
the current opinion that the pineal is absent in reptiles 
rests on a mistake. In serpents the pineal is greatly modi- 
fied, being a very large lymphoidal body occupying a 
sling of membrane above the supra-commissure, and is 
connected either with it or the " Polster," or roof in 
front of the commissure. The structure of the body is 
very like that of the glandular part of the pituitary. In 
turtles there is a large and well-developed tubular pineal 
as well as a strong flexiform outgrowth cephalad. It is 
easy to discover that the tube is connected directly with 
the third ventricle just caudad of the supra-commissure. 
In ganoid fishes the tubular pineal is well developed 
and is closely associated with the dorsal sac or expanded 
roof of the thalamus and aula. There is an enormous 
plexiform development of the pallium taking the place of 
the praeplexus. In all essentials teleosts agree with the 
ganoids. 
Among the most remarkable structures are the hypo- 
aria of fishes (Fig. 484) which are not externally obvi- 
ous in other groups. 
The hypoaria have usually been considered appendages 
of the thalamus, but Herrick insists that they are morpho- 
logically caudad of the mammillaria, and contain ele- 
ments of the pes pedunculi or the cephalic part of the 
floor of the mesencephalon. In this connection he iden- 
tifies the peculiar cells with which the motor peduncles 
unite with similar cells in the reptilian mesencephalon 
and that of mammals. The corpus rotundus is identi- 
fied with the nidulus ruber, and the latter is shown to be 
the centre of sensory redistribution, as the before-men- 
(SUPPLEMENT.) 
tion of the saddle cleft. The isthmus, or cephalic neu- 
romere of the medulla, is obscured by the development of 
cerebellum and pons and has no corresponding nerve- 
roots. The trigeminus springs from two neuromeres, the 
facial and auditory from a single neuromere, as does the 
glosso-pharyngeal. It is not yet clear what relation is 
sustained by the tenth and twelfth nerves to the neuro- 
meres from which they spring. The relation of the 
chorda to the neural tube, from a morphological point of 
view, is greatly illuminated by the discovery of Seienka,25 
Fig. 485.-Illustration showing the Relation between Chordal Sac, Ali 
mentary Canal, and Brain Flexure in Opossum. (From Seienka.) 
that in the opossum there is a curious tortuous tube, ap- 
parently related to the cephalic end of the entoderm, but 
which is really a hollowed and contorted modification of 
the chorda. Seienka reminds us of the origin of the 
chorda as an originally hollow diverticle from the ento- 
derm. 
The contorted modification must be ascribed to the 
head-fold which interferes with the normal forward 
growth of this body, and coils it within the space behind 
the infundibulum. 
This tubular body is quite distinct from the hypophy- 
sis, which develops as usual from the ectoderm. This 
fact, taken in connection with Professor His's statement 
that the neuropore is coextensive with the whole area 
from infundibulum to terma, strongly enforces the view 
that the infundibulum (or at least the basilary ridge) is at 
the morphological front of the neuraxis. 
C. L. Herrick. 
1 Hatchek : Die Metamerie des Amphioxus und des Ammocetes, Ver- 
handlungen der Anat. Gesellschaft attf der sechsten Versammlung in 
Wien, 1892. 
2 Rabi: Ueber die Metamerie des Wirbelthierkopfes. As above. 
3 Kupffer : The Development of the Cranial Nerves. Tr. by Strong. 
Journ. Comp. Neurology. October, December, 1892. 
4 Kupffer : The Development of Petromyzon Planeri, Arch. f. Mik. 
Anat., 1890. 
6 Hatchek : Zur Metamerie der Wirbelthiere, Anat. Anzeiger, viii., 2, 3. 
9 Edinger : Das Zwi>chenhim der Selachier und der Amphibien, Ab- 
handl. Senckenbergischen naturf. Gesellschaft, xviii., 1892. 
7 Burckhardt : Das Centralnervensystem von Protopterus annectens. 
Berlin, 1892. 
8 Kupffer : Studien zur Vergleichenden Entwickelungsgeschichte des 
Kopfes der Kranioten, 1, 1893. 
9 Willey: The Later Larval Development of Amphioxus, Quart. Journ. 
Micro. Science, xxxii., 1891. 
10 N. Goronowitsch : Das Gehirn und die Cranialnerven von Acipenser 
ruthenus, Morph. Jahrbuch, Bd. xiii.. 1888, pp. 427 to 674. 
11 Herrick ; Morphology of the Nervous System, iii. Topography and 
Histology of the Brain of Certain Ganoid Fishes, Journ. Comp. Neurol., 
June, 1892. 
12 Rabl-Riickhard : Zur Deutung und Entwickelung des Gehirns der 
Knochenfische, Arch. f. Anat. u. Phys., 1882. 
13 Rabl-Riickhard : Das Grosshirn der Knochenfische. The same, 
1883. 
14 Herrick : Contributions to the Morphology of the Brain of Bony 
Fishes, ii.-Studies on the Brain of some American Fresh-water Fishes, 
Journal Comp. Neurology, vols. i., ii. 
15 Burckhardt : Untersuchungen am Him und Geruchsorgan von 
Triton und Ichthyophis, Zeitschrift f. wissensch. Zoologie, lii., 3. 
19 Osborn : Contribution to the Internal Structure of the Amphibian 
Brain, Journ. Morphol., ii. 
17 Osborn : The Relation of the Dorsal Commissures of the Brain to the 
Formation of the Encephalic Vesicles, American Naturalist, October, 
1887. 
Fig. 484.-Transection of the Brain of a Small Bass. Diagrammatic. 
Especially designed to show the position of the mammillaria and for- 
nix tract (tr. f.) as well as the general relations ; gel. tr. tor., gelatin- 
ous tract from the torus to periphery of the tectum. 
tioned cells are of motor connection (especially with the 
cerebellum). 
The great consolidation in this region in mammals, 
and higher vertebrates generally, is largely effected by 
what Professor His terms the saddle cleft, i.e., the fold 
of the floor of the mesencephalon, which fills the cavity 
of the mesencephalon. In embryonic reptilia the mesen- 
cephalon is obviously double, and this seems to be uni- 
versally true at some stage. The cephalic diverticle is 
pushed cephalad and participates in the curvature of the 
first embryonic vesicle, while the second is lost in forma- 
690 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Nervous System. 
Nervous System. 
18 Osborn : The Origin of the Corpus Callosum, Morph. Jahrbuch., 
xii. 
19 Edinger : Untersuchung uber die vergleichende Anatomie des 
Gehirns, das Vorderhirn. Frankfort a.-M., 1888. 
20 Herrick: Notes upon the Brain of the Alligator, Journ. Cincinnati 
Soc. Nat. Hist., January, 1890. 
21 Herrick : Topography and Histology of the Brain of Certain Rep- 
tiles, Journ. Comp. Neurology, vol. 1., March, 1891. 
22 Turner, C. H. : Morphology of the Avian Brain, Journ. of Comp. 
Neurology, vol. i. 
23 Meyer, Ad. : Ueber das Vorderhirn eininger Reptilien, Zeitsch. f. 
wis. Zool., lv., i. 
21 His, W. : Zur Allgemeinen Morphologie des Gehirns. Archiv f. 
Anat. u. Physiol., 1892, v„ vi. 
26 Seienka : Studien liber Entwickelungsgeschichte der Thiere, iv. 
(SUPPLEMENT.) 
vous elements are formed. The primitive cells which 
are thus modified are spongioblasts, and are the non- 
nervous elements in the neuro-epithelium. The spongi- 
NERVOUS SYSTEM : HISTOGENESIS OF ITS ELE- 
MENTS. To Professor William His, Sr., of Leipzig, 
science is chiefly indebted for the generalizations formu- 
lating the laws of development of the nervous elements. 
Three sources may be recognized for the various ele- 
Fig. 489 (From Herrick). - Part 
of the Mesencephalon of a Gar- 
ter-snake Embryo, showing nu- 
merous neuroblasts, with kary- 
okinetic figures and two spongi- 
oblasts (sp') in the same process. 
Fig. 488 (After His). - Spongi- 
oblasts, with Mitosis of Nuclei. 
oblast, then, consists of an inner columnar portion, a mid- 
dle nucleated zone, and a peripheral marginal or "veil" 
portion. The columnar inner portion never loses its in- 
dividuality, and forms the so-called lining epithelium of 
the ventricles and other cavities of the central nervous 
system. 
In reality this endyma is not a true epithelium, but is 
composed of the persisting bases of cells which, morpho- 
logically, and generally structurally, retain a connection 
with the ectal part of the brain-tube. The so-called con- 
nective or supporting elements of the retina, organ of 
Corti, and even of the olfactory 
epithelium, have essentially simi- 
lar structure. The spongioblasts 
multiply to supply the exigencies 
of the growth of the organ, and 
mitosis may occasionally be de- 
tected in the nuclei. (Figs. 488 
and 489.) 
Professor His considers that the 
spaces in the marginal portion of 
the neurospongium are all pro- 
duced from vacuoles in the cells, 
i.e., are intra-cellular. The pres- 
ent writer is convinced that in 
lower vertebrates, at least, these 
spaces are intercellular, and the 
peripheral portion of the cells sim- 
ply collapses, leaving the inter- 
spaces to be filled by an exudate 
soft and nutritive enough to facili- 
tate the growth of the neurons. 
(Figs. 489, 490, 491.) 
That the entire thickness